Anny Xiao Week 3 General Surgery Day 2

This morning we observed a laparoscopic cholecystectomy in a patient who had sepsis secondary to cholecystitis. The patient also had heart failure and respiratory disease so it was a rather high risk operation. Possible complications during the surgery that Dr. Ou mentioned were cardiac arrest and respiratory failure. Fortunately, the operation went smoothly and the gall bladder was removed successfully. From the laparoscopic camera view, we saw that the liver was a pink/yellow color, instead of the dark brown/red color that we usually see, and Dr. Ou informed us that color is indicative of a fatty liver. The gall bladder was enlarged and distended with pus and the surgeon punctured it to drain the pus which was a cloudy yellow color. We learned that leakage of pus into the abdominal cavity can cause local inflammation, fever and pain in the patient during recovery, but they are given antibiotics as prophylaxis against infections and the inflammation usually resolves in a couple days. After the pus was drained from the gall bladder, it took on a flattened shape and we could see a large lymph node on its surface, which was visible due to the infection.

The second operation we saw this morning was the removal of a large lipoma from a patient's left arm. The tumor was located on the anterior medial side of the patient's biceps and had a evenly round shape. The patient was given a sedative and local anesthetic before the operation. An electrocautery wand was used to cut into the skin and revealed the lipoma just underneath the skin. Dr. Ou used the electrocautery wand and tweezers to separate the lipoma from the skin and was able to quickly and easily extract the tumor, which was almost 4" in diameter. Because the tumor was so large, it had its own blood supply and electrocauterization was needed to stop the bleeding. Dr. Ou then cut away some of the excess skin that resulted from the tumor growth so there would not be any overlapping skin to suture.

In the afternoon, we observed a partial gastrectomy to treat a patient with chronic peptic ulcer who was unable to eat due to gastric outlet obstruction. The doctors believed possible causes of obstruction were fibrosis, peptic ulcers, and adenocarcinoma. An endoscopic biopsy had been done that looked benign, but Dr. Liu explained that its possible the biopsy missed the malignancy. The patient had severely compromised nutrition status due to his inability to eat. He was extremely thin and Dr. Ou explained that a conventional open surgery would be indicated for this patient, since it would be completed faster than a laparoscopic procedure and this would be better for a weaker patient. As they dissected the stomach away from the greater omentum, Dr. Ou commented that the gross appearance of the obstructed gastric outlet appeared malignant and decided to resect half of the stomach. However, the stomach was also enlarged, which is usually caused by a benign process, but Dr. Ou said that removing the affected part of the stomach would be the safest option for the patient to avoid missing a possible malignancy. The surgeons used a Roux-en-Y with a Billroth II anastamosis to connect the stomach to the first part of the jejunum in a side-to-side manner, a method that allows resection of the lower part of the stomach. This surgical procedure is called a gastrojejunostomy and often indicated in peptic ulcer disease & gastric adenocarcinoma. Dr. Ou explained that the other option, a Billroth I anastamosis, was contraindicated because it would directly anastomose the stomach to the duodenum, which would create too much tension and impair healing of the resection wounds in this patient. Although the Billroth II was a more time consuming procedure, the long-term outcomes would be better for the patient.

After removal of part of the stomach, Dr. Ou cut open the stomach to show us the ulcer that had caused obstruction of the gastric outlet. The margins appeared smooth and benign, although large in size and thickened due to fibrosis. 

Roux-en-Y anastamosis

Dr. Ou showing us the ulcer on the inside of the stomach

 

Surgeons must have an amazing knowledge of anatomy in order to know where to find each blood vessel to tie off or lymphatic vessel to avoid cutting during each surgery. I'm also impressed with the endurance and technical skill of the surgical team, many of whom are young residents who are already capable of completing a 4+ hour surgery each day.