“Will this case take very long?”
“If the surgery gods are with me we should be done in an hour.”
The above brief exchange took place between me and the anesthesiologist attending to my patient on a recent surgery. The patient was a middle aged woman who was about to undergo surgery to relieve a small bowel obstruction. She had been visiting her husband in a distant city where he was working and had become ill. She was hospitalized and after several days of testing surgery was recommended. Her husband was reluctant for her to undergo a major operation in a city far away from home and their regular doctors.
He drove her home against medical advice and she was admitted to the hospital. I was called in as a consultant and it was clear she had a small bowel obstruction. Despite this obvious fact, she did not appear toxic. She had a mildly elevated white blood cell count, her vital signs were completely normal and her abdominal exam was unremarkable. Her medical history was most significant for multiple previous abdominal surgeries: total abdominal hysterectomy with bilateral salpingo-oophorectomy, partial colon resection, cholecystectomy, two Cesarean sections, and exploratory laparotomy for a previous small bowel obstruction.
Thus, my reluctance to rush her into surgery. A day of watchful waiting would not harm her in the least, she’s already had eight days. The operation had the potential to be long and tedious, given her surgical history. She was as comfortable as could be expected with a nasogastric tube decompressing her stomach. But, her obstruction persisted and surgery became necessary; thus my supplication to the surgery gods.
The operation commenced with a midline incisions. Upon opening the fascia and saw bowel adherent in this area.
Where are you gods of surgery?
They can shine their face upon you and keep the common bile duct from sneaking away from its normal position to a vulnerable point directly behind or even lateral to the gallbladder, or, if angry, can command the ureter to adhere to the back wall of the colon, leaving it vulnerable to division by sloppy surgeons. These gods can be vindictive if not properly appeased.