I love hernias. Repairing an inguinal hernia seems to be an activity most akin to juggling several balls while standing on your head facing backwards. In other words, after doing it a couple of times, and reading three different textbooks prior to the most recent effort, I still have only a minimal understanding of which piece went where and why.
There are four or five main layers to the abdominal wall, I get that much: skin, fat, Camper’s fascia, Scarpa’s fascia; then you get the external oblique muscle – but down that far, there’s only the external oblique aponeurosis, which runs into everything else; and the internal oblique, and its aponeurosis; and the transversus abdominis, which blends into stuff, and the transversalis fascia; plus the preperitoneal space/fat, and the peritoneum itself. Now if all that would just lie flat, it would be enough trouble. But then it bends, apparently through a warp in the space-time continuum, and you get the inguinal ligament, Cooper’s ligament, the external inguinal ring, the internal inguinal ring (if only I had One ring to bind them all!), and the cremaster fascia. I keep reading the textbooks, and turning them around and around trying to figure out what Cooper’s ligament is and how it relates to all the rest of this stuff, and I still can’t see it. As a sign of how lost I am, when they illustrate this anatomy unilaterally, they usually don’t label left/right, up/down, and I can’t even tell where we’re at, or whether we’re looking from the inside out, or the outside in, let alone where things connect to.
So it’s a good thing I’ve been doing this with one of the quiet attendings. He doesn’t say much of anything unless you’re recklessly out of place (for instance, being so awe-struck by the sight of the hernia suddenly dropping back through the hole – a hole, any hole - actually the internal ring - back into the peritoneal cavity, that you completely forget how to tie knots, and start tying them a couple inches into the air, when he mildly observes that maintaining tension on the suture tends to make for a tighter knot, and thus a more durable repair). (That was last time, this time I got a grip on myself, and the suture, too.) Anyway, although I have no doubt that I’m making all kinds of wild gestures through my lack of comprehension of where we are or what we’re going to do next, he hasn’t said anything, at least to me.
I feel like this is fascinating enough to keep doing straight for a couple of months at least; maybe by then I’d figure out which way is in and which way is out.
(In other news, when the ICU nurse warned me that the critical care attending was doing things with my patient, and likely to go farther, I tracked him down, and remarked in a polite manner that I’d been talking to the patient’s family. He informed me in a rather high-handed tone of his intentions to completely manage my patient in the future. I said no, now that he mentioned it, the patient was on my attending’s service, and the surgical team felt quite comfortable taking care of the foreseeable future. He did a double take, and I stuck my chin out and said we could handle it quite nicely, thank you. It felt good to get that out in the open, and certainly he hasn’t been seen or heard from since. Unfortunately it didn’t improve my patient at all. I wish I could ward off the angel of death as easily as that.)