gynecologic surgery

I really enjoyed my day in the operating room today.  I was first assistant to the gynecologic surgeon today for placement of Essure (permanent female sterilization using a device that causes scarring over of the ovarian tubes, placed via the vagina) and for a robotic cystectomy (removal of a cyst from an ovary)/ removal of scar tissue. 

I have finally over the last two weeks finally managed to mostly scrub in without contaminating my sterile hands on the faucet, my hairnet, another person, the door, or my gown.  I fortunately have managed not to contaminate the entire tray of instruments.  It is rather difficult to be constantly aware of my whole body and not bump into stuff when actually gowned up to be sterile.  The processing of scrubbing in involves using a fingernail pick to clean under the nails, scrubbing each of the four "sides" of my fingers/hands ten times each with a brush, then the forearms, while rinsing off with fingers always upward so that contaminated water does not drip down.  Then you back into the operating room when a scrub tech hands you a gown and you magically manage to get the gloves on without contaminating anything.  I'm definitely still working on getting the basics down.  But then, the surgery is the best part.

In the first surgery, I got to hold onto the hysteroscope, a "gun"-like instrument with a fiber-optic light that is placed through the vagina and cervix (opening to the uterus, the muscular organ that holds a baby during pregnancy) into the uterus.  He allowed me to move the hysteroscope to visualize the small openings to the left and right ovarian tubes, which bring eggs from the ovaries into the uterus.  He then threaded the applicator for the Essure, a long wire that ultimately, upon pressing a button, released a wire coil into the opening which would ultimately scar over and cause permanent sterility (in theory).  He let me click the applicator wheel to forward the device and press the button that released it, but unfortunately, the first Essure applicator was broken and did not release the coil on the left.  It was surprisingly difficult to maneuver the hysteroscope to keep the ovarian openings in sight, as one had to coordinate hand motions with the images on the video screen.  Surgeons make it look terrifically easy, but in fact it was rather awkward and difficult.

In the second surgery, he let me place a port for the robotic tools into the patient's abdomen and dock two of the robotic arms to the ports!  In a robotic or laparoscopic surgery, the surgeon makes a number of tiny incisions through which ports are placed.  The tools then are inserted through the ports and can be maneuvered in multiple directions.  Inserting the first port is tricky because he did it blindly without visualizing the intestines underneath; after the first port is placed, he inserted a camera so we could visualize insertion of the other ports.  Air is blown into the abdomen to raise the skin away from the visceral organs and allow maneuvering and visualization of instruments.

The peritoneal layer is surprisingly difficult to pierce with the pointed tool they hand me.  I am terrified that I will somehow push to hard and end up stabbing into the intestines or worse yet, the aorta (major blood vessel to the body).  Finally, the surgeon ends up putting his hand over mind to shove in the port and makes fun of me for not working out enough (not true - I was just being overly cautious).  I line up the robot arms in the rough direction of the port then press two buttons to dock the port to the robot arm.  We then place various tools through the ports.

He makes quick work of piercing and scissoring off a cyst on the right ovary and then using the robot scissor arms to cut/burn through some adhesions.  He checks everything for bleeding and is in and out within forty minutes.  He puts a few stitches through the peritoneum, the deepest layer of fascia under the muscles that wraps around the intestines and pelvic organs, then leaves the physician assistant and myself to place a single stitch closing the skin over each of the keyholes (the absolute least important part - mostly cosmetic).  Thanks to my residents, I have practiced knot-tying and stitching and am not completely clumsy, but I learn how to instrument-tie knots (wrap twice towards you, pull the other end through; wrap the suture once away from you, pull the other end through; then repeat two more times, wrapping once towards and once away to finish). 

We clean off the patient, apply strips of surgical tape over the incisions and add bandages.  The anesthetist discontinues anesthetic and we put the patient back into a neutral position on the operating table to wake up, be extubated (breathing tube taken out of her throat), and then transferred to a gurney to be wheeled off to the recovery room.

Watching the staff move is almost like watching ballet.  Everyone knows their place and what comes next, moving in practiced, seemingly effortless efficiency.  I enjoy the operating room the same way I enjoyed coding: there is quiet and deep concentration, and we achieve a state of "flow" the same way I did when doing math, solving problems, or running during my research years.

I love that I don't have to constantly manage interpersonal interactions the way I did in medicine.  I felt emotionally tired at the end of each day from dealing with the stress of sick patients, busy physicians, angry consultants, and navigating my way through other people.  I used to think I was a people person, but I get tired after a while of having to talk and interact.