This morning we had a lady (schizophrenic, just to make it interesting) with an ovarian mass, discovered by the chief resident in his continuity clinic. On opening her up, it turned out to be a nice, benign-appearing encapsulated cyst, with some lobulation. It was easily removed and sent for frozen section while they proceeded with the hysterectomy. Out of the blue, the attending asked if I knew how to tie, and handed me the knot he’d just thrown around the round ligament. While I was tying (struggling, of course, with the long threads, and being under the eyes of two experienced surgeons) he asked what the artery in the round ligament is. There isn’t any labeled in the anatomy books. It’s called the artery of Samson, and, while it manifestly supplies the uterus, the residents themselves were not sure where it comes from, since it’s not mentioned in any book. I guess it’s the private discovery of the gynecologists. So then he handed me the Bovie and showed me how to cut it! It didn’t feel anything like I expected. When the surgeons pick it up, it cuts through things like butter, so I thought it would be smooth. But actually you’re pushing against resistance, as it burns through.

Before they closed, the report came back that the mass was struma ovarii, which is a kind of dermoid cyst (aka teratoma, aka benign germ cell tumor) consisting primarily of thyroid tissue, perhaps functional. In this patient it was nonfunctional; classically, you can have a patient present with symptoms of hyperthyroidism (hypertension, tachycardia, flushing, heat intolerance, weight loss) and find that the thyroid hormone is coming from this ovarian mass rather than from the thyroid itself. Since it originates from germ cells, which are pluripotent, the usual teratomas have tissue from all three layers, ectoderm (hair, teeth, skin), mesoderm (muscle, stroma), and endoderm (blood vessels, etc), thus making the creepiest tumor ever. Also the stinkiest, I’m told. Struma ovarii is unique among the teratomas in that it has a higher potential for malignant transformation. They had already checked the lymph nodes, which felt fine. So the attending just snipped off a chunk of omentum to be sure there were no tumor cells in it.

Then he walked off, leaving me to close half the incision, without watching me. I got to start the thread at the very end (before the resident has always done that), and take off up the incision, while the chief started on the other end. It was terrific. I wasn’t making any mistakes – at least, none bad enough that anyone corrected them – and it came out looking beautiful – in my humble opinion. Of course I could only manage a third, before the chief came up to my line, but it lay flat and wasn’t puckered. I wanted to look at it and pat it for a couple minutes, but for some reason the nurse wanted to put a dressing on and clean things up. I felt as proud of those three inches as of any cross-stitch I ever did.

This is dangerous. They let me touch two things on the patient, and I was walking on air. I made a permanent change to someone’s insides. And I sewed her up, and it looked good, and the patient would like it (if she was with it enough to pay attention to a scar). I want to do more of this. I want to do this all the time. This is different from just watching. I can’t imagine how good it will feel when I can do more.

The surgery department chair was making a speech to people interested in surgery (yes, that now includes me), and he was emphasizing that residency is for teaching people when not to do surgery. He said, “There is an indescribable joy to doing surgery. . .” This, from a dried-up old man. I’m beginning to discover why surgeons always want to be in the OR; why, if you consult a surgeon, he will almost always recommend surgery; why they move so fast when they’re out of the OR, to get back into it.

So now I’m beginning to wonder if I shouldn’t do surgery instead of ob/gyn. The main drawbacks are: babies are still very exciting; ob/gyn residents get to operate earlier (apparently surgery interns are barely ever allowed in the OR); and surgery is five years long. And here I thought I was going to avoid having to make decisions; I thought everything was settled.

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