There is no routine procedure in general surgery

The life of a general surgeon is one fraught with contingency, soul-crushing doubt, unexpected disaster, and overwhelming stress. I wouldn’t wish it upon my worst enemy. Fortunately, I was brainwashed to a sufficient degree during residency such that I actually don’t mind my job.

One of the reasons general surgery is so tough is that it is nearly impossible to map out your week according to a strict schedule. Maybe at some point in a career, when you’re the established, Big Kahuna of the group, you can load up your work week with elective breast biopsies, hernia repairs and lap choles and leave the middle of the night disasters for your more junior partners. In general, however, most surgeons never reach this stage of “easy livin’”. It’s a lifetime of inconvenience and last minute alterations and ulcer inducing pressure. If you’re worth anything as a surgeon, you figure out a way to make things work.

Beyond the scheduling squeeze, the actual business of doing surgery can get to be pretty nerve wracking, no matter how routine the procedure. Anatomic variants, sick patients, hostile abdomens, and the inexorably crushing statistical likelihood of complications (no matter how careful you are) all contribute to the inordinately tight sphincters of surgeons even during the seemingly routine elective gallbladder or breast biopsy.

A few weeks ago I had one of those cases that take a few years off your life. An older thin lady visiting from New Mexico presented to the ER with a partial large bowel obstruction. Her ileocecal valve was incompetent so we were able to decompress her with an NG and prep for colonoscopy. The scope showed a partially obstructing lesion in the hepatic flexure of the colon. She had had a Whipple procedure back in the 80′s for benign disease so I planned to do a standard open right hemicolectomy.

The surgery went beautifully. She was one of those thin old ladies with very little intra-abdominal fat. Even her mesentery was an ochre yellow sheet of semi-translucent tissue, like a smudged window in the attic. You could see everything. The case took 45 minutes. The ileocolic anastomosis looked perfect. She then did well for the first three days. On the fourth morning, she looked like hell. She was diffusely tender and had developed an elevated white blood cell count. I’m thinking worst case scenarios—-anastomotic leak, inadvertent bowel injury, ureteral transection, etc. So I take her back to the OR and encounter something entirely unexpected: 25 inches of dead distal small bowel. I resect frankly gangrenous bowel and start to investigate. First thing I notice is a lack of pulsatile flow in the area where one would normally be able to palpate the superior mesenteric artery (SMA). Then, as I start to mobilize the left colon for either a new anastomosis or a stoma, I discover a rope-like, pounding arterial branch in the sigmoid mesentery, arising from the IMA. I follow it to the transverse colonic mesentery. I think I know what’s going on, but I scrub out at this point and open up the CAT scan on the OR computer and get on the phone with the radiologist. I always get a pre-op CT scan of the abdomen on patients with colon cancer. I ask the radiologist to reconstruct the images in a coronal fashion. He calls back in five minutes and confirms my worst fears.

The lady suffered from severe mesenteric arteriosclerosis. We depend on three main arteries to feed the bowels; the celiac, SMA, and IMA. Her celiac artery and SMA were both occluded by thrombus. Her IMA was open and there was a giant meandering mesenteric artery that had developed over the years to compensate for her lack of flow through the other main trunks. So when I performed an oncologic resection of her right colon cancer, I basically transected that lifeline of blood coming over from her IMA to feed her small bowel. When I scrubbed back in, her remaining intestine was starting to look worse. She didn’t have a lot of time. She was about to infarct her entire intestinal tract.

While I waited for the vascular surgeon to arrive, I dissected out the SMA origin and harvested some saphenous vein. Then we revascularized the SMA via a saphenous graft coming off the IMA. The next day, her stoma looked awful and I took her back for a second look. I resected another 6 feet of small bowel. The graft had clotted on the SMA side so I did a quick throbectomy to re-establish flow. I heparinized her and said a little prayer. The graft stayed open. She ended up leaving the hospital. Her life will never be normal again. She will suffer from short bowel syndrome and severe fluid/electrolyte disturbances from the high output stoma. The graft could shut down again anytime. But she made it through this battle. I’ll take it.

We wade into shark infested waters every time we press scalpel into flesh. Your eyes better be wide open and your head on a swivel. There’s no such thing as routine in general surgery. If you have masochistic tendencies, then by all means come join our club. Otherwise you might be better off in dermatology.

Jeffrey Parks is a general surgeon who blogs at Buckeye Surgeon.

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  • http://other-things-amanzi.blogspot.com bongi

    Buckeye, a man after my own heart.

  • everyman

    as an internist who whines daily about stupid forms, i commend the work you guys do.

  • surgical resident

    Agreed. I hate when my students say,”it’s just a line.”

  • PAULMD

    I’ve said it before and I I’ll say it again. General surgeons are the uber heavy lifters in the hospital and I am truly humbled by their effectiveness and yeoman’s contribution to healthcare. I certainly don’t have the guts for it. Pay them whatever they want and keep them sane and cutting because if and when they break down, the machine breaks down.

    It’s also one of the areas in medicine that usually gets harder after you leave training. With the fellowship trend in gen surg, our hospital has faced trouble in service and trauma call. Endovascular, breast and baro etc not wanting to do gen surg call.

  • imdoc

    This piece is a good example of why we ought support doctors in any specialty who take care of the really sick patients. All of the incentives today propel physicians toward higher paying, low risk pursuits with reliable hours and reasonable lifestyle. If the life saving and critical medical system is dismantled, everyone suffers, particularly the most vulnerable. An increasingly complex and onerous regulatory, legal, and reimbursement environment is toxic to maintenance of an effective system. I am now seeing doctors doing cosmetic outpatient procedures or health-spa services at the top of the food chain.

  • steve weaver

    great article. it’s not easy and you have summed it up very well. and it always sucks when one has complications.

  • http://www.ethicalnag.org Carolyn Thomas

    “..All of the incentives today propel physicians toward higher paying, low risk pursuits with reliable hours and reasonable lifestyle..”

    Imdoc, from a patient’s perspective, this certainly appears to be true.

    My longtime family doc has recently opened up a “clinic” within her small office where she injects Botox and Juvederm into the faces of happy cash-paying customers. We sit in her waiting room surrounded by big ‘before and after’ posters demonstrating her new age-defying skills, and watching a big-screen TV showing a continuous loop video of all the wonderful new procedures available to us now!

    Her non-Botox people, her actual patients, cool our heels in the waiting room and wait months (literally) for our next appointments to see her for actual physical problems. My daughter was recently reminded that it’s time to book her annual physical exam – next available date: July 2011 – and oh by the way, the new policy is that our annual physical will now be broken up into two visits, one for ‘waist up’ examination, and the second for ‘waist down’. A clear cash grab, with little if any consideration for the inconvenience of patients who have to book time off work for two visits instead of one.

    We wonder aloud why she doesn’t she just post a big sign announcing that she is no longer interested in the practice of medicine? That way, those of us who have not yet been driven away in search of good medical care will be accurately warned.

    This Botox business on the side is her retirement plan, and I do understand its appeal after decades of all the headaches of ‘managed care’.

    But as a heart attack survivor, I despair of this trend in the medical profession.

  • doctor

    Great post. I’m in OB/GYN, possibly the only other specialty with less predictable schedules. But your surgical observations are spot on- how do you code (or explain) for anatomic variants, having to go back to the OR for outcomes that are unexpected, but not your fault. You pick up responsibility for someone’s life covering the ER, you save her life, and you have to hope she understands and accepts your explanation of why she needed two operations, lost a significant portion of her bowel, and has a stoma. No wonder surgical practice leads to ulcers. (mine was last winter!)