I feel sorry for the OR team that got stuck working the same night with me. We had a case of perforated appendicitis, the kind where you start regretting the decision to operate the minute pus starts oozing out of the first incision. (Note to ER doctors: unless the patient has a creatinine of 3 [indicating real renal failure] never ever ever do a CT scan without iv contrast (ok, unless you’re looking for kidney stones); and there is literally no excuse in the world for not giving oral contrast to a patient over the age of reason – appropriate use of antiemetics should enable the patient to get at least a modicum of the contrast down, and some is better than none. For the non-medical readers, iv contrast is invaluable for demarcating abscesses, which are characterized by a vascularized wall, and no blood flow inside. It also helps to diagnose dozens of other surgical conditions, including mesenteric ischemia, ischemic gut, and small bowel obstructions which need an urgent operation (as opposed to the ones that can wait). Oral contrast is necessary to show which round objects are intestine, and which could be something else, like an inflamed appendix or an abscess. Not having contrast is like trying to peel potatoes in the dark – a waste of time and radiation.) (Note to self: next time, when the patient has diffuse peritonitis on exam, you should ignore the worthless noncontrast CT scan which may or may not show an abscess, and go with your clinical diagnosis of a perforation that’s had time to spread.)

(Appendicitis complicated by perforation and an abscess ought to be treated nonoperatively, because surgery is too difficult and risky in that setting. Like many other medical pearls, I didn’t quite believe that one until I proved it for myself. Someday, I’ll stop reinventing the wheel.)

It’s not that I did the case badly, just very very slowly. I’m doing better at getting the laparoscopic instruments where I want them to go, but things take twice as long when I drop everything I pick up, and have to grab it again and again before I get a grasp that works. However, as the attending observed, since there was already pus everywhere, things could hardly get any worse. . .

Better luck the next night, I guess.

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