This morning, I and the other student starting on the general surgery service looked at the list of operations this morning, and discovered that the chairman of the surgery department was going to do a six-hour surgery, to remove a strictured segment of esophagus, and replace it with a piece of distal colon. Since the other student was coming off the night shift, I agreed to scrub in on this one.

I was looking forward to a morning of being totally humiliated. Last Wednesday, I was the first student to be assigned to present, in a weekly case conference with this chairman. I was well-prepared, based on what I’ve seen all year at other case conferences. But by pulling out all kinds of rules I never heard of before (“Must not write down lab values; must know your patient so well that you can present the entire history, physical, imaging, and labs, without writing anything down;” “must include surgical history under history of present illness, certainly not under past medical history;” and so on) he managed to make me look very unprepared and amateur. I thought I was doing a good job of smiling, and not responding to his criticism; but the other students said afterwards that I looked angry at him; so I also learned that my face does a very bad job of saying what I tell it to.

Anyhow, after he finished ripping my presentation, he then took on all the other students, as they tried to make a differential diagnosis; and they didn’t come off very well either. So, I figured, if I walked into a long operation with him, without any preparation regarding the pathology involved (and it’s not a good idea to ask the attending what’s going on with the patient, because it looks like you’re trying to pimp him), and without much of a clue about the relevant anatomy, I would be toast for the rest of the day. And I would deserve it too, because of course every student on surgery ought to have every blood vessel and ligament in the abdomen thoroughly memorized. . .

The first good sign was when we met in the hall outside the OR, and he asked my name. I guess, if he didn’t remember my name, after I stood and glared at him (apparently) for half an hour last week, maybe he doesn’t remember the rest of it either. Then, in the OR, as the anesthesiologist was struggling with the lady’s difficult airway, the resident asked if I knew how to do Foleys in women. I do, to be sure; I’ve done four the last two weeks, plus countless numbers in men. Of course, with my luck, after saying I knew how to do it, I couldn’t find the most elementary pieces of anatomy, and took ten minutes and two sterile kits before I could get it in. I love surgical masks, they allow me to blush bright red, and bite my lips, without people noticing (I think).

The first four hours were spent in the abdomen, carefully dissecting through various adhesions, and then through all the layers of the omentum, and various bits of mesocolon, and the legendary ligament of Treitz (one of few subjects on which I would appreciate a question!), ligating all the arteries. The end result was to “mobilize” the stomach, and a section of the colon, near the splenic flexure. This piece was then cut loose using the amazing GI stapler gun; I have no clue how it works; but somehow it fits pieces of bowel together, and attaches them, so that you hardly have to cut or sew at all, to make an anastamosis. This section of colon was left with one major artery coming through its mesocolon. This was then rotated up, and attached to the top of the stomach. Then they closed the abdomen, and went to get a drink (amazing signs of humanity!) while the patient was turned over on her right side. They entered the left thorax by a “controlled fracture” of the seventh rib, which allowed the ribs to be spread wide. The left lung purposely collapsed, so you could see the heart beating, and the aorta and esophagus under it. At this point the dignified chairman began to be quite ecstatic, and showed things off to me and all the nurses, like a little boy with a new toy. He changes into a different person – a nicer one – in the OR; he loves thoracic surgery. So then they pulled the other end of the colon up, and cut out part of the esophagus, and stapled the end of the colon in, and she was put back together, just with two huge scars, and a chest tube.

The “lesser of two evils” part is that, about an hour into the surgery, some chance remark revealed that I don’t watch television. The chairman was astonished, and for the rest of the surgery he was making various jokes/inquiries about “Luddites.” He wasn’t really being mean, just amazed, and I would far rather discuss my family’s religious and cultural convictions, than the blood supply of the esophagus or colon. Perhaps that’s not studious of me; but it was easier. It also forestalled the point, about an hour from the end, where he became bored, and asked for jokes. Not getting any, he began to relate his own, which were generally of the kind best left untold.

I haven’t been able to write much on here about how fascinated I am by surgery, to the point that I’m seriously reconsidering my career plans, and struggling to remind myself why I was attracted to ob/gyn so much. But there was one point this morning, when I put my hand in to touch the heart and aorta, beating together, that I thought, this feels exactly like a uterus, so warm and smooth and wet, such strong muscular contractions. . . I think I’d better stick to OB. A heart open in the operating field is amazing; but a baby is still more miraculous.