When Tiger Woods addresses the ball, he’s focused like a cat that heard a rustle in the leaves. He takes a few practice swings, moves up to position, adjusts his feet, steadies his shoulders, locks his eyes onto the target. He waits until there’s absolute silence, brings his breathing under control, funnels all his energy into the impending swing; takes the club back, and explodes in an immensely balletic movement. It stops the breath of an onlooker, ripples the air in a wave that goes forever. Making a surgical incision is nothing like that.
But it almost is; and it should be.
Having held the patient’s hand as she goes to sleep, having whispered “We’ll take good care of you” as his eyes flutter to stillness, the personal remnant is still very much there as I begin, even as the person is covered in sterile green paper, exposing only the belly. It’s the midline incision, especially the one in the upper belly, from breastbone to navel, that’s the most intimate. To me, anyway. It’s so direct, so frontal, so against the rules of personal space. Maybe even sexual. Because it’s right into the middle of who she is — the thrust aimed where anyone — even a friend — would hunch away to protect himself; yet, here I am, purposefully slicing deep into his core, willing and able, allowed, invited, trusted, observed.
Going through the skin, the initial cut — that’s the cataclysm, the breaking of the barrier, the crossing of the line. It’s the leap of her faith, the breaching of the wall, the stepping into space. Within moments, it’s routine, nearly generic: his insides look like mine, yours. Been there. But the primal cut, the slice through that first and last line of protection, his skin, her freckles, the fine little hairs, the vulnerable innocence: I feel the intrusion, the awfulness, the promise made and broken simultaneously. After all these years, I never lost the wonder, the momentary look inward, the catch of breath, the faint crescendo of pulse. Primum non nocere!
These young guys: they like to cut only part-way through the dermis and put down their knife, finish off the skin with electrocautery; cook their way through the fat, smoke rising, stops and starts, pissily branding each little bleeder. I think they don’t know — really know — what an incision is. No wonder their love for it is less personal, more abstract, more easily stolen. Take the knife in your hand, sister, and don’t put it down.
Watch me: take a clean and deep stroke through skin, fat, right down to fascia. Have the courage of your convictions; make good on your promise and carry that same cut through the white line, the linea alba; let’s see that little layer of fat that covers the peritoneum, let it show on the first swing. The patient deserves your best shot, your most bold. Honor your covenant to address him with all of your conviction and purpose. Swaddle the wound with pads, the bleeding isn’t much and can wait.
I will reach in gently and caress the liver, the stomach and spleen. Slide over the top, into the recesses, curl the fingers enough to sense the texture, the fullness. The bowels move away and under, and over the top as I direct my hand. I can describe your kidneys now, I’ve circled the top of your rectum, held your uterus, measured your ovaries between my fingers. Part of you is gone at the moment, but I’m here, I know you now. You trusted and let me in, you opened your belly to me, and I entered with force. I’ll stay until it’s right. It’s what I must do. You think you’ll never touch me so intimately as I’ve touched you. But you have. You have.
Sid Schwab is a retired surgeon and author of Cutting Remarks: Insights and Recollections of a Surgeon.
