My surgical Blog & More

This has always been a tricky situation.  In the past 2 years I have seen 3 patients with clinical signs of peritonitis. They had a visibly normal looking X ray chest and Abdomen but  Ultrasound revealed moderate amount of free fluid in abdomen. On closure inspection of X ray chest all the patients had strong suspicion of free gas under left dome of diaphragm, which was distinctly separate from the fundus gas shadow. This was later confirmed on plain CT abdomen. All patients had ileal perforation as the intra-abdominal finding.

I first met this boy of about 14 one week back. He had come with a severely ill patient; he was diagnosed as a case of massive  liver abscess with jaundice with hepatorenal failure. Patient was in hypovolemic/septic shock. He was already turned away (or he ran away) from 2 previous hospitals. The patient was admitted but there was no one except this boy with him. Two relatives showed up later but refused to take care of the patient, they turned out to be distant relatives. The dillema wa that there was no one to explain the prognosis to. It was real bad..

We had to start him on ionotropic support and and aspirated about 500 ml pus from the liver. Blood transfusions and the usual supportive care was given and patient showed gradual but limited improvementThe relatives kept coming in short bursts but showed no real interest.

T o be cont..

The patient’s condition deteriorated and he started having intraperitoneal bleeding and hypotension. Blood was transfused and symptomatic care was carried out but we could not revive the patient. He died in the ICU 1 week after the admission. The young boy did not flinch through all this and was very strong. he had nowhere to go after the death of his father and he told us he could not go back to the relatives.

Later we heard that he went to his grandfather in a nearby city.

Surgery residency is not only about slogging and sulking, there can be a bit of humor too. Take a look at this

1. Big surgeons make big incisions.

2. It was dry when i closed it.

3. I love to operate, you manage the post op period.

4. If you dont find something you are looking for, find harder, Everything is in books

I never realized it would be so tough. Although i have a few publications I never imagined it would be this tough to write one again. The previous few days I was busy gathering and sorting out all my clinical photographs and found quite a few interesting ones. I decided to write a few case reports, although i finished one in 2 days, but it was hard. Checking and maintainig all the refrences was tough. I hope it gets published though.

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1. Never rely on the diagnosis and opinion of your juniors. Seniors are right most of the time in clinical diagnosis.

2. Check the instrument/sponge(atleast) after the floor nurse announces “Counts Complete”

3. While operating listen to the surgeon assisting you. He’s seeing things you cant see.

4. Respect tissue planes, take time off to tie bleeding vessels

5. Most important two words  Be patient

The eyes cannot see what the mind doesnt know. Fortunately for the modern age surgeons, the mind knows a lot or maybe we like to think that way. Surgery or as a matter of fact MEDICINE is a dynamic field, things are evolving every day.The principles we follow today may become irrelevant 5-10 years hence. New innovative ideas and enormous amount of research work may lead us to an era where we are able to offer surgeries with minimal morbidity and mortality. Robotic surgery and Tele conferencing surgeries are already being carried out. Maybe in a few years time surgeons would operate sitting in a console room controling Robots doing the actual work. Infact surgeries are being done using MRI to give real time information about the blood vesses and anatomic stuctures.

All this development comes at a price ofcourse, the scientists of the 19th and 20th centuries have toiled hard and some even gave their lives for their passion and work.

Marie Sk?odowska Curie (famously known as Madam Curie) died of aplastic anemia obviously unaware of the hazards of radioactivity she discovered.

In the discovery of Helicobacter Pylori, Marshall swallowed live bacteria to prove their existence and fullfill the Koch’s postulates.

Numerous dedicated doctors and scientists have worked very hard in the best years of their lives to bring medicine to the state it currently is.

But we can not sit back and enjoy the moment, still a lot of research work has to be done, New diseases like AIDS, Hepatitis C , most of the cancers have no cure. New innovations are coming up regularly and I am sure the day is not far when we have cure for the incurable.

I am in this field from 2001, thats almost 7 years and have a fair bit of idea about different type of surgeons. The one thing common in all of them is their ego and desire to do things in a different way.

In my 1st year as a junior resident, I was confronted by two senior residents, one was considered to be very good, the other one was just average. The 1st one was a perfectionist and liked to do things exactly as they were written in the books, the 2nd one hardly ever cared.

Then there was an assistant professor, he used to sing songs in OT when he was nervous or when extremely happy. Some of the songs were awesome and I used to add them to my playlist immediately.

Then there was my thesis guide, he was extremely well behaved with everyone in the OT and was an excellent surgeon, respected by everyone.

There was another one; just an average surgeon who thought he was the best. He used to look up frequently to see who was admiring his skill and handywok.

Later in my 2nd and 3rd year I had a unit head who had very limited or outdated knowledge and used to prefer thyroid surgeries.. He was a good speaker and initially everyone was highly impressed. Only after a few weeks you would know what a jerk he was.He used to make up OT table stories and we had to put up a straight face. The moment he left everyone used to burst into spontaneous laughter.There were evenings dedicated to him and we would just sit and talk about his stories. (He was a nice person thiough).

After My post graduation I worked a bit in Cardiac surgery unit and was confronted with two surgeons of extremely opposite nature..

To be continued

One was extremely confident and sure about the work he was doing , it was fun to work with him , the other one it seemed was highly distressed while working, he was not very proficient in his work and always used to find excuses to blame us for his mishaps.

I have already come to a conclusion in my short career, no matter how the surgeon is inside the theatre, he would always be a different person outside it.

One of my juniors said this to me when I demanded why a few simple things could not be done on time. We were all overworked, As post graduate students we were in the hospital for upto 60-70 hours at a stretch on every 3rd weekend. (24 hours sunday + 24 hours monday + 8 hrs OR on tuesday

sleep in the ward 3 hours + postoperative round 9 pm Tuesday)

At that time I didnt give this remark much attention but now I realize how right he was. How can a hospital system in which the three working residents( who havent slept for 18-24 hours ) provide effective services to their patients. Of course these things are understood by everyone concerned still no effective action is taken.

To be cont…

To continue rest of the thoughts…

Of course all our consultants know about the kind of physical and mental stress a resident has to go through, yet they choose to ignore it with the simple “We have undergone the same thing during our residency days” Point is taken but what about the patient load. Was it still the same as it was 10 years ago.

Answer is a an owerwhelming NO. You cant expect to treat patients the same was you were  doing 6-10 years ago.

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Every time i come out finishing a laparotomy, relieved though i am There are numerous “What ifs” in my mind. The system I work in is not certainly the best in the world and there are certain areas in which mistakes can occur.
Like for example we always forget to take the critical “time off ” before surgery to correctly identify the side and organ to be removed. The floor nurse is hardly visible except at the time of the final counts and the scrub nurses keep rotating if the surgery is long. Obviously they all are very efficient in their work and so far no mistakes have occured but we need to strenghthen our thoughts and minimise the mistakes.Blog Portal

This one is a real interesting case I have in my ward. She is a 35 year old lady with history of upper abdominal distension after meals.2 years ago she had features of gastric outlet obstruction and was operated in a govt hospital outside. No records of the previous surgery are available.
Now she has a small upper midline scar and scars of 4 laparoscopic ports. ( We are assuming lap assisted gastrojejunostomy was done). She has distension abdomen with bloating and a pelvic mass with ascites.
CT abdomen shows thickening of the pylorus and is suggestive of bilateral ovarian mass (Krukenberg’s tumor). Barium meal is suggestive of dilated stomach with an irregular ulcerative growth in the antrum.
Endoscopy was done which showed normal mucosa and two normal openiings.Palliative Surgery is being planned to relieve the upper abdomainal symptoms followed by B/L salpingoophrectomy and hysterectomy.

Surgery was done today, there was a growth in the antrum with malignancy spreading to the GE junction. Previous surgery was just gastrojejunostomy which was infiltrated by tumor.

We did a palliative partial gastrectomy with roux en y gastrojejunostomy.It was followed by Bilateral salpingo oophrectomy and hysterectomy.