Anny Xiao Week 3 General Surgery Day 1

Today was our first day in the OR for our surgery rotation. The first operation was by the orthopedic surgery team to correct a hallux abductovalgus, also known as a bunion. The deformity occurs when there is lateral deviation of the big toe, which causes a valgus deformity in the first metatarsophalangeal (MTP) joint. The deviation can cause subluxation of the first MTP joint and the big toe can sometimes overlap the second toe. The surgeon corrected the deformity by removing the abnormal bony enlargment of the first metatarsal bone and restoring normal alignment of toe joint.

Next, we observed Dr. Fan as he removed a suspected foreign body from a patient's forearm. We could palpate a small firm tube-like body under the patient's skin. Dr. Fan made a small incision and began dissecting out what appeared to be hardened segment of a blood vessel. After he removed it, he sutured the incision and used the ultrasound machine to scan the patient's arm for any remnants of what was removed. He suspected it was part of a blood vessel that had become hardened but sent it to pathology for the final diagnosis.

The second orthopedic surgery we observed was an ankle fracture and dislocation. The patient's distal tibia and fibula were both fractured, dislocating the ankle joint. The surgeon made the first incision to reveal the fracture tibia, which was fractured in a jagged line about 4 inches down to the lateral malleolus. I was surprised with how long it took to get the bone in exactly the right position. Perfectionism seems like a quality that orthopedic surgeons must have, as it took 45 minutes to clamp the bone together so that the fractured surface was perfectly flush. A thin metal plate with 8 holes was placed along the bone and the surgeon drilled 8 screws to hold the bone in place. For the fibula fracture, the surgeon first palpated the patients ankle and then made a precise incision over the fracture. After he repositioned the bone into place, he drilled a long pin to temporarily fixate the 2 surfaces of the fracture together. Two long screws were used to hold the fractured bone together. First sutures then staples were used to close the two incisions.

The surgery board with the patient list (not shown), diagnoses & procedures

In the afternoon, we saw an emergency appendectomy. The procedure was laparoscopic, so it was minimally invasive making only 3 small incisions in the patient's abdomen to accommodate 3 trocars. The largest incision (2 cm) was made just below the patient's umbilicus, to accommodate the larger laparoscopic equipment, and was used to inflate CO2 into the peritoneal cavity, creating a pneumoperitoneum that creates more space for the laparoscopic surgery. After CO2 inflation, the laparoscopic camera was inserted through the larger incision and a clamp & electrocautery wand were inserted through the two smaller incisions. The surgeons first visualized the entire abdominal cavity using the camera, and then meticulously dissected the appendix away from the cecum and its attachments to the abdominal contents. The electrocautery wand heats the tissue to cut through it and simultaneously seals off blood vessels to minimize bleeding during surgery. When the appendix was adequately separated from the rest of the abdominal contents, an endoscopic GIA stapler was used to cut off the appendix and seal off the cecum. To avoid potential rupture of the appendix during its removal through the trocar, a plastic bag was inserted into the abdominal cavity and the appendix was placed in this bag before being pulled out of the largest trocar. Two incisions were closed with sutures & staples while one was left open for a drainage tube, in case of leakage from the cecum, to be removed in 2-3 days if no drainage was present.

Surprisingly, this afternoon's surgery was done by the residents, who were all female. I've noticed at this hospital that there are very few female physicians, especially in cardiology, nephrology and pulmonology. However, in the OR we've seen more female physicians than anywhere else in the hospital, which is interesting, since surgery is generally considered a male-dominated specialty in the US. I did not see any female attending surgeons but it seems like more females are entering the younger generation of surgeons in Taiwan.