Colectomy

I assisted on an awesome case today, right partial colectomy. What made it great was not the procedure itself, although it was a good one, but rather the fact that first, I worked with an excellent surgeon, and second, the degree to which he let me assist.

"Clamp please, and give the second one to Ms. Assist."

Finally! I get to actually place a clamp in addition to removing it.

"Now, I'll hold this one open and you come in right in between. Be sure you find the hole. Now come a little closer towards me. Perfect."

Amazing that such a simple thing could be such a thrill the first time. As we continued the dividing the omentum around the metastatic tumor that was unexpectedly found, I placed several more clamps. Tips curved toward each other and on opposite sides of the piece to be divided, the tip of the surgeons clamp pointed at me, the tip of mine pointed at him, I remembered my instructor from my First Assistant course telling us to "...place your clamps in the 69 position." Of course we all giggled, but I'm positive no one has forgotten it.

And then, another right of passage.

"Clamp please.....another one......metz to Ms. Assistant"

The actual cutting of tissue. I want to do it correctly so that I may be allowed to do it again. There really isn't much I can screw up at this point. The tissue is isolated between two clamps and elevated in such a manner that there is nothing hiding nearby that might be inadvertently cut. I'm sure that is why he is allowing me the opportunity at this juncture. So I cut with the tips of the scissor as I have been taught, incising the tissue at midpoint between the clamps.

"Do I cut right down the middle, or closer to one clamp?" Is all I can think to ask. It sounds lame as soon as I hear it uttered from my lips. Fortunately Kind Surgeon doesn't penalize me for stupid questions.

"Right in the middle." He assures me.

As we begin dividing mesentery, preparing to take our specimen of terminal ileum, cecum, mesenteric nodes, and portion of omentum, Kind Surgeon places all of the clamps and does all of the tissue cutting. My job, once again, is to remove clamps as he pulls his free tie tight across the base of the amputated stump of tissue, and cut the suture ends after the knots are thrown. Clamps with the handles on his side of the patient I remove with my left hand. Handles on my side, removed with my right. Fingers open and slightly curved behind the lower ring of the handle of the clamp, index finger behind, pad of the tip of my thumb resting in front of the upper ring on the clamp, they are released with a subtle motion without placing the digits through the rings. Just like I had been taught and spent hours practicing. Having clamped a large vessel, it's function as blood supply to the portion of bowel we are removing no longer required, Kind Surgeon tells me, "We are going to flash this one."

I understand. In order to flash you must slightly open the jaws of the clamp as the surgeon begins to tighten the first throw of the tie, allowing the tissue to slide as the tie tightens. Then you must close the clamp again, all without loosing the tissue that was originally within the jaws. This allows the surgeon to place one tie around the vessel while still maintaining control of the vessel with the clamp. A second tie can then be placed as an added security against bleeding.

Kind surgeon looks at the position of my hand (it is my left hand), before placing the tie. "I want you to open the clamp just like you would if you were putting it on."

"Okay." I reply. I don't change my hand position. As described earlier my fingers, open and slightly curved, pad of thumb.

He repeats. "No, see how you are holding the clamp? I want you to open it the same way you would if you were placing it. So put your thumb and finger through the rings. You need to have complete control of the clamp when you are flashing it."

I place my finger and thumb as told but the clamp is perpendicular to the patient and my wrist is twisted at an awkward angle.

"My left hand." I mutter, as if an apology.

Kind Surgeon gently rolls the clamp to a more parallel position.

"There, isn't that better?"

Well yes, it is. Why didn't I think of such a simple motion? That is why I am not the surgeon.

"You should remove all clamps this way. It gives you better control and it prevents that popping off that happens sometimes. Have you ever had that happen?"

"Yes" I reply. In my head I am thinking of all of those hours of practice removing clamps without thumb and finger in the rings. I was proud of my ability to do so smoothly and slowly, especially left handed. Except for the occasional "popping off" of course.

" You should remove the clamp with enough control to be ready to close it again quickly in the same spot in case something happens and you need to control bleeding."

I had never thought of that. Looking back I can think of at least one occasion where that information would have been useful.

Kind Surgeon places the tie. "Okay, flash."

I flash the clamp as instructed, with complete control.

He finishes tying his tie.

I begin to remove the clamp, totally forgetting that we have just flashed this large vessel and a second tie is customary before removing the clamp.

"No, no no!" He exclaims.

I realize what I am doing as I do it. It seems to be in slow motion actually. I immediately secure the clamp again.

"I'm sorry! I know we just flashed and you need a second tie first. But look! I closed the clamp quickly and it's in the same spot. Just like you said! A good lesson learned!" My feeble attempt to cover up a rookie mistake provoked no response.

Forgiving me my previous mistake, I was allowed to fire the GIA 80 stapler when it was time to transect the ileum. He planned this from the beginning because he inserted the stapler from my side, handles to me, when it just as easily could have come from his side.

After the primary tumor had been resected and passed to the back table, the rest of the case was uneventful. The usual sequence, a side to side anastomosis, mesenteric defect approximated, irrigate, check for hemostasis, adhesion barrier material placed and closure.

Maybe next time, Kind Surgeon will let me tie!

A special kudos to the Anaesthesiologist. Although this patient was thin, the amount of sustained relaxation made the case a pleasure, all the way through to closure.