Thursday, October 1, 2015
It was Friday afternoon and I was on call for the weekend. Dr. A. from the ER was on the other end of the phone.
I really don’t feel like working.”
“I’ve got a good case for you,” she began, “Mickey M., forty five, no medical problems has had abdominal pain for four days and CT shows a large amount of free intraperitoneal air.”
“Is he stable?” I asked.
“Vital signs are normal, no fever, white count is eighteen thousand, but…”
There’s always a but.
“…he weighs four hundred and ten pounds.”
“Okay,” I sighed, “I’ll be there to see him shortly.”
A good case?
I called the OR and scheduled him for surgery and then walked across the street to see Mickey.
At least he had the courtesy to come in at 1:30 in the afternoon instead of midnight.
Mickey was large in every sense of the word. He was six foot three, his belly was almost as tall as he lay on the ER stretcher, his face was flushed and he was a little sweaty and a more than a little short of breath.
His numbers didn’t look that bad: heart rate 90, Blood pressure 145/85, respirations 24, oxygen saturation 97% on room air, temperature normal. He had never had previous surgery, took no medications. He winced when I tapped his abdomen.
Besides the elevated white blood count he was anemic with a hemoglobin of 9.2.
The CT Scan of his abdomen revealed inflammation around the sigmoid colon with free fluid and air.
“Perforated colon,” I explained to Mickey, “which will need surgery today. Most likely the cause is diverticulitis, but it could also be a tumor. We’ll probably need to do a temporary colostomy also.”
“Whatever you need to do, Dr. Gelber, just make the pain better,” he answered.
Funny thing about peritonitis; nobody that truly has generalized peritonitis ever says “I don’t think I want any surgery.”
Mickey was wheeled into OR ten about an hour later. A generous midline incision was made and, upon entering the peritoneal cavity, the surgical team was greeted by the foul odor of stool and pus which began to well up into the wound.
Ah, the fine smell of festering stool. A fine way to start my weekend.
“Suction, cultures, more suction,” I called out as what seemed to be gallons of fetid, infected fluid were evacuated from his abdomen. There were thin adhesions between the loops of dilated small bowel which were broken with light finger dissection. This small bowel kept trying to insinuate itself between me and the source of Mickey’s woes. The inflammation led me deeper and deeper into the lower abdomen and upper pelvis until the culprit was isolated: a perforation in the colon at the rectosigmoid junction.
The small bowel was packed out of the way as I prepared to attack the evil villain who had fouled poor Mickey. The attachments of the left colon were divided to help me approach the area of perforation. As I carefully dissected, the small bowel decided it should try to help and escaped the barrier of lap pads which vainly tried to contain them out of my way. I packed the small bowel out of the way again, this time using a wet towel instead of mere lap pads. I next did my best to identify the ureter and I was pretty sure I saw it as I gingerly searched beneath inflamed layers of fat and fluid.
My hands, then forearms, elbows and almost my shoulders disappeared into the depths of Mickey’s abdomen as I did my best to dissect below the area of perforation.
Maybe I should have someone tie a rope around my waist so I don’t get lost in this pelvis.
“There’s a mass here,” I announced to no one in particular as I managed to bring the diseased segment of bowel out of the pelvis.
At this point the resection proceeded quickly. The proximal colon was divided with a stapler, I managed to get a stapler below the area of perforation and the bowel was divided and stapled closed. The mesentery, which contains the blood vessels, was divided with the usual clamp, clamp, cut and tie of most bowel resections and the rectosigmoid colon was removed, thrown on the back table to be examined later.
I checked Mickey’s abdomen for bleeding, looked at the ureter again and then washed out his abdomen with bucket after bucket of warm saline solution. Once I was satisfied that Mickey was clean I examine the resected specimen.
It was about twenty centimeters long. About five centimeters from the distal end there was a hole about one centimeter in diameter. There was a hard mass just distal to this hole. I opened up the bowel and saw the tumor, ugly, ulcerated, almost filling the lumen.
“Not good for Mickey,” I concluded. “Maybe all the stool in the belly killed any cancer cells that may have escaped.”
Time to get on with the surgery.
“Three O Prolene,” I requested. The blue Prolene sutures are used to tag the end of the rectum, making it easier to find should I came back in the future to reverse the colostomy Mickey was about to receive.
A colostomy is where the colon is brought out to the skin surface. Stool then passes into a bag, rather than its normal passage through the rectum and into the toilet. The bag is necessary because there is no sphincter muscle to control when and where the stool will pass.
Mickey stayed on a ventilator overnight. His recovery was remarkably uncomplicated, considering how sick he should have been, He left the hospital nine days after his surgery.
One week later he rolled into my office, smiling, feeling quite well.
“I feel great, Dr. G,” he reported, “no pain, everything’s working.”
“That’s great, Mickey. You look good,” I answered as I took out his staples, perused his colostomy stoma, and palpated his rotund belly.
“When can I get rid of this bag?” he asked.
“Well, you need to heal a bit more and I think you’ll need chemotherapy. The pathology report says there was cancer in two of your lymph nodes and the cancer was perforated. We’ll get you an appointment with Dr. H to get his opinion about chemotherapy. After you’re done with chemo, and assuming everything else is OK, we can schedule surgery to reverse the colostomy. I’ll see you again in about a month.”
And I sent him on his way.
Should be about six months until I have to tackle that belly again.
It was about 5 weeks later that Mickey’s wife called my office and reported that Mickey was bleeding from his colostomy, mostly dark blood, but sometimes bright red. As an afterthought she added that he was having intermittent drainage from the midline wound through a tiny, pinhole opening.
“Bring him in,” I responded.
An hour later the massive form of Mickey along with his diminutive wife graced exam room three.
“So, tell me what the problem is, Mickey,” I began.
“Just take a look,” he answered and he pulled up his shirt.
His colostomy bag was full of thin dark, bloody fluid. The skin was retracted, although he had done a good job of keeping his appliance in place. Adjacent to the colostomy his midline wound had a gauze dressing which was stained with yellow brown fluid.
“You’re right, you are definitely bleeding. When did this start?” I asked.
“Two days ago. I’m not having any pain, Oh, and the colostomy doesn’t stick out any more. It’s been quite a chore getting the bag to stay.”
“Well, I think you need to be back in the hospital; I’ll get the GI doc to check out your colon to figure out why you’re bleeding.”
Please be something simple, I’m not ready to attack Mickey and his bowels so soon.
As he stood up to leave I immediately figured out the problem. Mickey’s big belly hung down about eight inches below his belt line. Following his belly was his colostomy stoma, except his poor colon was tethered by its blood supply, causing it to pull on the skin. The stoma retracted under the skin while the blood vessels were stretched.
The final result was a portion of colon which was both congested and ischemic leading to the dark bloody drainage. The retracted stoma allowed the stool to collect beneath the skin level and form the sinus tract which was draining through his wound.
I shared my thoughts with Mickey and his wife and tried to formulate a plan to correct the problem, something simple I hoped. Alas, it was to be everything but simple.
Once he was safely ensconced on the surgical floor at the hospital, Mickey stayed mostly in bed and the bleeding abated. My friendly neighborhood Gastroenterologist was consulted and colonoscopy scheduled.
I sat at Mickey’s bedside and presented my plan to him and his wife.
“It’s a little earlier than I’d like, but the simplest way to fix this problem is to reverse your colostomy,” I explained.
They were both in agreement, his colonoscopy checked out OK and surgery was scheduled for the following day, Friday.
It was noon when Mickey was rolled into OR five. He scooted from stretcher to table like a lithe teenager and, in short order, the operation began.
The midline incision was made and the peritoneal cavity entered in the upper abdomen, above the area of his previous surgery and, I hoped, any adhesions.
Maybe this won’t be too bad.
As if to punish me for having such thoughts I ran into the proverbial wall, or, in this particular case, net of adhesions. Omentum plastered to colon which was wrapped around small bowel which filled the pelvis. No blue sutures to tell me where the closed off stump of colon was hiding, but also, no cancer.
Minutes rolled into hours as I inched my way around bowels, omentum and adhesions, finally spying one of my Prolene sutures after more than three hours of chiseling away.
I’m supposed to be doing a gallbladder in ten minutes.
“Could you please call ‘elsewhere hospital’ and let them know I’m late. I may be there by four or four thirty,” I requested of my kind circulating nurse.
“Maybe doing this surgery earlier than planned was a bad idea,” I remarked out loud to no one in particular.
“Looks like we’re almost there,” my assistant commented as more blue suture popped into view.
Sure enough the blue sutures which would lead me to the closed off stump of rectum now loomed large in front of me. A final snip freed the last loop of small bowel, which was then examined from beginning to end and safely tucked away.
I now stared at a long tunnel which was Mickey’s pelvis. Down in the depths was the object of my intentions: a stump of rectum which I hoped would accommodate the EEA stapler.
The proximal colon was dissected free from the abdominal wall and the big moment arrived.
The EEA stapler is a clever device which fires two rows of staples while cutting out two donuts of tissue between the circular staple lines. This leaves an opening between the two organs which have been stapled together. I find it most useful for constructing anastomoses at the ends of the GI tract, those involving esophagus or rectum.
This stapling device has a detachable part call the anvil which goes into one end of the colon, usually the proximal portion. An opening is made and the anvil is passed through this opening which has had a “pursestring” suture placed which is tied around the “anvil”, closing the colon wall around this anvil.
I’ll get one shot at this, it better work.
Mickey’s bottom had already been prepped and I began the process of passing the stapler. First the anus was stretched with a series of lubricated metal dilators up to a size adequate to allow passage of the stapling device. After the device has been inserted it is guided to the proximal end of the closed off rectum. The stapler is then opened and a spike appears which pierces through the closed off rectum and is connected to the anvil. The stapler is tightened and fired and then withdrawn.
The big moment arrives as the stapler is opened and the donuts removed. In Mickey’s case the donuts looked complete, but very thin on one side. I next checked the anastomosis to see if it was airtight. I filled Mickey’s pelvis with water so that the colorectal anastomosis was completely submerged. Next, I instilled air into the rectum and watched for bubbles. If the colon inflates, but there are no bubbles released, then the anastomosis is airtight. Bubbles percolating through the water mean there is a hole somewhere.
Much to my disappointment, a large number of bubbles appeared.
Now what? Do it again? You had one shot and you blew it.
Maybe do another colostomy? But, what about his big belly? Problems, problems, always problems. Only skinny people should be allowed to get sick. At least they should pay us by the pound.
“We’ll need to do a transverse colostomy,” I announced to the OR crew.
I decided that creating a loop colostomy in the upper abdomen would minimize the pendulous abdomen issue while allowing my newly constructed coloproctostomy (colorectal anastomosis) the time to heal.
The new stoma was constructed with my usual workmanlike efficiency and Mickey was closed up. I had spent five and a half hours in Mickey’s belly, battling large and small bowel, scar tissue and fat. As I pulled off my gloves I felt a tightness in my knee, a common occurrence after long surgeries which command my utmost attention for a long period of time. Over the years I’ve discovered that cases like this which require concentration to the extent that I forget to move or change position, block out much of what is happening around me, be it my cellphone or music which may be playing or the beeps and chimes coming from anesthesia’s machines. The patient increasingly becomes my only focus as I become oblivious even to the pain which grows in my knee.
I wish I could say that every patient requires such intense concentration, but that wouldn’t be true. Most surgeries are straightforward and, thank God, uncomplicated, such that this level of concentration is not necessary. If every case was like Mickey, I don’t think I would still be practicing surgery.
Mickey recovered uneventfully. Three months later I checked his colon and found that the anastomosis in his pelvis had completely healed. He underwent an uncomplicated reversal of the transverse loop colostomy. I felt fortunate that I could stay out of his big abdomen and avoid further skirmishes with his bowel.
He has remained cancer free to this day.
Monday, September 7, 2015
Our lives are full of firsts.
Parents wait for their baby’s first tooth, first words and first steps.
We may remember our first day of school, first solo bicycle ride without training wheels, first automobile drive, first date, first kiss, first sexual encounter and others that I don’t recall at the moment.
A surgeon also has firsts.
I clearly recall the first surgery I ever saw. Now, you might think that because I am the son of a surgeon that my childhood was replete with trips to the hospital with my father where I accompanied him into the OR and became his right hand man at the age of thirteen.
On rare occasions I did go to the hospital with my father when he made rounds, but the closest I ever got to an operating room was sitting on a bench outside the gift shop, watched over by the volunteer behind the cash register while my father went upstairs to see his patients.
There were occasional conversations at the dinner table which delved into the world of surgery:
Dad: “Dr. A, the anesthesiologist, is getting a divorce. Isn’t his wife, Betty, in your Bridge Club?”
Mom: “She’s the reason the bottle of Scotch is almost empty.”
Dad: “Well, she was sleeping with Dr. K while Dr. A went off and spent a weekend with one of the nurses in the OR.”
Mom: “I guess I’ll need to somebody new for the Bridge Club, one who doesn’t like Scotch. Anything new at work?”
Dad: “My new office nurse is pregnant.”
Mom: “You mean the one who said she hadn’t been able to get pregnant for two years? She’s only been with you for two months.”
Dad: “I guess some of the Gelber fertility rubbed off on her,”
Mom: “That’s the third nurse who’s gotten pregnant in the last eighteen months. And, none of them had been able to get pregnant before.”
Dad: “It must be something in the air.”
There have been many important “firsts” over the years. I remember my first day of medical school when I was introduced to Herman, my anatomy group’s cadaver, a constant companion through the first semester and Sigrid, last name Gelber, my lab partner, adopted sister and friend through medical school and afterwards until her death from breast cancer at the far too young age of 35.
Then there was my first day of Internship, a Sunday, when I arrived at the hospital where I was greeted by a list of patients and instructions from my second year resident to make rounds, do the necessary H&P’s on the new admissions and he would see me the next day. This particular resident, not surprisingly, was fired before the year was out and is now tormenting surgeons as an anesthesiologist.
It was in medical school that I actually witnessed my first operation. I was assigned an advisor, Dr. C. Nelson, a Neurosurgeon. His job was to smooth the transition from the rigors of college to the even greater exactitudes of medical school. I don’t remember much of what he did, except that he invited me to watch an operation. He was performing a transsphenoidal resection of a Pituitary tumor the following day. Finally, something more than the formaldehyde of anatomy and squinting into a microscope in Histology.
I managed to find my way to the OR assisted by an OR nurse who directed me to the locker room where I donned the blue surgical scrubs of Strong Memorial Hospital, 60% Cotton, 39% Polyester and 1% stainless steel.
I managed to find my way to the OR room where the operation was about to commence. I managed to come within six inches of contaminating the scrub tech’s back table, while I looked upon the patient, prepped and draped with her upper lip pulled back, exposing her teeth and gums.
“This patient has Nelson’s Syndrome caused by a tumor in her pituitary gland,” Dr. Nelson explained. “We’ll approach the pituitary through her sphenoid sinus, which is behind her maxilla.”
I nodded my head, then asked, “Is Nelson’s Syndrome named after you?”
“I wish,” he answered, “that was a different Dr. Nelson.”
I watched as the Chief Resident began the surgery, incising above the teeth, removing bone and finally reaching the pituitary gland. An operating microscope was wheeled into position and Dr. Nelson began the real operation. I was able to watch through a second teaching port.
I saw some reddish tan stuff and then some yellow gray gunk and then I saw Dr. Nelson tease the yellow gray gunk away from the reddish tan stuff.
“The thin grayish tissue is the adenoma. She’s making too much ACTH which is causing her adrenal glands to secrete too much cortisol, resulting in her having Cushing’s disease.”
“I thought you said she has Nelson’s Syndrome?” I asked in my ignorance.
“Nelson’s Syndrome is causing her to have Cushing’s disease,” he explained, displaying far more patience than I deserved.
After a few hours the operation was finished. The Chief Resident closed her up, sealing the surgical site with some fat and superglue.
“It looks painful,” I commented as he glued the bone back in place, while I considered what it would feel like to have someone cut me along my upper gums.
“Surprisingly not,” the Chief Resident responded.
“How do you learn to do such an operation,” I wondered out loud.
“I take notes, read about the technique, assist on cases and then do the surgery,” he answered. “It’s all about studying and observing.”
One thing he didn’t mention was innate talent. When I finally began doing surgery I realized that natural ability and technical skill was something that could be taught only to a certain extent. Truly great surgical technicians are born, not made.
It was years after this first experience with surgery that I actually performed my first real surgery. It was my first month of internship and I was on call when Peter was admitted to the “Resident’s” service. He’d had pain for three days, with nausea, vomiting and elevated White Blood Cell count. He had exquisite tenderness in the Right Lower Quadrant of his abdomen. Peter was a textbook case of acute appendicitis.
It was about seven pm when my Chief Resident, Dr. S and his Attending, Dr. T. joined me in the OR for Peter’s appendectomy. I had read the book on appendicitis and studied the technique over and over.
The surgical tech handed me the scalpel and I began to make my incision.
“Your shaking like a Goddam Parkinsonian,” commented Dr. T.
I did shake a little, but not enough to interfere with the actual surgery.
Once the incision was made, I switched to the electrocautery and buzzed the bleeders in the skin edge and then made the incision deeper until I saw the diagonal fibers of the external oblique fascia. Just like in the book I incised in the direction of the fibers and retracted this muscle.
“Take a Kelly clamp and split the muscle of the next layer along the direction of their fibers. First with the muscle, then perpendicular to it, so that it spreads apart. By the way, which muscle is this?” Dr. S asked
“Internal Oblique,” I answered without losing a beat.
“Right. If you didn’t know, then I would have to take over the surgery,” He added.
The Internal Oblique and Transversalis muscle fibers were split apart exposing the peritoneum.
“Clamp,” I requested.
The scrub tech slapped it into my hands, just like in the movies.
I picked up the peritoneum with the clamp.
“Another clamp for my assistant,” I said, a bit too softly.
“Another clamp for my assistant,” I replied, much more loudly.
“OK, OK, you don’t have to yell,” the tech added.
I opened the peritoneum and some cloudy fluid poured out.
“Culture,” I said loudly and I was handed a swab.
“Now, put your finger in and see if you can feel the appendix,” Dr. S instructed.
“I feel something hard,” I replied.
“Let me check,” he suggested as he put his fingers through the opening in the peritoneum. “That should be the worm (nickname for the vermiform appendix, the complete name for the appendix); see if you can flip it up into the wound.”
I put my finger in and swept it around the offending organ and it came into view. It was swollen to the size of a Hebrew National Knockwurst.
“Don’t grab the appendix,” Dr. T. barked. “Find the cecum.”
Years later another Attending surgeon, Dr. Bronsther taught me this one surgical nugget about appendectomies, the only thing I ever learned from him.
“Appendectomies are surgery of the cecum.”
What he meant was that the appendix always arises from the cecum, which is the first part of the colon. It is always found where the three Tenia coli, which are the three longitudinal muscle layers which are seen on the colon, coalesce. Over the many years I’ve been doing appendectomies, these two pearls of wisdom have served me well.
Back to Peter. I identified the Cecum and gabbed it with a Babcock clamp and delivered it up into the wound. Once enough of it was protruding through the wound, I grabbed it with a sponge, rocked in back and forth until the entire cecum popped into the wound, followed by the very swollen and inflamed appendix.
Now it was time to actually do the surgery, that is remove the sick organ.
“Wait, wait,” Dr. S. said forcefully.
The three of us stared at the swollen appendix, greatly enlarged all the way to its base. The normal procedure would be to divide the mesoappendix, which carries the appendiceal artery, ligating the blood vessels, then divide and ligate the appendix close to the Cecum, usually leaving a small stump. There was controversy in those days about inverting the stump or merely tying it. The consensus was that simple double ligation was appropriate. Inverting the stump potentially created future problems.
“Start with the mesoappendix?” I wondered out loud.
“Right,” Dr. S. agreed.
We clamped along the fat which led to Peter’s appendix and then tied each blood vessel within the clamp until the appendix was free from any attachments all the way to the Cecum. There was a short segment, about three millimeters, of normal appendix.
“Clamp it there?” I suggested, pointing to the uninflamed stump.
“Yeah, but use a Kelly on the appendix side,” He added.
Clamp, clamp, cut and that sick appendix was gone.
“O Vicryl tie?” I requested, a touch of doubt in my voice.
“Right,” my assistant agreed and we’ll need some 2-0 Vicryl stick ties, also.
We tied off the appendiceal stump and then sutured the cecum over this ligature. I admired my handiwork for a moment.
“Put it back where it belongs, Dr. Halsted,” Dr. S. ordered, “the patient’s not getting any younger.
I closed him up, irrigating and suturing each layer before stapling the skin closed. Peter was wheeled off to Recovery as I trailed slightly behind holding his chart and sporting a big grin on my face. He went on to an uneventful recovery.
Years later, during an interview, I was asked about my most memorable moments. I cited two:
My wedding day and Peter’s operation.
Wednesday, August 26, 2015
It was 4:45 on a Wednesday afternoon, clinic had just finished and I’d be on my way home in fifteen minutes, unless…
Rats, it’s the emergency room.
“Dr. Gelber, we’ve got an 85 year old lady from the county nursing home with a distended abdomen. Could you come and take a look at her?”
So much for going home on time. You think they could have waited fifteen minutes.
I made my way to the surgical side of the ER and found Madge. She was a wrinkled old lady, weighed in at 102 pounds, white hair, black glasses which magnified sharp blue eyes. Her most distinguishing feature at that moment was a belly that was the size of a medicine ball.
“Hello, Ms. W, I’m Dr. Gelber. How long has your abdomen been so blown up?”
“Glad to know you Dr. Gelber. Call me Madge. This old belly’s been growing for the last five days. I think it’s a boy.”
“Well, Madge, I think we’ll need to deliver it soon,” I answered. “Are you having any pain, nausea or vomiting?”
Her look turned a bit serious as she answered, “Mostly pressure, not really pain and a little nausea. And, I haven’t pooped in a week.”
“Passing anything out? Gas, diarrhea?”
“Nope, not a toot or tweet for five days.”
She had a collection of associated medical problems, typical for your average octogenarian. She had a little hypertension, a bit more congestive heart failure, atrial fibrillation, myocardial infarction a year ago, previous hysterectomy, nothing unusual, but enough to cause the Cardiologist to say she was at considerable risk for complications. She had mild abdominal tenderness, but her abdomen was tight as a ripe watermelon and about the same size. Her heart was beating at a rate of 124, blood pressure was 85/50.
Plain abdominal X-rays revealed massively dilated colon. In particular, the cecum (first part of the colon) measured eighteen centimeters in diameter, well beyond the 12 centimeter diameter when one begins to worry about it bursting.
I called my Chief resident, Dr. J, who deferred to the Chief on call, Dr. B., who came to see the patient and then disappeared. In the meantime I did all the paper work to get Madge admitted and prepared to go to the OR.
Her diagnosis was acute large bowel obstruction.
“At last I get to be around some young blood,” she commented as I finished my H&P. “All the men at AHP (the nursing home) are wet noodles, if you get my drift; you know soft and limp. Maybe, when I’m better, you can show me around the hospital, Dr. G?”
“Let’s get you better first. But, I don’t think my wife would appreciate me carrying on.”
“She’d never know. Besides I don’t see any wedding ring.”
I glanced at my naked finger.
“I don’t wear it. Too much taking it off and putting it on. I’d lose it in a week.”
Dr B. returned and he said a cecostomy was in order, under local anesthesia.
“I guess you talked to the Chief?” I asked.
Our Chairman, Dr. Di was a staunch proponent of cecostomy in this situation.
We took her up to surgery and performed the cecostomy, which means decompressing her cecum by placing a tube into it, under local anesthesia. The cecum was massively distended with the muscle fibers of the outer layer split apart by the distension, but there was no gangrene or perforation. It was the size of a volley ball. After it was decompressed it looked much healthier. The tube was left connected to a drainage bag and Madge went to the ICU.
Her journey was just beginning.
Over the next forty eight hours she stabilized. Her vital signs, renal function, lab abnormalities all normalized. She was ready to embark on the next stage of her odyssey.
The next step was to figure out the cause of her severe distention. Based on the tests that had been done, the assumption was that she had a mechanical obstruction on the left side of the colon. The most likely causes would be a tumor or narrowing secondary to diverticulitis. There was an outside possibility she had suffered from Ogilvie’s syndrome, otherwise called colonic pseudobstruction, although the initial X-Rays were more suggestive of a mechanical cause.
She was wheeled from the ICU to Radiology where she underwent a barium enema (BE), a test where a radiopaque dye is instilled into the colon and X-rays are taken at various points. This provides information as to the length, contour of the colon, demonstrating areas of narrowing (stricture) or dilation. Large tumors also can be seen with this test. Madge’s BE revealed an abrupt termination of the column of dye in the distal sigmoid colon.
“She’s going to need another operation,” I told Dr. B.
“Try to prep her using the cecostomy and we’ll try to do her surgery in three days.
It fell on me and my junior residents and interns to begin to flush her colon with saline every few hours, attempting to clean the abundance of stool trapped within the obstructed colon. The hope was that a clean colon would allow for a single stage resection and anastamosis, avoiding a colostomy and the necessity that she wear a bag.
It was a tedious job. Instill a few hundred cc’s of saline and let it drain, add some more and let it drain. At first it seemed hopeless as we kept getting some light brown saline, but little else.
Through it all Madge managed to keep her sassy edge.
“You know, Dr. G, when I’m all better and back at the home you should come and see. I’ve got my own room and it’s so cold and lonely at times. All the men there are just wrinkled old prunes.”
“Let’s just get you well first, Madge,” I answered.
“Oh, I’m not worried about that. You doctors here are so hard working and caring and conscientious. Some are pretty sexy, too. I know I’ll be back on the dance floor in no time.”
“Were you a dancer, Madge?”
“Third prize in the Queens borough ballroom dance off 1919. Leon and me knocked them over with our cha cha. Poor Leon, he was killed a few years later; run over by a horse. He was the love of my life, definitely not a dried up prune or a wet noodle, if you get my drift.”
I smiled at her as I finished my flushing of her colon.
“One of my interns will be back a couple of hours. Sorry about Leon.”
She didn’t answer. She was staring off at nothing, a smile on her face, lost in memories of Leon and happier days.
After four days and flushing and draining, flushing and draining we pronounced Madge clean. By we I meant my Chief resident, the Chairman of Surgery, myself, the second year resident, the intern, four ICU nurses, the custodian and two cockroaches who called the ICU home. Her surgery was scheduled for the next morning.
It was a big event. Dr. B was operating with the Chairman, with the intern and second year resident on hand to provide proper retraction. I was left out to hold down the fort in the rest of the hospital, but I managed to hover around the OR to see what was happening.
The surgery started uneventfully, but, as the colon was examined the surgical team was greeted by a left colon full of solid stool. The plan for a single stage resection and anastamosis faded away in a column of poop as they went to plan B.
Madge’s sigmoid colon was resected, the end was brought out to the skin as a colostomy and the distal colon was closed off and left in the pelvis, a so called Hartmann’s pouch.
Madge came through the surgery without a hitch and was wide awake and ready to flirt when I saw her on afternoon rounds.
“Did you guys give me a nice flat tummy? I want to look good in my string bikini this summer,” she quipped.
“You’re already nothing but skin and bones,” I answered, “but you do have a colostomy now, at least for a while.”
She gave us a pout and look of disappointment, followed by a shrug of her shoulders as we continued on rounds. She had completed stage two of her journey.
Her recovery was uneventful and she was back tormenting the male residents of the nursing home in a little more than a week. She came back to the clinic a week later where she was seen by one of the interns.
“An ole lady named Madge is asking about you, Dr. G,” Intern reported. “She says you missed ballroom night at the nursing home.”
I made my way into her room.
“I really can’t dance, Madge,” I confessed. “Dr. B, now he can dance.”
“Well, I guess we can skip the dancing and go straight to bed,” she propositioned.
“I think you’re more than I can handle, Madge.”
And, she went on her way.
She made a second appearance in the clinic a month later, looking quite well, eating, walking, she even gained three pounds.
“When can I get fid of this shit bag?” she asked.
She was now about six weeks post op and she still had the cecostomy tube, which was clamped.
“Let’s get your colon checked and then we can think about reversing the colostomy,” I explained.
“Good, the sooner the better. Even the old prunes at the home won’t give me the time of day with this bag.”
I set her up for a colonoscopy the following week, to be done by me, one of the last colonoscopies I ever performed.
As she was wheeling back to the endoscopy suite she remarked:
“You really know how to show a girl a good time.”
I smiled, “We’ll take good care of you Madge and we’ll get you all put back together as soon as we can.”
“I like a man who whispers sweet nothings …” and she was out.
The colonoscopy was uneventful, revealing diverticular disease in the descending and proximal sigmoid colon. She was scheduled for reversal of her colostomy ten days hence.
“We’ll leave her cecostomy for now. It may add a bit of protection for her after the colostomy reversal,” my Chief decided.
At 7:15 am ten days later Madge was rolled into OR room 12. Miss C, our cranky, dour, and very experienced circulator and Mrs. J, our equally skilled scrub tech made up our crew along with Dr. B, me and one of our interns. The Chairman, officially the Attending surgeon on the case, sat nearby in the OR lounge. Dr. B was in the last month of his residency and was functioning independently and was acting as teaching resident on this case. I was to be the surgeon of record.
And so it started. A midline incision was made and we entered the abdomen, greeted by a few adhesions to the abdominal wall which were quickly and easily dispatched. The small bowel was examined and packed out of the way. The colon leading to the colostomy was identified and freed from scar tissue. All that remained was to find the other end of the colon, dissect enough of it so that the two ends could be connected.
It was like running into a stone wall. Madge’s pelvis, where the elusive segment of colon resided, was socked in, a mass of adhesions with tissues more resembling concrete than colon.
Where’s the colon?
Where’s the bladder?
Where are the ureters?
Where, oh where will I dissect next?
“Let’s find the ureters first,” I announced to no one in particular.
“Good plan,” Dr. B responded.
Starting higher up in the abdomen away from the dense mass of pelvic scar I began my search. The proximal colon which led to her colostomy was freed from adhesions first. Behind was a mass of small bowel. I commenced the tedious dissection of this small bowel.
“Do you really need to free up all the small bowel?” Dr. B asked.
“You know the rules: either you leave it all alone or cut away all the adhesions,” I recited.
“Ok, Ok,” he answered.
Like the barber/surgeons of old I began to snip and trim, starting where it was easy and them moving along centimeter by centimeter until, an hour and a half later, all the small bowel was free.
This actually was very helpful. Some of the bowel, as expected, had occupied the pelvis and now it was liberated and safely tucked away in the upper abdomen.
(I have to comment on my terminology, specifically the term liberated. It’s a bit tongue in cheek. I remember reading an operative note for a colon resection. The surgeon dictated that “the splenic flexure was liberated…” I immediately had visions of colons running through the streets chanting, “I’m free, I’m free…” the term “liberated” in this context always brings a smile to my face.)
Progress was slowly being made. With small bowel out of the way, the ureter was easily identified. The foley was palpable within the bladder and careful dissection behind the bladder revealed a staple line; the staples within the closed off end of the colon.
“I think I just need to dissect enough to be sure that there is only colon, no vagina or bladder”, I concluded.
My Chief disagreed.
“You need to be sure it is free enough so there is not tension and adequate blood supply,” he answered.
I disagreed, believing that the more the distal colon was dissected, the greater the likelihood that blood supply would be compromised or a nearby structure would be injured. But, I complied with his wishes. He was, after all, more senior, more experienced and had the power to make my life miserable should he so choose.
With the ureters safely in view and the bladder now out of the way I worked on the colon and rectum.
First, straight down to the sacral prominence, a safe area where there were no vital structures. Then in front of the colon, separating it from the posterior vagina.
“Is this free enough,” I wondered out loud, clearly conveying my view that it was more than enough.
I received nod of acquiescence.
The colostomy was quickly freed from the skin, the actual stoma was resected (removed) to provide a clean end to anastamose to the distal colon. It was immediately apparent that the two ends would not reach each other. More dissection of the left colon followed, which meant liberating the splenic flexure (there’s that image again) which allowed the two ends to meet.
“Use the EEA?” I asked, requested, implored.
“Hand sew. You know what they’ll say in conference,” Dr. B replied, alluding to the required presentation of the case at one, or several, of our weekly meetings where the cases done that week were presented and discussed.
“And, I’ll take the heat,” he continued, “not you.”
“Ok, I’ll sew it. But it won’t be easy. We’re pretty far down in the pelvis.”
I did my best to put the two ends back together. First the back wall of interrupted silk sutures, then the inner layer of continuous Vicryl, an absorbable suture material, and, finally, the outer front layer of silk.
Each suture placement was a chore as I endeavored to be precise; to be sure I caught the full thickness of the bowel wall, while not compromising the lumen diameter. When I finally finished, something just didn’t feel right.
“You know,” I commented, “something isn’t right. I just can’t be sure that the two ends have come together properly. Do you think the cecostomy will provide some protection for the anastamosis?”
“You know it won’t,” Dr. B replied.
“Well, I just don’t trust my anastamosis. Maybe we should do a proximal colostomy?” I wondered out loud, a bit facetiously.
Dr. B didn’t say a word at first. I suspected he was wondering if he should call the Dr. Di, the Chairman of the Department and the official Attending on the case.
“I’ll be back in minute,” he said and he broke scrub.
“Dr. Di agrees. We should do a transverse colostomy,” he announced when he returned.
While he scrubbed his hands again, I mobilized the right transverse colon and we created a transverse loop colostomy, fashioned so that it functioned to completely divert the fecal stream away from my pelvic anastamosis. We closed Madge up and she woke up without a problem, after five hours of surgery.
She sailed through the post operative recovery. Stage Three was over. She still wasn’t finished, however. Now she sported a tranverse colostomy and the cecostomy was not completely closed either. She was going to need at least one more surgery.
A month later I was walking past one of the exam rooms in the surgery clinic when I heard a familiar voice.
“There goes my young stud,” she cackled.
I made an abrupt U turn and went into the room where Madge was being checked by one of the interns.
“You know I’d be with you in a minute, Madge,” I answered, “but I’m spoken for.”
“Another broken heart,” she replied, “and I’m stuck with dried up prunes. And, I still have to wear this bag.”
“Let’s see,” I mused as I perused her chart, “it’s about six weeks from the last surgery. I think we may be able to do something about that in the next few weeks.”
I was Chief Resident now, so I went to talk with Dr. Di., who agreed Madge could have her next procedure in two or three weeks.
I examined her again that day. Her midline wound was healing well, the colostomy looked pink and healthy, but the cecostomy site still had not closed completely. There was a five millimeter open wound with some mucus draining.
“It’s getting smaller,” Madge commented, “doesn’t hurt a bit.”
She was scheduled for the seventh, which was in three weeks. Orders were written and she went on her way, with plans to be admitted to the hospital on the sixth, the day before surgery, when she would have all the necessary preoperative preparation.
The big day came and Madge said she would be happy to be rid of the bag. Of course she took the opportunity to offer herself to me one more time.
“After this surgery you must stop by and see me in my rook over at the home, Room 202. Every night it’s the same routine: dinner, television, the sounds of arteries hardening and saliva dribbling. Come by and see me. We can go dancing.”
And she winked at me as she was rolled into Room twelve.
This surgery was a straightforward closure of a loop colostomy. The actual surgery was done by my fourth year resident with me acting as teaching assistant.
The incision was made around the stoma and the dissection carried down into the subcutaneous tissue.
“Did you take your slow pill today?” I wondered out loud. My junior resident, Dr. T., was moving like a glacier, one cell layer at a time.
“Open your eyes and see,” I suggested. “There is a plane of dissection between the colon and the subcutaneous fat. The mesentery and the subq fat look different and, look, god has left a white line which says ‘cut here’.”
With a bit of guidance the fascia, the layer below the fat was finally reached.
“Now, dissect along the fascia so that the colon can be liberated (there’s that word again),” I instructed.
My words were greeted by a lost stare out into space.
“Right angle clamp, please,” I requested.
I hated to do it, that is take over the dissection, but, poor Madge was not getting any younger.
I dissected the colon free from the fascia using the clamp, allowing my junior resident to cut in between the jaws of the clamp, which provided some semblance of “doing the case.”
The colon finally free, it was delivered up into the wound and continuity restored via a two layered, sutured, side to side anastamosis.
“What next?” I asked as the fourth finished tying the final silk suture.
“Put it back inside, close her up and then make rounds?” he answered.
“Well, some people would consider that a right answer. If I were actually doing the surgery, I would tack some omentum over the sutures lines. It adds an extra layer of protection, although the way Madge handles surgery, I think you could have used paste to put her back together and it would have healed just fine.
The surgery finally done, after four tedious hours, Madge was tucked away in the Post Anesthesia Care Unit and proceeded through another smooth and uneventful recovery.
She did manage to proposition me on a daily basis until she was discharged once again.
I thought she was done with surgery. Four stages for the treatment of a colon obstruction was a bit unusual. One of the frequent discussions/controversies in general surgery was how to handle acute large bowel obstruction. Should it be a one stage procedure with resection of the offending segment of colon coupled with some sort of on the OR table bowel cleansing, a two stage procedure with resection of the diseased segment and creation of a temporary diverting colostomy, followed by a second operation to restore colonic continuity, or a three stage procedure with an initial diverting colostomy, a second operation to remove the cause of the obstruction and then a third procedure to reverse the colostomy.
Dear Madge had undergone four stages.
I saw Madge in the clinic a week later, healing quite well, eating normally, having normal bowel movements and overall quite satisfied. Her only complaint was persistent drainage from the cecostomy site.
“It should close, just give it some time,” I reassured her.
“I’m sure it will, Dr. G,” she replied and then she smiled at me. “of course, It might be best if you came to check on it over at the home a couple of times a month.”
I smiled back. Good old, dependable Madge.
“I think your coming to the clinic will be adequate,” I answered.
“Stuck with all the old prunes,” she murmured.
I saw her again a month later. She was still draining from the cecostomy site. As a matter of fact, the open area looked larger, with a bit of intestinal mucosa poking out.
“It looks like you’ll need another surgery to close up the cecostomy,” I informed her.
She shrugged her shoulders and nodded her approval. Then, as if sensing some disappointment on my part, she added, “Can I have a private room this visit? One never knows when a handsome young red headed doctor will come calling and try to take advantage of a girl.”
I smiled and said, “See you next week.”
The surgery came and went off without a hitch. My second year resident performed the surgery while I acted as teaching assistant.
We dissected around the cecum, following it down to the fascia, cutting away all the scar tissue and, finally, delivering the cecum into the wound. There was a 1.5 cm hole which was closed in two layers, then reinforced with a bit of fat before it was dunked back into its rightful home within the peritoneal cavity. We closed her up and she went to the PACU, for the final time, I hoped.
Sure enough, except for shifting her affections from me to the younger and handsomer junior resident, her post operative recovery was smooth sailing.
“I’m a little disappointed, Madge,” I explained to her on the day she was discharged, “you seem to have shifted your amorous affections from me to Dr. K.”
“Well, Dr G., I’m not getting any younger. You had your chance and you blew it. Besides, Dr. K is really hot,” she answered.
“Good luck, Madge,” I responded. “And, I say this with all affection, but, I hope I don’t ever see you on my OR table again.”
She smiled and nodded her understanding, but then added, “Do you have Dr. K’s phone number?”
“You’ll have to ask him yourself. I’m sure he’ll be around to see you before you leave.”
She sighed and then added, “I guess it’s back to the prunes.”
I did see her back in the clinic about a week later, one last time. She healed without a problem and thanked me for helping to save her life.
Her case had been different than most. There was no discussion about one stage, two stage or three stage procedures.
Madge had undergone a five stage procedure.
A few weeks later I had a meeting with our Chairman, Dr. Di, and I brought up her case.
“Remember Madge, the old lady who had the large bowel obstruction and had the five stage colon resection?” I asked the Chairman.
“She was a rat,” he answered, his response taking me by surprise.
“I thought she was very nice,” I answered.
“I don’t mean a rat, as in James Cagney, ‘you dirty rat’, sense,” he said in his grandfatherly tone. “No, I meant she’s a rat because she could be operated on over and over and never turn a hair.”
He explained further.
“Years ago there was an experiment done. A number of rats had surgery, all the same sham operation. After the first operation, some of the rats died. The survivors were operated on a second time and a few more died. The third time a few more. But, after a number of operations some of those rats just went on like nothing happened. You could operate on those rats every week and they wouldn’t turn a hair. They just woke up and went on their way.
“Madge was a one of those rats.”