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Seeing Surgery From The Inside Out

Mon, 09/16/2013 - 3:56pm
Bruce Campbell, M.D., Medical College of Wisconsin Otolaryngologist

Bumping the door open with my right hip, I enter the operating room, water still dripping from my elbows. Toweling off my arms, I visually survey the patient, the equipment, and the instruments.

A stack of papers on a table next to the door catches my eye. One of the residents has taken copious notes from textbooks and journals. On a single sheet of paper, he has created a step-by-step “how-to” guide of today’s operation from incision to closure. The listing is very, very thorough. I smile and make a mental note to use a different sequence whenever possible. 

How I loved learning all about surgery when I was a resident! I, too, had carefully summarized and underlined all of the surgical descriptions I could find. I had hoped that creating those lists would give me confidence. 

My attention returns to the operating room activity. I slip on my gown and gloves. While the nurse scrubs the neck skin, I make a final visual check of the patient, whose elbows and wrists have been carefully padded and tucked at his sides. A sheet has been positioned beneath his shoulders, extending his head and fully exposing his neck. I look again to make certain that the back of his head rests gently in a sponge support. I take in the entire room, noticing the lines, cords, and tubes, which connect to the patient. The sounds in the room – the hum, the beeps, the ventilator, the chatter – are all familiar and correct.

After stepping to the table, the technologist and I place the first of the sterile towels that will cordon off the rest of the body from the operative field. We add more and more sterile coverings until only the operative site is visible. The warming blanket comes to life and the drapes rise as heated air circulates between the patient and the overlying drapes.

The residents and a medical student join me around the table. After marking the proposed incision, I assume the familiar stance I will hold for the next two hours.

Finally, I place my hand on the patient’s neck, gently manipulating the enlarged masses below the surface. 

“Here,” I urge the trainees. "Feel the tumors and how they sit below the muscles. Can you appreciate how they move in relationship with the other tissues?"  The medical student wiggles the growths, simultaneously afraid of and yet fascinated by them. The older trainees move the tumors around with more self-assurance, yet I wonder what their hands are saying to them.

Now, I take my turn.

I take hold of the cancer. The patient’s taut neck skin below my fingers gradually becomes translucent and the room goes silent. Soon, the muscles, arteries, veins, nerves, bones, viscera, and the lymph nodes come into focus; I knead the tissues, gauging their textures and resilience, gliding the masses over the underlying structures, and testing their mobility to determine if they will yield to the dissection. I work my fingers along the normal landmarks to make certain that they are not affected by the tumors. The muscles and vessels intertwine with each other and with the invasive cancer. As my mind reconstructs the scene below the skin, I visualize how the completed surgical dissection will look two hours from now, once all of the structures have been cleared of nodes, fat, and cancer, and all of the tumors have been sent to the laboratory. 

The sounds in the room again reach my ears as I release my focus on the neck.

From this point, I can take hundreds of potential paths and arrive at the procedure’s completion. Across the table from me, the resident who created the step-by-step list stands ready, as well. I assess his level of anxiety. His cookbook method allows for just one clear path from start-to-finish.  I try to remember how I felt as a resident just prior to a major operation, but all I can recall is “fear.” For just a moment, I wonder what I did with all of those lists I carefully created.

The team is poised. The challenges of surgery and teaching remain thrilling; the anatomy remains elegant.   

"Ready?" I have already glimpsed the surgical procedure’s outcome. The knife hovers above the skin. "Let's begin."

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