Category Archives: laparoscopy

SEEING IS BELIEVING

It is a common and traditional practice for a surgeon to display a removed organ after his efforts.

The patient’s relatives go goggle-eyed as the surgeon describes graphically how difficult the operation was, how risky, and how brilliantly he managed the situation to save the patient.
The bigger the tumor, the better. If, however, a removed gall bladder has only one or two small stones, the surgeon is looked at ( “Oh, is that all? My mother, who was operated by Dr. Enviable, had two hundred and eighty stones”) with raised brows and curled lips, as if the surgeon was at fault for not having produced stones of adequate dimensions. The size problem always crops up to haunt men. The specimen removed at operation is, clearly, of great importance to people.

I have been perplexed in the past, when I was environmentally colored greener, by certain instances of human behavior (in this regard). Once, after doing a circumcision, I went to the parents to reassure them that all was well. The mother insisted on seeing the specimen (the foreskin). We had to scavenge the trash buckets to retrieve the small piece of skin. It seemed that unless I showed them the specimen, I would be clearly identified as a cheat who was charging for nothing, under the pretext of doing a surgery.

After hernia surgeries, people are very disappointed when I come out without any grotesque piece of flesh in hand. So, nowadays, I carry a packet of the mesh that is implanted in one hand and the bill for my services in the other.

When it comes to private parts, you will be amazed to know of peoples’ attitudes. If you asked a man to display his wife’s breasts to his relatives and friends, he would probably assault you. But that same man (in the company of six other people) may well ask to see the specimen of a mastectomy done for his wife’s breast cancer.

Today, I was operating at a hospital where the operation is normally shown live at the reception, where the relatives of the patient watch the proceedings. This patient’s husband was very eager to watch the operation live. The operation was a laparoscopic hysterectomy. As I was, from inside the abdomen, incising the vagina with my instruments (just prior to removing the uterus), I thought that this, most private, part of a woman’s anatomy was being displayed in public, though from the inside. No skin was visible, but the inside of the vagina was what was on sight.

Is a private part private only if seen from the outside? Or is it important only when the viewer realises what is being seen? The relatives, after the operation, wanted the specimen to be displayed, not realising that they wanted to see the innards of a woman, which they would never dare to otherwise.

Is there something here I am missing? I don’t understand people’s notions of private parts.

DADI IS SMILING AND I AM AWAKE

It is two hours past midnight, and you might wonder why I am not asleep like decent people with two brains and one kidney would be expected to. Did I get that right? Whatever.
Well, it’s a longish kind of story, intricate in its human situations. It needed a Tolstoy or somebody comparable to do justice to it, but please make do with me, okay? I will use my special editing and writing skull skill and make it just bearable.

    THE BACKGROUND

Day before yesterday, I operated on an eighty year-old lady, Dadi, at a posh hospital (called Hippocratic Medical Center) in the grand old city called Unknown. The operation went smoothly, and I, the surgeon, modestly boasted to the two daughters of the lady that it couldn’t have been better done. Period. I am not known for beating about the bush with words. As the girls keep saying, “Give it to me straight and hard, baby!”

Yesterday, the old bird was smiling in delight. She apparently did not expect to survive my surgery. Not one to misunderstand such low expectations as a poor reflection on my reputation, I gave her a dazzling smile, and said she could go home the next morning. Which was today.

    TODAY

This morning, I started off early as usual, for I had a long operating list of seventeen cases, but at another hospital. Happily doing the chop-chop job that characterises the peculiar perversity of being a surgeon, I got a call around noon. It was the old lady’s son-in-law.

“Doc, she is feeling a lot of acid and is puking a fair bit.”
“Hmmn, that is not supposed to happen. Do one thing. Keep her in the Hospital for the day, for I don’t want you to take her home and then have problems. Later in the day, I will come in and look her up. In the meanwhile, let me send another physician to check her up”, I said.
“Okay, doctor.”

I tried calling the internist physician who had been treating the patient as part of my team. He was stuck in an angioplasty, and had loads of work. He couldn’t visit the patient right away, but promised to visit her later in the day.

    SHILA

Shila, the nurse looking after the patient, was a struggling young nurse. With an alcoholic gambler of a husband, she had to earn the bread for her little daughter, and save for her schooling as well. She had got this job of private nurse (where she gets paid for her hours of serving the patient in hospital) with great difficulty. For the few hours since morning that she had been with Dadi, she got paid for a full day. Now she was looking forward to another ‘case’ that would double her day’s income.

Shila did not have much trouble in reassuring the patient and her daughters to take the patient home. She said, “Everything will be alright. I have spoken to your doctor. I have given the anti-emetic as he has advised”.
She called me up and said, “Sir, the patient is feeling much better now. I have given her an injection for vomiting. Her discharge papers are all complete, and if you want to keep her today, she will have to be re-admitted, with extra costs. The relatives don’t want this. So shall I discharge her?”

I was operating while I got this call. I said “If this is what they want, then it is okay.”
Shila got paid twice today.

Back in the hotel (for the family was from another city), the patient continued to get sick, vomiting repeatedly. The family called me, and I assured them I would send my assistant at the earliest. However, with so many cases, he, too, would be able to come in only by late afternoon.

    IN DADI’S HOMETOWN

Around this time at noon, Dadi’s eldest son was shot dead. Dadi’s son was a rich businessman with no vices and an obsession to expand his business. In his hometown, he was the target of extortionists and kidnappers. Recently, Maoist guerillas had warned him to pay them three crores of rupees (around $800,000) or he would be killed. He had refused, and jacked up his security. Today, in spite of that, he was shot at from a hand shake’s distance and dropped, all life spurting out from his chest.

    THE FAMILY OF DADI

Dadi’s family of her daughters, sons and sons-in-law, needless to say, was shell-shocked. Not only was their beloved mother sick, but their own brother and family head had just died a brutal and unexpected death. Very few people live expecting death, very few. Immortality is an invisible stain inherent in human actions and thoughts.

The family privately held a conference, and decided not to inflict the sick old woman with the shock of her son’s death. They decided to leave one daughter-in-law with Dadi, and all of them left for their hometown.

    RE-ADMITTING DADI

My assistant, Parthiv, went to see her, and called me, giving me the picture of the patient. I ordered him to readmit the patient to Hippocratic Medical Center (HMC). Time: 7.00 pm.

I left my office, finishing off some consultations, and headed towards the hospital. Both Dadi and I reached around 7.30 pm. One immediate problem. The family had left for home in disarray. They had forgotten to keep any money for Dadi’s further treatment. The 40-ish daughter-in-law looked to be a housewife protected by her family from the vicissitudes of city life. I took the responsibility of the admission. My patient, after all.

    THE INVESTIGATIONS

I needed a set of x-rays, a few blood tests, and most importantly, a CT scan of the patient’s belly to find out what her problem was.

At HMC, the day technicians in charge of the blood and x-ray departments took off by 7 pm. The night duty staff came in only at 9 pm. This two hour gap could not be avoided at HMC because the trade union of the employees was very strong, and had strongly refused to extend their duty hours.

Therefore, I had to wait for two hours for the investigations to begin. I had already started an IV, put in the tubes and catheters that you don’t normally see in the hospital scenes in movies.
Work temporarily over and all alone, I wandered off into the narrow streets of Unknown city. I stopped at a corner tea shop, and had hot spiced tea served in an earthen mug (bhaanr). To keep busy, I bought and lit a smoke. I don’t generally smoke, but now seemed to be a good time. After an uneventful hour of this, I returned and waited for the tests to start.

After another hour or so, the CT scan was going to start now. A full two hours later, the cause has been found. Dadi has a temporary malfunction of her intestines. A couple or more days of treatment would likely see her through.

    ME

What struck me today was that I behaved the way I used to as a young resident doctor: taking risks for a patient, pushing the patient’s trolley, drinking tea and smoking (both without count), proffering a bowl to the retching patient, holding her shoulders and back to help her sit up, regularly asking how she was feeling and reassuring her that everything would be alright. She smiled sleepily at me, contented and relieved that she was not alone.

Today, I am reliving this feeling, this rewind of a life long past, and I can’t say I am not enjoying this. A consultant (at whatever humble level I practise) does not get his hands dirty. Today, I am not shy to say this, I had some of her puke on my hands. I must say that I have done far worse: shaved heads and pubes, pushed wheelchairs, got my dress mucked up with blood and pus, and removed thousands of maggots from the festering sores of drug addicts, beggars and alcoholics.

Thinking of all that, I can almost smell the old, smoky canteen of the medical college, and the anorexia which getting dirty used to generate. Today, I am not hungry. I have not eaten all day, and am going to be awake till morning. But I am not feeling dirty.

IS YOUR DOCTOR A CAD?

Anupama’s mother fell down in the bathroom and broke her hip. She was rushed to a good hospital in her city. An orthopedic surgeon, who took up her case for surgery, put in a metal screw to fix the fracture. When Anupama asked him whether her mom would have any long-term complications, he replied, “Oh, she shouldn’t have problems for five years at least!”
Apprehensive now, she asked him what would happen after five years. The doc remarked, “I don’t think she will live for longer than that!”
The shocked daughter now goes around bad-mouthing the doctor.

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(pic credit: http://www.smh.com.au)

Dr. G, a surgeon, operated on a patient for gallstones. The patient developed jaundice soon after, because a stone was obstructing the bile duct. Though this can happen, in this case the surgeon knew the diagnosis even before the operation. “Why didn’t you fix this at the time of the surgery—after all, this is related to gallbladder surgery?” the relatives asked. The surgeon shooed them off with the remark, “You have paid me to do a gallbladder surgery. The budget you people came with was enough only for that, not for a bile duct surgery. So why are you complaining now?”

Yet another surgeon tried to break the Guinness record for the maximum number of surgeries done in a day, and operated on 50 patients in a few hours. As a result of this, he got enormous publicity in his city, had a big spurt in practice, and made more money. His patients, though, paid a small price. One patient died of undetected post-operative bleeding, because the surgeon was too busy trying to break the record, and around ten more patients got bad infections in the wounds, because our man had not given adequate time for instrument sterilization. Time, after all, is everything when it comes to making or breaking records.

When one such patient’s husband asked him why her wound got infected, the great man shouted at him, “Your wife is dirty, and that is why her wound got infected. Ask her to take baths properly!” The humbled and humiliated patient never raised her voice, and suffered daily dressings for months, taking tons of costly antibiotics.

In modern India, patients are asking hard questions at doctors. Most of the latter are trying to be reasonable with them, but the worst are getting away.

A urologist I know cannot operate. He has a trained assistant who operates, while this great specialist advertises like a sexologist or astrologer and manages to maintain a brilliant private practice. The division of responsibilities is clear. Surgery: unqualified but trained assistant. Business, fronting, marketing, etc.: qualified, but highly unskilled urologist.
This gent once had a tough time with a man whose father died after a kidney stone surgery that led to massive bleeding, re-operation, ICU stay, and an expensive death. The urologist was unfazed at the phone calls asking for compensation and threatening litigation. He coolly paid just five hundred rupees (around $12) to a local thug, and asked him to set fire to the thatched dwelling of the caller. “House on fire, this man will not have the time to bother me. He will be too busy fending for his own problems”, confided the morally upright doctor over cocktails at his club. Problem solved.

In India, achieving the impossible is only an issue if your means or moral boundaries are limited. Without the hindrance of these, one can get away with blue murder, especially if you are in a position of trust. It is both a fortune and a misfortune that doctors are still trusted today. In the years to come, they promise to stand beside politicians, lawyers and policemen in the rogues’ gallery of untrustworthy and parasitic institutions we cannot do without.
So, just check: is your doctor a cad?

SECOND OPINION: 101

http://www.childrenshospital.org/arthur/pop_surgeon_en.html

CNN Health reports that there are five situations where you should take a second medical opinion. These include brain tumors, hysterectomy, medical termination of pregnancy in fetal abnormalities, varicose vein surgery and heart bypass surgery.
I think this is silly pop stuff. What about a diagnosis of tuberculosis versus lymphoma, or cancer, or Crohns’ disease? What about whether a hernia or a gallbladder needs a surgery or not?
There are three main reasons I think a second opinion is important:
1. What is it?
Recently I saw a young girl who was being treated for several months for proven tuberculosis of her lymph glands in her neck. In spite of the treatment, her glands were increasing in size, and I removed a piece, thinking it to be a case of drug-resistant tuberculosis, which is an important health issue all over the world. When the biopsy report came, I was surprised to read the report stating that there was no tuberculosis at all. What would one do now? One report was clearly declaring the presence of TB, and the other (from an equally reliable lab) was refuting it. In the past, I have found a diagnosis changing from TB to cancer! Similarly, TB of the intestines (a very common Asian disease) may be confused with cancer or Crohns’ disease, which, though uncommon, are important diagnoses.
In these cases, it is important to get an experienced specialist to decide further course of action.
2. To treat or not to treat?
Investigations have become commonplace these days, with people going for comprehensive check-ups just to find out if they are okay or not. In addition, people go for thorough health check-ups before they are hired for new jobs, or prior to getting life insurance. These tests are throwing up diagnoses of diseases. People get worried about these findings and queue up for treatment, including surgery. A common example is a young man who is found to have gallstones, or a sailor with a small hydrocele.
It is very important not to treat these people unnecessarily. “You can’t get better than asymptomatic” is a truism for the over-enthusiastic doctor. The patient should earn the surgery, and the surgeon should not sell it. So, in case a doctor recommends surgery or another invasive procedure (like an angiogram) for something that is not troubling you too much, it is good to get a second opinion.
Another example is appendectomy for chronic pain in the right side of the tummy. This is a total no-no, in most cases. Surgery is not needed in more than 90% of cases, as the diagnosis itself is not appendicitis! This is so common that I find it ridiculous that CNN does not talk about it, dealing instead with rare stuff like birth defects detected in pregnancy.
3. What treatment to follow?
Let us take the operation of hysterectomy (removal of uterus). Recently a young woman of 39 years came to me with a tumor (myoma) in her uterus. She had heard that I do laparoscopic surgery, and wanted to hear from me that I would be able to remove this by the keyhole method.
She showed me a previous consultation with a gynecologist (note that I am not one), and this guy (with international degrees, working in one of India’s best hospitals) had told her, “You need an open operation to remove your tumor, because it has become very big.”
In this day and age, I thought, my Gawd!
Here is why I was shocked: it is now established by science that most uterine tumors (and we are not talking of cancer) do NOT need surgery. If treatment is needed at all, it can be something even less invasive than keyhole surgery. In other words, uterine artery embolisation, a procedure whereby a tiny tube is placed from the groin into the artery of the uterus and the blood supply to the tumor cut off by injecting some magic materials. The tumor shrinks because its blood vessels get clogged. End of story. But, no, this is not good enough for many of the gynecs, who want to get their hands into blood, and feel they are actually doing something.
This is another example of when a second opinion should be solicited, and CNN does mention it, to its credit.
So what should you do when faced with a new disease, or with a surgery for something you are scared of? Chances are that the second opinion you take will be equally wrong, or end up confusing you thoroughly. This may be less so in the US or in Europe, for example. In India, it would be most likely! For example, those people who come to me for getting their appendixes removed have already got the same opinion from three other doctors, including medicine specialists and gynecologists. They get shocked when told that no surgery would be needed. It is only because they trust my opinion that their confusion is resolved. If not, they probably get the surgery done by someone else, and, much later, when the pain recurs, remember my opinion.
So, the thing to do in the situation I described is to read. Doctor Google. Web MD.
And some doctors’ blogs!

AHEM!

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Today, I learnt that the World Journal of Surgery was published.
I find a vaguely familiar name, but somehow cannot place the guy. Must have been a blogger at some point in time.
I am fairly sure this is some silly, inconsequential, self-serving noise made under the guise of respectability (and if you have been reading this blog for some time, you know how academia likes its pomp and nomenclature), a so-called invited commentary, bah!
Hmmph! Wonder what the WJS folks will call this blog if they read it: Global Acknowledgment of Stupid Surgeons (GASS)?