It’s been a while since I’ve had to realize that just because something looks easy doesn’t mean it really is. How many times I’ve watched from the sidelines as an attending and senior resident waded deep into the abdomen, hunting out a cancer or perforation and resecting it. For some reason, that particular endeavor, more than peripheral vascular surgery, or breast surgery, or bariatric surgery, has captured my interest. (The closer I get, I’m starting to question that interest, but that will take a while to sort out.) First I was impressed, then I started to think that it didn’t look that difficult, and surely I could do it, too.
So it has been my picture of the glory of being a senior resident to participate in a major abdominal case. I got one, once, as a second-year, but I was pretty lost, and mostly just assisting the attending. She did let me do a few key parts, and that has pulled me back for more; but I had never really done such a big case.
Until last week. The chief was scrubbed in a Whipple, so I got the colectomy. Which was fair, as I had been rounding on the patient for the last week, as the attendings discussed back and forth whether or not to proceed with surgery. The indication was a little uncertain, and the patient was far from being a good operative candidate. Textbook, in fact, for who you should go to all lengths to avoid operating on. Finally, though, circumstances forced our hand, and we decided to go ahead.
It was a little bit of a rocky start when, while anesthesia was intubating the patient, and the attending and I were reviewing the CT scan, he asked me, “So how many of these have you done?” I’m a bad liar. I hesitated for a second. “A few.” He raised an eyebrow. “Well, one actually – and a couple more, laparoscopically, on pigs.” He started laughing. “Next you’re going to tell me, none, but you dissected it in anatomy class first year of med school!”
I was kicking myself for once again being too truthful for my own good, (such a fine line between endangering the patient by claiming to know how to do something you don’t, and destroying your chance of getting to practice by admitting to too much ignorance), but when we had all the drapes up, and the suction and bovie cords thrown off, the attending, hardly glancing in my direction, said, “Let’s start” – and the scrub tech handed me the knife. First time any attending ever let me set out on my own private expedition, as it were, to get into the abdomen. No directions, no comments, as I started cutting down to the fascia; just a minimum amount of counter-traction.
It only got better from there. He discussed the next steps with me as though I had any idea or say in the matter, and then let me do virtually every bit of the work, for the next several hours. And it was work. I had thought holding a retractor for hours at a time was hard work. Not much, compared to trying to hold back six feet of intestines with three fingers, spread the mesentery with the other two, and cut with an accuracy of millimeters with the other hand. And at every step, the thought that if my hand shook, or I misinterpreted the nature of what I was looking at (harmless fat, vs. a significant vessel), I could kill the man who had put his life in my hands.
I was tired, and ready to be done a good while before the end; but of course the most significant parts – the anastomosis, and the fascial closure come at the end. The idea of doing a couple of these a day – and maybe more at night – as early as next month, and certainly for years afterwards, is a just a little bit staggering. (And I now have a lot better understanding of what the attendings and chiefs have been complaining about when they discuss the difficulty of operating on obese patients. Even in a person who’s only moderately obese, the weight and depth involved in abdominal surgery, and the strength needed to work against it, is significant and exhausting, and the visualization is frustratingly poor.)
But everything comes with practice, right? And what triumph when I found the right plane, when the anastomosis went together, when the skin was closed, when the patient woke up (and was still alive a week later, proving that the textbooks don’t have the final say).