“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?
The adhesions were gently lysed and I was able to enter the peritoneal cavity. I had managed to open the fascia at the only point where there were adhesions to the abdominal wall. The remainder of the abdominal wall was completely free and the incision was opened into the peritoneal cavity without further difficulty. The markedly dilated small bowel was delivered into the wound and followed distally to the point of obstruction. The adhesions in this area were divided and the obstruction was relieved. The bowel was inspected from its beginning at the ligament of Treitz all the way to the terminal ileum. It all looked healthy with no other adhesions and no holes. It was returned to its home in the peritoneal cavity and the fascia and skin closed without difficulty. Thirty minutes from start to finish cured the patient’s condition and started her on the road to recovery.
In this case the gods of surgery smiled upon me and my patient as the surgery was uncomplicated and the problem fixed with a minimum of fuss. This is not always the case, however. Small bowel obstruction is a common diagnosis. High grade obstructions that require surgery are most commonly caused by adhesions; scar tissue which arises in response to inflammation, most often after previous operations. Such adhesions may be only a single fibrous band that the bowel can wrap around or travel under or through causing a slight kink or a tight stricture or a complete obstruction.
Other times there are cases like the one presented. A few adhesions are present and the bowel manages to find a path that leads to blockage. Despite persistent attempts, the trapped bowel can’t break free and surgery becomes necessary. Often, the bowel finds a way to free itself, perhaps by breaking free from flimsy adhesions or figuring out a way to liberate itself from the entrapping web. The patient begins to feel better and surgery is avoided.
Then, there are the extreme cases; patients who have had multiple previous surgeries or previous severe intrabdominal infections. The bowels are glued together by a mass of adhesions that require painstaking dissection to carve out the many feet of bowel and find the point of obstruction. In such cases the surgery gods are definitely not smiling as the operation proceeds millimeter by millimeter, hours pass and adhesions seem to form as quickly as they are divided. Cursing the gods of surgery may make the surgeon feel a bit better, but often leads to enterotomies (holes in the bowel).
The surgery gods can be your best friend or your worst enemy. 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.
And, if one chooses to ignore the gods of surgery, it is in one’s best interest to be fully knowledgeable of anatomy and pathology and how one can affect the other and vice versa. In the end, knowledge and experience will always trump these capricious gods, but it doesn’t hurt to try to appease them with a token sacrifice from time to time.
David Gelber is a general and vascular surgeon who blogs at Heard in the OR and author of Behind the Mask.
