It
looked like it was going to be a good day. I wasn’t on call, I would be off the
weekend and all I had scheduled for the day was four elective cases, all
laparoscopic cholecystectomies.
How could the day be any better?
The
surgeon’s prayer popped into my head:
“Lord,
please protect me from the interesting cases and don’t let me screw up today.”
Cholecystectomy
is the most common operation that is performed in the United States.
Gallbladder disease occurs as a consequence of diet, hormonal changes, genetics
and physiologic changes involving the rest of the body. It seems that
everything affects the gallbladder. Gaining weight, losing weight, pregnancy,
illness, stress and probably a whole bunch of other things cause the
gallbladder to form stones, stop functioning or become inflamed. Whenever the
gallbladder starts to behave badly one can rest assured that a friendly general
surgeon is nearby to address the problem.
It
was six thirty in the morning, the dogs were fed and I was scheduled to start
in an hour.
Maybe I can get rounds done before I
surgery.
It
was a rare day. I only had patients at one hospital, the same venue where the
cases were scheduled. I arrived at six fifty five and greeted my first patient
in Day surgery.
Maria
was forty, about five foot one and weighed in at two hundred sixty pounds. She
had multiple gallstones and had suffered through repeated episodes of right
upper quadrant abdominal pain. She had gone to the ER once, but otherwise had
endured multiple nights of suffering.
“I
just get up and walk around or sit in the chair until the pain goes away,
usually after a couple of hours. I take some Motrin, which helps a little.”
Textbook case. All Four F’s: Female,
Fertile, Forty and ‘Rotund’.
I
went to the hospital computer and checked on each of my in house patients,
their vital signs, lab results and such. I only had five patients to see.
Everyone looked good in the computer.
I guess I need to see each one in
person.
I
ran up to the third floor, the post surgical unit. I saw Bill and Irma and
Lucille, each post op from laparotomies and each was doing well. Notes and
orders were written (the good old days, before computerized everything) and
then I ran down to the OR to start Maria’s surgery.
She
was just going to sleep when I walked into OR five. I went out to wash my hands
while she was being prepped.
“Draperies
please,” I asked.
The
tech handed me a towel and I began to drape Maria.
All
the proper tools were passed off and connected and surgery commenced.
I
infiltrated some long acting local anesthetic in Maria’s belly button area,
made a small incision, elevated her abdominal wall and tried to pass the Veress
needle. This needle is what I commonly use to insufflate the abdomen, that is
blow it up with carbon dioxide gas. Only the needle wouldn’t pass. I put it in
up the hilt, but no go.
She doesn’t look to be that large.
But, women tend to have their adipose tissue in the abdominal wall, I guess
Maria has a bit more than I thought.
“I
need a longer Veress needle.”
In
about a minute the circulator returned with the 150 cm needle which I was able
to pass into the abdomen without difficulty.
I hope that’s the only glitch for the
day.
And
Maria’s case went off without a hitch. Inside her abdomen there wasn’t much
fat. Each structure stood out. The gallbladder was hanging off the liver, the
common bile duct was easily seen, and the cystic artery nearly jumped out at
me. It was spread, spread, clip, clip, clip, cut, clip, clip, clip, clip, cut,
then snip, snip, snip, snoop and in five minutes the gallbladder was in a
pouch, pulled out through the epigastric wound and on the back table. Ten minutes
later the final band aids were laid over the last of Maria’s wounds as she
began to wake up. Thirty five minutes after she had gone to sleep she was in
the Recovery Room.
I should have time to see my other
two hospital patients.
I
saw Joe and Juana on the fourth floor. Neither had a problem which would
require surgery. I stopped to say “hello, how are you, you should be going home
soon and then went back to the OR to operate on Michael.
Michael
had been having pain for years, always in the upper abdomen, radiating to his
back, occurring almost every day. He had gone through endoscopies, CT Scans,
MRI’s, ultrasounds and more endoscopies. Finally, he found a GI specialist who
ordered a HIDA Scan. This is an anatomic and functional test of the
gallbladder. In Michael’s case the HIDA revealed his gallbladder only emptied
4% when stimulated and, maybe more important, his symptoms were reproduced,
exactly. I told his there was an 85-90% chance his pain would be relieved by
surgery.
He
was being wheeled into the OR as I finished my rounds.
Should be straightforward. No stones,
chronic symptoms, overall in excellent health.
Never
make such assumptions.
Michael’s
surgery started off simple enough. The gallbladder was partially intrahepatic,
but that just means a little more dissection until the gallbladder is free. I
began in the usual way, incising the thin layer of peritoneum over the neck of
the gallbladder and dissecting this peritoneum and the some surrounding fat
away from the wall of the gallbladder. I lmost always start on the inferio
lateral aspect of the gallbladder, where I should be safely away from the
common bile duct.
As
I began Michael’s dissection I saw a bluish structure just below the cystic
duct and going towards the liver.
Not the right spot for the common
bile duct or any bile duct. Be careful. Maybe it will be easier on the other
side of the gallbladder.
I
began dissecting on the medial aspect of the gallbladder.
It looks like there is another duct
on this side. Maybe the gallbladder is lying between the right and left hepatic
ducts? The structure in the middle looks like the cystic duct.
I
started working higher on the gallbladder, away from any ducts, I hoped.
This is becoming far too much work.
This was supposed to be my easy case.
As
I dissected along the medial wall of the gallbladder I was able to identify a
duct running along this part of the gallbladder and then going towards the
liver. Luckily, I was able to separate this duct from the gallbladder.
That must be the left hepatic duct.
At least Michael is not too chunky.
I
retracted the gallbladder to the right and began teasing out the cystic duct.
Better check that duct like structure
on the right side of the gallbladder.
It’s
a good thing I did, because what I thought was all cystic duct turned out to be
what I now presumed to be the right hepatic duct almost fused to the back wall
of the gallbladder. I tried to separate these two structures. No luck. I did
manage to find what I presumed was the cystic artery, very short and running
along the medial aspect of the gallbladder, almost tethering the gallbladder
between the two hepatic ducts.
Maybe take it from the top down, like
the old days.
And
so I began working on the fundus of the gallbladder. I pushed the liver up and
retracted the gallbladder down and was able to separate the gallbladder until
it was attached buy only the cystic duct, which was still fused to the right
hepatic duct.
I’ll just take where it’s safe and
leave the rest behind.
I
used a stapling device to divide the gallbladder at its neck, being careful not
to injure the bile ducts.
Finally it’s done. This was far too
much work.
Michael
woke up without a hitch, oblivious to the torture I had suffered. His operation
which normally would have taken about thirty minutes had lasted over two hours.
Next
was Michelle, twenty one, with pain for a week and a big stone impacted in the
neck of the gallbladder. Michelle was typical of most patients with
cholecystitis. That is she had persistent episodes of pain, and stones which
either intermittently passed from the gallbladder through the bile duct,
causing “biliary colic” or had big stones which would cause obstruction of the
gallbladder with either acute symptoms of severe pain and tenderness, “acute
cholecystitis” or paroxysmal pain, “chronic cholecystitis.”
Michael and Michelle, good name for a
duo. And now we present “Michelle and Michael” the gallbladder singers.
My
first glance at Michelle’s gallbladder revealed only that is was very
distended. It wasn’t very inflamed and there was only a brief moment when it
seemed like there might be some difficulty grasping it. There was a big stone
filling the gallbladder neck, but I was able to retract the gallbladder to the
right so that I could dissect the cystic artery and duct. Fifteen minutes later
the gallbladder was in the endopouch.
Homefree.
But,
it wouldn’t come out. The pouch was half in and half out of the abdomen,
pulling it out through on of the larger trocar sites. I grabbed the gallbladder
and tried to deliver it out of the pouch and abdomen. I was rewarded with a
tiny piece of the gallbladder wall.
Keep at it. You always win in the
end.
I
tried to grab the stone with the ring Forceps, a clamp which has two rings
which is ideally suited to grasping gallstones and pulling them out of the
Endopouch. Michelle’s stone was big, really big. With one lucky swoop I managed
to get the jaws of this clamp around the stone. I pulled it up towards the
small opening in the abdominal wall. It was equivalent to trying to put a camel
through the eye of a needle.
Maybe I can break the stone up.
I
tried to close the jaws of the clamp and break the stone into pieces. There was
a “snap” and then I was able to pull the clamp out, minus one of its jaws.
That is one tough stone.
I
tried a different type of clamp. No luck.
After
twenty minutes of pulling, prying and hoping I did what I needed to do.
“Knife
please.”
I
made the incision bigger, big enough to deliver this baby. I made it bigger and
bigger until it was a mini laparotomy. Finally, I pulled pouch gallbladder and
stone out of Michelle’s abdomen. T
The
stone was five and a half centimeters in diameter, the size of a chicken egg. I
took a break for a minute, shaking my hand to relieve a cramp and stretching my
fingers after this ordeal. I closed Michelle in short order and got ready for
Owen.
I’m not sure they pay me enough.
Maybe Owen will treat me better.
I
shouldn’t think such thoughts, surely I jinxed myself. Owen. Even now the name
makes me shudder.
Owen
was 78 years old and had typical complaints of RUQ abdominal pain. He had been
having pain almost daily for 6 weeks. His ultrasound revealed, and I quote,
“Multiple mobile stones,” and the gallbladder was not visualized on HIDA scan,
which suggests cystic duct obstruction and certainly explained Owen’s frequent
symptoms.
“Are
you ready to get this over with?” I asked.
“Sure
thing, Doc. I’m planning to play eighteen holes tomorrow,” He answered.
“Well,
you may want to wait until the weekend,” I countered.
Owen’s
case started well enough. Pneumoperitoneum established without difficulty, all
the trocars placed and then I looked in with the scope.
No
gallbladder.
All
I saw was a bit of omentum stuck to the spot where the gallbladder was supposed
to be.
It must be underneath those
adhesions.
I
teased the omentum away and was rewarded with a structure which looked like it
was the gallbladder. It was small to say the least, but it was where the
gallbladder was supposed to sit and I was sure I could see the common bile
duct.
Once
the adhesions were gone I began to retract the gallbladder superiorly as is
almost always done during laparoscopic gallbladder surgery. The gallbladder was
not only shrunken it was very hard to grasp. Every time I tried to grab it, it
would slip away. Finally, all I could do was push the liver superiorly. As I
tried to dissect this diminutive little beast it tore. I did see some stones
inside but I realized I was fighting a losing battle.
“Scalpel,
please and get all the instruments to open,” I requested.
Better to have a big incision and a
healthy, whole patient, than four small incisions and a piece of the common
bile duct in the specimen jar.
Over
the years I have never had a patient complain that they had to have open
surgery. However, they definitely are not happy if they require multiple
surgeries to fix a complication.
For
the next hour and a half I wrestled with Owen’s little nubbin of a gallbladder.
I managed to separate it from the liver and I thought I found his cystic duct
and junction with the common bile duct. The cystic duct was very short. I
stitched it closed, being careful not to narrow his CBD and I left a drain in
place.
I
delivered a gallbladder which was the size of a nickel and contained a couple
of stones which filled its tiny lumen.
Two hours of work for that little
thing?
Owen
woke up without a hitch.
“No
golf for a few weeks,” I informed him.
“There
goes my handicap,” he answered.
At least I’m done.
My
phone went off.
“Consult,
ICU 21. Tad Schultz, acute cholecystitis.”
I thought I was done.
It
was now 3:30 in the afternoon. My plan to be done and home by one was just a
fading memory.
I guess I need to go check out Tad. I
wonder why he’s in ICU if it’s just his gallbladder which is the problem?
Tad
was not in the ICU just because of his gallbladder. He had undergone coronary
artery bypass surgery thirty six hours ago. Now he was complaining of severe
upper abdominal pain, nausea and vomiting, all of which had commenced twelve
hours earlier.
“Hello,
Mr. Schultz. I’m Dr. Gelber, one of the General surgeons here. They tell me you
have pain in your abdomen?” I inquired.
He
was sitting still in his bed, an oxygen cannula draped across his face which
was flushed. The monitor to the right of his bed gave a clue to his condition. Heart
rate was 112, blood pressure 100/50, Respirations 22, oxygen saturation was
100%.
Looks like something is going on; something
more than just post op discomfort.
“It
hurts right here,” he replied as he pointed to the right upper quadrant of his
abdomen, right where his gallbladder sat.
“It
hurts to move, to breath, even to smile,” he added.
I wonder if it’s more than just his
gallbladder?
“Any
nausea or vomiting?”
“All
night.”
“Had
a pain like this before?”
“Never.”
I
palpated his abdomen. He winced when I lightly tapped beneath the right costal
margin (below the ribs).
It feels like there’s a mass there.”
“I’ll
be back in a few minutes,” I said and I went to check the results of any
testing which had been done.
I
sat a the computer, waiting for Tad’s data to appear.
I don’t feel like ding another
surgery today, especially on someone fresh from open heart surgery.
The
tests revealed that his white Blood Cell count was 23,000, H/H 10.5 and 32.
Total bilirubin was 2.0, ALT 125, AST 114 and Alkaline Phosphatase 201. His
other labs were more or less normal. Ultrasound revealed a very distended
gallbladder with stones and a thickened wall at 10 mm.
No question, Tad is sick and the
culprit is his gallbladder. Surgery would best be avoided if possible. Maybe Dr.
L can help.
Dr.
L was our local, friendly Interventional Radiologist.
“Percutaneous
cholecystostomy, if you have the time,” I requested from Dr. L. “Mr. Schultz,
ICU 21. I think it would be best if he does not have to have surgery again so
soon.”
Dr.
L agreed and two hours later Tad was sitting up, smiling with a tube running
from his right flank to a bag which was filled with golden brown bile.
It
was not definitive treatment, but the drainage procedure bought time, allowing
Tad to recover from his open heart surgery without further complication. Six
weeks later he had a second surgery, an uncomplicated laparoscopic
cholecystectomy.
The
day ended at around 6:00 pm. I had performed four cholecystectomies, tackling
gallbladders of a variety of shapes and complexities. My hand was still a little
sore from battling Michelle’s ostrich egg of a gallstone, but otherwise it had
been a successful day.
Cholecystectomy
can be one of the easiest surgeries to perform or extremely difficult. An
elective gallbladder surgery in a thin patient with little inflammation and
normal anatomy may take all of ten minutes. Meanwhile, at the other end of the
spectrum, a case like Owen, a small contracted, fibrotic gallbladder with anatomy
which is unclear will cause the best surgeon to pause and rue the day he chose
to work with a scalpel, rather than sit a dark room all day and read chest
X-Rays.
I
thought about the surgeon’s prayer.
“Lord,
please protect me from the interesting cases and don’t let me screw up today.”
Maybe
it needs an addendum:
“And
please make all the gallbladder surgeries easy.”
