Sunday, July 22, 2007
apparently michaelangelo sculptured like no other. he would not first get a rough shape, but would immediately work down to the final product. the result, a perfect form partially liberated from a block of stone. when asked how he did it, he apparently said he just chissels away whatever doesn't look like the final product he sees in his head. i imagine chipping a human out of the stone in which he is trapped. the chances of injury to the human must be high. sid has often spoken about tissue plains, but there is another side to it.
she was overweight. she had apparently had a previous nissen repair, which had turned ugly and ended in an open splenectomy. thereafter, by her account, she had had a laparotomy for bowel obstruction (must have been a vicious splenectomy?). then someone had been thoughtful enough to repair her ensuing incisional hernia with a dual mesh (gortex apparently). on gastroscopy i could see no evidence of a nissen. what i could see was a very large hernia. it looked like half her stomach was an illegal alien in the chest. i bet the heart was pretty pissed off, not to mention the lungs. the lungs were even more annoyed about the nightly visitations of gastric juice in their bronchi.
i did what any self respecting surgeon would do in my situation. i referred her to the guru in pretoria who taught me laparoscopic surgery (prof heine van der walt). for whatever reason the patient couldn't go there. damn, turf and bounce. i was stuck.
i then did the next best thing. i phoned the prof and asked what i should do. on his advice, i put my head down and went for it...open.
frozen abdomen. there are no tissue plains. on the contrary, you find yourself trying to chip someone out of a block of stone. if you actually find human tissue, you've probably injured it already. and yet that is exactly what you must do. separate everything. find the anatomy and repair what needs to be repaired. as i suspected, there had been no actual previous nissen repair, but one stitch had been inserted into the crus anterior of the esophagus-stomach complex. so i soldiered on. and finally, after a good few hours i had everything as it more or less should have been. i did the repair and ran for the hills (closed).
sometimes in the life of a surgeon you can't help wondering if it's worth it. when you get bogged down and your next move might be the patient's last and there is an irritating voice in your head screaming "first do no harm", at times like this it may not seem worthwhile. but in all honesty, once you get yourself and the patient through, there are few feelings as exhilarating as it. one more accomplishment to feed the already inflated surgeon's ego.