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

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.


Jeffrey Parks MD FACS said...

I actually enjoy those kinds of cases. Blocking out three or four hours of time so you're not rushed. Meticulous, slow dissection until something resembling normal anatomy is delineated. I recently took down a combo ileostomy/mucous fistula on a guy I had operated on a year ago for a perforated cecum with liters and liters of fecal contamination. I better not have to go back inside him again.

Bongi said...

i know what you mean. i was thinking of putting a tattoo on this patient's abdomen saying "do not go here. here be dragons!" but there were consent problems.

Sid Schwab said...

Working laboriously through that sort of frozen field can be the most challenging and sphincter-puckering thing a surgeon does. When it's over -- assuming you eventually get there -- it does feel good. I've done some and said, "Well there's no way I could have done that in training..." It's nice to know you have skills.

On a more beautiful note: in med school I travelled to Yugoslavia for a research summer, and stopped in Rome on my way in. I saw Michealangelo's pieta in the Vatican and it was literally breathtaking. The most beautiful work of art I could ever have imagined. To bring such a thing out of rock: that may be a higher thing than what we do.