Scalpel's Edge

A surgeon's notes

I claim thee, in the name of general surgery (and Friday’s list)

With a change to being a more general surgeon, I have picked up a few procedures which weren’t my responsibility in Australia.  Mostly this means I sweat and review neonatal surgery textbooks and get generally scared out of my pants.  But there are some procedures, which I think I will claim for my people.  

First, and probably no surprise, caesarian sections are lots of fun.  A great operation, technical, but with extra points for efficiency.  As I was taught it, and because we don’t do many elective caesars, the emphasis is on getting to the baby quickly, so it is operating with a scalpel, rather than electrocautery. It always reminds me of that paragraph in Top Knife, which talks about experienced trauma surgeons enter the abdomen in three cuts of a No 23 scalpel blade.  Surgical nirvana – skill and efficiency with little time for pedantry.  And then as an extra bonus, there is a cry and wriggle of a little baby, which always brings a face splitting smile and a feeling of wonder.

Also with references to Top Knife, the second best operation I have found also “belongs” to our gynaecological friends.  In the last three days I have operated on two ruptured ectopic pregnancies.  These are healthy young ladies, bleeding to death from a ruptured fallopian tube, due to a mis-implanted pregnancy.  They arrive very unwell with hemorrhagic shock.  On opening the abdomen, there is a belly full of blood (2-3 litres), but it is generally very easy to find and control the bleeding point.  In trauma laparotomies, we think it is easy enough to take out a ruptured spleen, but you  still have to dissect and manipulate until you get control.  The fallopian tube is sittiing exactly where you expect it to be. And for that, you get a young person who recovers relatively quickly from a lower abdominal laparotomy and life-threatening blood loss, and generally a lot less long term implications than an emergency splenectomy.

So, these two operations I claim in the name of general surgery.  It would bump up our “feel good” outcomes considerably.  Sorry, obs/gynaecologists – you’ve been hiding these operations for too long. (You can have the hysterectomies, though.  That operation confuses my head.)

And now to Friday’s list. We are in monsoon now (although it is a pretty dry season this year, apparently) so patients are choosing not to have elective surgery right now. There are two reasons for this, I think.  Many patients help in rice paddies at this time, so are busy, and most believe infections are more likely, which is partially true because they are all walking around in flooded rice paddies.

IMG 4695

Our cases today were

  • 3M – Inguinal herniotomy 
  • 40F – ruptured ectopic pregnancy (2.5L of blood in abdomen, heart rate 75, BP 120/70, Haemoglobin 72.  Young people are amazing)
  • 5F – incision and drainage submandibular abscess
  • 40F – haemorrhoidectomy
  • 47M – perianal fistula lay open
  • 65M – debride chronic foot wound in an old burn contracture (yes, I sent a biopsy for Marjolins ulcer, but I think this was purely mechanical from having such a big callus on the top of his foot)

So altogether an enjoyable day.  We did some good today.  I hope you did too.  Have a great weekend, and see you next week.

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