Recently, a patient came in via the ER with jaundice and severe RUQ pain. The ultrasound demonstrated clear evidence of cholecystitis with stones and wall thickening and fluid around the gallbladder. The jaundice was the hang up. Obstructive jaundice in a patient with gallstones always raises the specter of choledocholithiasis (stones in the common bile duct--- CBD), which often requires a secondary procedure to address (ERCP). Well the gentleman got admitted in the middle of the night and when I saw him the next day, his repeat bloodwork revealed improvement in the liver function panel. Furthermore, his CBD was only 3 mm on the US. It seemed likely that if he did in fact have a stone in the duct, it may have already passed into the stomach. So, after consultation with the GI doctor, the patient was booked for a laparoscopic cholecystectomy, with plans to perform an intra-operative cholangiogram in order to definitively assess the duct.
This was late afternoon case. I popped in the umbilical port and insufflated the abdomen. Within 39 seconds I realized this was going to be a grinder of a case. The gallbladder was cloaked beneath a thick drapery of omentum, stuck up against the inferior edge of the liver. Ordinarily that omentum can be fairly easily swept away with a couple of quick maneuvers. But not this time. It was like someone had dumped a bucket of some epoxy resin in the guy's upper abdomen. The omentum wouldn't budge. Strand by strand I had to cauterize the plastered fat from the edge of the liver. Even that wasn't enough. The duodenum soon revealed itself, tented up against the undersurface of the liver. Again, a meticulous peel down dissection ensued. After about 45 minutes I finally saw the makings of actual gallbladder.
Now the the gallbladder is usually egg-shaped or at least orb-like, with a tapering toward the cystic duct. This one was shaped more like a Cuban cigar--- long, cylindrical, and of a uniform diameter. The uniform diameter thing is a dangerous quality. We like difference and distinction in surgery, especially when trying to identify critical structures. A long thin gall bladder that fuses downstream with a common duct of equal caliber is frightening to the nth degree. And if only it were that easy. In cases of acute on chronic inflammation, the area of cystic duct/common duct confluence is a fused, woody, fibrotic sheet of adipose and scar tissue. Actual structures remain elusive. Strand by strand you have to slowly reveal the anatomy to yourself.
In tough gallbladder cases I use a principle called zoom in/zoom out. Yeah, it sounds dumb-- like some sort of faux-Zen, Pat Morita issued Karate Kid nonsense. But it works. It's all about attaining the proper balance between close up and far away. You need to be close. You have to see the structures. Each fiber of tissue has to be seen, categorized, defined. You need that camera right up on top of it all. But not all the time. Especially in biliary surgery, the most common cause of error (i.e. CBD injury) is a concept known as "visual perceptual illusion." The surgeon convinces himself that he sees what he wants to see. That strand of tissue he peels away has been defined in his mind. It's only scar, he thinks. A gestalt picture forms in his mind and the reality of the on-going operation is forced to adhere. That's how bile ducts get clipped and sliced. To avoid perceptual error---and the mind will construct an explanatory image spontaneously, you can't stop it from happening--- you have to shake it up, challenge the picture in your mind. Camera in, camera out. See from far, see near. The mind needs variety. Given limited information, it will construct a limited explanatory image. The most accurate representation of reality will occur when the mind is challenged, presented with a multitude of views and forced to reconcile them all. In and out. Push that gallbladder to the right and left. See the posterior space. This is how you do it safely.
This was late afternoon case. I popped in the umbilical port and insufflated the abdomen. Within 39 seconds I realized this was going to be a grinder of a case. The gallbladder was cloaked beneath a thick drapery of omentum, stuck up against the inferior edge of the liver. Ordinarily that omentum can be fairly easily swept away with a couple of quick maneuvers. But not this time. It was like someone had dumped a bucket of some epoxy resin in the guy's upper abdomen. The omentum wouldn't budge. Strand by strand I had to cauterize the plastered fat from the edge of the liver. Even that wasn't enough. The duodenum soon revealed itself, tented up against the undersurface of the liver. Again, a meticulous peel down dissection ensued. After about 45 minutes I finally saw the makings of actual gallbladder.
Now the the gallbladder is usually egg-shaped or at least orb-like, with a tapering toward the cystic duct. This one was shaped more like a Cuban cigar--- long, cylindrical, and of a uniform diameter. The uniform diameter thing is a dangerous quality. We like difference and distinction in surgery, especially when trying to identify critical structures. A long thin gall bladder that fuses downstream with a common duct of equal caliber is frightening to the nth degree. And if only it were that easy. In cases of acute on chronic inflammation, the area of cystic duct/common duct confluence is a fused, woody, fibrotic sheet of adipose and scar tissue. Actual structures remain elusive. Strand by strand you have to slowly reveal the anatomy to yourself.
In tough gallbladder cases I use a principle called zoom in/zoom out. Yeah, it sounds dumb-- like some sort of faux-Zen, Pat Morita issued Karate Kid nonsense. But it works. It's all about attaining the proper balance between close up and far away. You need to be close. You have to see the structures. Each fiber of tissue has to be seen, categorized, defined. You need that camera right up on top of it all. But not all the time. Especially in biliary surgery, the most common cause of error (i.e. CBD injury) is a concept known as "visual perceptual illusion." The surgeon convinces himself that he sees what he wants to see. That strand of tissue he peels away has been defined in his mind. It's only scar, he thinks. A gestalt picture forms in his mind and the reality of the on-going operation is forced to adhere. That's how bile ducts get clipped and sliced. To avoid perceptual error---and the mind will construct an explanatory image spontaneously, you can't stop it from happening--- you have to shake it up, challenge the picture in your mind. Camera in, camera out. See from far, see near. The mind needs variety. Given limited information, it will construct a limited explanatory image. The most accurate representation of reality will occur when the mind is challenged, presented with a multitude of views and forced to reconcile them all. In and out. Push that gallbladder to the right and left. See the posterior space. This is how you do it safely.
This case taxed me. There was always forward progress. I never felt stuck. There always seemed to be incremental progress but it was slow. A giant reactive lymph node bled everywhere. The gallbladder remained frustratingly undefined. Typically, the edema of acute inflammation is an opening to exploit. Slide through the plane created by the edema with a suction dissector and the extent of the gallbladder will be revealed. But this was an older guy who had clearly suffered from multiple prior episodes of acute inflammation and the resultant healing had rendered the critical area a fusion of entangled scar. This was a 3 hour case. At some point along the way, the right view appeared. It happens gradually and then suddenly. I had it. It was a form of Mirizzi's Syndrome, wherein the mass of the inflamed gallbladder impinges on the common bile duct, leading to a certain degree of biliary obstruction. The problem then became peeling the posterior gallbladder body away from the more proximal common hepatic duct. This is scary stuff. There is no plane, per se, rather just a general sense of where things ought to go and it's your job to put them there. This is where you can get into trouble if you aren't going in and out, shifting the perspective, forcing the mind to reconcile the images. Not only that, I'd been working a couple of hours already, focused intense concentration. It's not hard to lose focus for a moment and that's all you need. One second of impatience, a rushed maneuver, and boom there's an explosion of greenish yellow bile onto the video monitor from the porta hepatis and your stomach drops and terror freezes you up because you know you've made a wrong move. You don't want that. The same slow meticulousness you had at the beginning of the case has to be carried through to the end. You have to finish strong. Sometimes the whole damn thing has to be literally chipped out like a sculpture from stone. Sometimes there isn't a "hard part" to get past; rather the entire case is a mind sapping, back breaking trial. Sometimes a whisper of doubt hovers in the background on every move you contemplate. And it doesn't let up until the end.
This guy had an abbreviated, stubby little cystic duct and the common duct tented up in such a way that, if you looked at it a certain way, you could convince yourself that it was an extension of the cystic duct. God help you if you went with that perception. Ultimately, I got my cholangiogram. The anatomy was confirmed. The CBD was safe and unobstructed. The beautiful biliary radicles filled on both sides of the liver. I placed my final clips. Freed the gallbladder from residual liver attachments. Left a drain. It was over. I was done. I talked to the family. Did my orders. Long rambling borderline incoherent dictation (pity for the transcriptionist). And then I just sort of leaned back in the chair, stared vacantly into the middle distance. "That was a beat down", I said to no one in particular.
After a case like this you spend the next day or two in a fog. You don't even realize it. Loved ones ask if you're alright. You don't talk much. You don't hear what other people are saying. The world is happening, events are occurring. You have awareness of it all. You hear the sounds and see the images but it's all so muffled and distant and seemingly unattainable. You can sit in the den and nurse a gin and tonic. Nothing happens. You aren't even thinking. Sleep doesn't help. Talking about it doesn't either. It's almost like you've been injured. Something inside you has been depleted and there isn't anything you can do to make it come back faster. Time can only pass. The fog slowly lifts. Your wife asks you if want to come in for dinner. You hear her clearly. You smile without effort finally and rise and come in to eat.
This guy had an abbreviated, stubby little cystic duct and the common duct tented up in such a way that, if you looked at it a certain way, you could convince yourself that it was an extension of the cystic duct. God help you if you went with that perception. Ultimately, I got my cholangiogram. The anatomy was confirmed. The CBD was safe and unobstructed. The beautiful biliary radicles filled on both sides of the liver. I placed my final clips. Freed the gallbladder from residual liver attachments. Left a drain. It was over. I was done. I talked to the family. Did my orders. Long rambling borderline incoherent dictation (pity for the transcriptionist). And then I just sort of leaned back in the chair, stared vacantly into the middle distance. "That was a beat down", I said to no one in particular.
After a case like this you spend the next day or two in a fog. You don't even realize it. Loved ones ask if you're alright. You don't talk much. You don't hear what other people are saying. The world is happening, events are occurring. You have awareness of it all. You hear the sounds and see the images but it's all so muffled and distant and seemingly unattainable. You can sit in the den and nurse a gin and tonic. Nothing happens. You aren't even thinking. Sleep doesn't help. Talking about it doesn't either. It's almost like you've been injured. Something inside you has been depleted and there isn't anything you can do to make it come back faster. Time can only pass. The fog slowly lifts. Your wife asks you if want to come in for dinner. You hear her clearly. You smile without effort finally and rise and come in to eat.
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