Saturday, April 03, 2010
anatomy knowledge is essential for surgeons. i'm sure most surgeons would say it is the single most important thing in surgery. i would not. knowing anatomy may just not be enough.
somehow south african pathology is unique. by the time the patient presents to us things are a bit advanced (here and here or even here). i suppose you could say it makes diagnosis a bit easier, but it sure as hell does not make treatment easier. once when i was still working quite a lot at the state hospital this became clear to me.
the medical officer called me in. they had a bleeding stomach ulcer patient who for some reason just refused to stop bleeding. it was time to operate. the medical officer was so excited he was jumping up and down. he kept on telling me that he had never seen a gastrectomy before (removal of part of the stomach) and i kept on telling him that these days it is seldom that a gastrectomy is done but rather he was likely just to see the control of the bleeding artery and all would be well. i was less excited. it was late.
when i first laid eyes on the patient a few things bothered me. firstly there was a scar from a previous upper midline operation, probably also for a peptic ulcer. the next thing is his body showed wear and tear far above what his years would have dictated. his face had the signs of both long term alcohol and nicotine use. he was thin and almost wasted. i knew without asking that he was also a habitual grandpa user. then over an above his general state of health, he was pretty bled out. oh well, i thought, you work with what you get.
as we started, my excited medical officer asked me to give him an anatomy lesson during the operation. he knew i liked to teach and what better opportunity to learn anatomy than when the textbook is open before you. yet as i started the operation i went silent.
it was clear someone had operated here before. there were many adhesions to the anterior abdominal wall and it was quite a mission to actually get into the abdomen. once i was inside however, things went very rapidly from bad to worse. what once had been the lower stomach was just one massive ulcer that had penetrated into everything. the ulcer bed consisted of liver, abdominal wall, and transverse colon mesentry. the galbladder had been incorporated into the ulcer and therefore what passed for the stomach. in an attempt to heal itself it had grown into what looked like a fungating mass. in fact for a moment i actually thought it might be a cancer until i realised there was no real galbladder and this strange growth was in fact its remnant, complaining bitterly about its lot. i needed to decide what to do. clearly some form of gastrectomy was required. i should actually say some form of reconstruction was required. the ulcer had already done the gastrectomy. a bit more than a small amount of ingenuity was needed. i got to work, still in silence as i played through the options in my mind.
the medical officer was not silent. he reminded me that he wanted to learn the anatomy of the stomach.
"anatomy?" i asked, "there is no anatomy here. in fact i think we may have stumbled onto the unborn embryo of an alien that has invaded this body. just be glad the thing hasn't burst out and attempted to eat one of us."
i removed the remainder of the alien and tacked together what needed tacking together. driving home, i looked at the starry sky nervously.