Abdominal Drains are becoming a menace!

I've haven't been blogging for a while now but this is not due to lack of eventful happenings. I would blame it squarely on having no time to breathe let alone write!

Getting right into it, most of my regular readers would realize that the post on Abdominal Drain or Nasogastric Tube has got the most readership to date. It also has the most horrific pictures.

I guess I have a love-hate relationship with Abdominal Drains as this post will show.

Not too long ago, we had a patient who had a very bad stomach pain with severe constipation of recent onset. On the workup, he was diagnosed to be suffering from a low colon cancer. A straightforward decision for a resection and anastomosis was taken (cut and join for the lay people) and the patient underwent the surgery without issues and of course we put in an abdominal drain to prevent infection.

This is what happened!

It was fixed to the lateral wall of the abdomen. Where it was supposed to be fixed. Where it should have stayed. Where it generally always stays. But this is where I work you understand. It was done by someone else. But he came to us. The patient told us he was coming to remove the drain. As he was told by his doctor to do after 3 days. He had no clue. We had no clue at first. 

He was taken to the dressing room to remove the drain. Only there was no drain! There was nothing on the surface except the hole where the drain should have been. I asked him if the drain had been removed and he just wanted a dressing. He insisted that he was here to remove the drain. We got a feeling that something was wrong. We sent him for an Xray. This is it.

The drain had quietly and smoothly slipped inside the abdominal cavity. Inside. Without a mark or an ouch! Not even a sensation that the patient could feel. Just vanished into the body!

We knew this was going to be fun! We got him to a sonogram and tried to trace the drain but all we could see was the tip. We marked the area at the pelvis. We took a small incision and started digging. We emptied his bladder first, of course.

After some amount of fishing, this felt literally like looking for a needle in a haystack. Ultimately, we had to leave aside the instruments and move to our trusty fingers. They're the least traumatic you see. We hunted and hunted and finally felt the elusive tip. It took us about 10 minutes more to coax it out as it kept slipping back inside, but finally out it came.

That is how long it was. Luckily, it wasn't adhered to anything on the inside. The patient was discharged the same evening and made a complete recovery.

I don't think I'm going to use abdominal drains in the next few surgeries. Anyway, there is a lot of study as to the real utility in routine cases. What do you think?

Om Mangalam Mangalam

Every surgeon at one point of time has done a dressing for a patient. Each will have a story about it. None will be as wierd as this one.

This patient was one of those if-you-touch-me-I-will-scream-with-pain types who thought even a simple dressing would hurt her oh so much. What needed to be done was simple and painless. He abdominal drain needed to be adjusted as we thought it was blocked or irritating some part of her abdomen. Open the dressing, pull out the abdominal drain by a cm or two and re-dress.

I opened her dressing and she yelped for her aunt to come and hold her hand. I put on a pair of sterile gloves and she almost threw a fit. She had a pundit (Hindu Priest) in her room! She tells her aunt to tell her pundit to chant a mantra (prayer) for her pain. I start cleaning. He starts chanting. She starts screaming. She can't hear him. She actually orders him to chant aloud so we can hear. My face contorted in ways I cannot describe. I felt like you feel when you've found out your girlfriend is a transsexual. I almost couldn't help rolling my eyes. People who know me know my reactions to such people. It's not something I can write publically. Damn!!!

Well, anyway, i finished pulling out the tube. I even asked her if it hurt. She said no, no, not at all. I wonder whether that was because it was never supposed to or because in her head her pundit was chanting mantras.

Continuing the Nightmare

In continuation with my previous post, I am glad to inform you all that the patient is doing well. She is still in the ICU but 4 of 8 tubes are out, she's not spiking fevers any more, she is tolerating jejunal feeds (feeds directly into the intestine through a tube) and she has got off the bed and started walking with help.

The ryle's tube (through the nose) is out. The abdominal drain was zero so it came out. The neck drain was harldy anything so that came out as well. Neck staples from the skin are also out. Since she is now able to walk a bit we also took out the urinary catheter just to be nice.

By no means is she back to normal. She's not even close. She still has an ICD in place and a subcutaneous drain. She has a subcutaneous infection at her chest site where we had to open up the thorax. However, compared to her situation I think she's doing really well and should pull through.

Now I can go back to writing my blog with a smile on my face!

Living a nightmare on a manic monday.

Manic Monday has taken on a new meaning. People have nightmares. We worked through one.

I started work on Monday morning at 8 am. I finished work on Tuesday evening at 8 pm. 36 hours! We operated non stop for 12 of those hours. All of which were at night. 10 pm to 10 am. One break around 7 am.

I will not discuss the case in detail owing its sensitive nature. What I can tell you is what I went through, how we managed and how I felt.

We started Monday with our regular cases which went off smoothly, other than a minor glitch which was solved on table itself. That was a warning. Towards the afternoon, we got to know that we might have to re-operate on a patient from out of town. She was on her way and was not doing well. We planned to do an X ray and decide if it was required.

It was.

We had a plan. Go in, find the problem area, do minimal handling, leave abdominal drains and come out. Murphy's law was in full force. Nothing went right.


10 p.m. We started laparoscopically, found the rent in the oesophagus, tried to get at it, tried and tried. The liver was getting in our way, the spleen was oozing blood because its capsule was stretched to tearing, the camera kept fogging up, the omentum was playing policeman in the abdomen sealing everything off. 12 midnight. We got a stitch in. It wouldn't hold. Cut through. We stitched again, it cut through again, and again. We lost length of the oesophagus in the abdomen. We were literally pulling it from the thorax into the abdomen through the hiatus. 1 a.m. I know this is getting technical but there is no other way to say it. Once we knew we had lost a lot of length, we also unfortunately knew that now we couldn't just leave abdominal drains and come out.

The only option now was to open. Open and do what? We weren't entirely sure this time, but we knew we had to open. We did. 2 a.m. We tried to reach, we cleared blood, we started giving blood to replace losses. We endoscoped to look from above and find the defect. We did. We took a stitch. It gave way again. We decided to try the circular stapler. 3 a.m. We struggled and managed to insert it somehow through the oral cavity for the orvil. We fired. It gave way. We now had two rents, one in the oesophagus and one in the stomach where the circular stapler was fired from. 4 a.m Boss was exhausted and running out of options. We stood there with our mouths hanging open, knowing that this was not ending anytime soon.

Stenting the oesophagus was an option. Somewhere in the timeline we tried to get hold of a stent. All the company people were sleeping. Stenting would not happen this night. 5 a.m. We asked for help cause we needed an extra set of hands. We called the on call R.M.O. (Resident Medical Officer) No answer. People sleep at 3 a.m. We tried calling the surgical registrar for the O.T. No answer.

6 a.m. Blood pints given 4 FFP 1. We needed help and we knew it. They say a great surgeon is one who knows when to call for help. It was decided to do a thoracotomy and get the oesophagus through the chest and anastomose (join) it to the jejunum (intestine) bypassing the stomach.. We needed a thoracoscopic surgeon and we called for one. The one we called said he had prior commitments later that morning but would come in at least and also advised us to call one more surgeon so that in case he had to leave, the other could take over. Smart idea. I respect that man and this was just one more reason to. We called and the other thoracic surgeon also came.

7 a.m. My first break. My anaesthestist watched me falling asleep on my feet and rightly told me to go wash and come back. I did. Ate breakfast which was a roll ordered last night for dinner. Had to get something in for energy.

The surgeons had arrived and taken over. Literally. We were too exhausted to be the lead team. We assisted. Chest cut, neck cut, oesophagus mobilised, nasogastric tube inserted. The tube came through the food pipe into the abdomen. What more could go wrong. We were no longer flustered. We just continued on instinct.

10 a.m. Skin closed with 4 drains. One ICD for the chest, One abdominal drain for the abdomen, one neck drain for the neck, one subcutaneous for the wound..

Unfortunately, the day did not end there. The regular cases posted were to be operated and we had commited to them so we did. It took longer than normal but we did it. 8 p.m.Finally we were done.

If you get nothing else from this post, get this. The level of respect for boss has gone up skywards. He just did not give up. I pray that she makes it. She's in the ICU now. Will follow this up once she's better (fingers crossed)

You're too busy to call

......And people ask me why I'm sooo tired and can't call.



The last two days of my life have been spent in the operation theatre looking down on people with guarded abdomen and pain all over.


All this started on that fateful double emergency weekend when I felt a strange sense of niceness about an old man who came in holding his stomach telling me he hadn't moved his bowels in 4 days....Well normally he would have won himself an enema but something told me we should admit him and keep a watch on him.....Little did I know that at the same time my junior resident was feeling a little nice towards another person who had an abdomen as hard as an ironing board! Thik hai, it was important, nay, imperative that he be operated as soon as possible, so we set about getting his work up done so that the anaesthetists would agree to give him anaesthesia...


We did his blood count, sent his urine for examination and tried to get a chest X ray. That's when all the fun began...Our great hospital run by the great BMC with a Great Medical Superintendent and great Technicians inform us that the X ray machines are not working. After explaining to them that this is indeed an emergency and not an ordinary ward patient whose work up hasn't been completed in time, (Yes we do that sometimes) they finally agreed to get a portable X ray machine to take the X ray but also were quick to warn us, "quality ka koi bharosa nahi dete hain, jaise niklega usise kaam chalana padega" (no gaurantee on quality, you will have to make do with whatever image comes in).


It wasn't like we had a choice so we got that done. Then the anaesthetist says we're not on call, so please arrange for a private anaesthetist as its past 2.00 pm. It was a Sunday, little chance of finding a private anaesthetist who would come and work for just Rs. 200 ( that's right, that's all they get paid for coming to a BMC hospital ) but nevertheless I tried. One said I'm not going to come and waste 4 hrs on a Sunday, the other cleverly said she was busy and I should try and send the patient to Sion where there was an on call anaesthetist and the case could be done there. I called Dr. Broadwalk and asked him what to do. He says, "Its ok, transfer the patient." So I went up to the patient and told him what was decided. This dude for some reason or the other tell me that no matter what happens he wants to be in this hospital only. I warned him that his life was in danger. He tells me that he doesn't care even if he dies but he's gonna stay right here.Well he didn't die but he was sure taken to the limit.


Enter Monday and we do rounds as usual and suddenly Dr. Broadwalk says to me, "This guy needs to be opened." We rush helter skelter and get him ready for the OT. I shall spare you the nasty details but let me tell you he had a hole in the Intestine: what we call a 'Perforation' and it was leaking stools onto the insides of his abdomen so much so, that what is supposed to be pink and healthy was looking Yellow and severely diseased. We fixed him up in about 2 hrs and left him with drains on either side of the abdomen to relieve any fluid which may collect inside!


The second guy was taken with all the work up done and in him we found a perforated appendix. What that means is that he probably had multiple episodes of inflammation of his appendix and it finally gave way and punctured!!! This led to fluid in his abdomen and the hard abdomen with all the pain. He was left with just one drain on his right side.


I wish this was the end of the story but come Tuesday we had more emergencies happening with one persons umbilical hernia becoming strangulated (basically meaning that the hernia was cut off from blood supply causing obstruction to movement of the intestine and impending gangrene of the bowel). He was taken in and operated on and everything did not go smoothly. Firstly this guy was fat and I mean FAT! He had a belly girth of 48 inches. To top it off he wasn't prepared for the surgery and it showed. He passed stools in the middle of the operation and as if that wasn't enough he proceeded to Vomit on the table. This led my great BMC employed Dr. Broadwalk to exclaim, " What the hell, we are now operating in SANDAS."

The other case was this lady with a huge mass in the right side of her abdomen which needed removal. On the table it turned out that this was a huge cyst arising from her ovary which prompted the removal of her uterus, ovaries and part or her cervix.


As a result I haven't had lunch in two days, I had a migrane on the first day due to hunger which is quite common with me and am sooooo tired that I can barely talk to any of my friends on the phone and they probably think I'm being a real high nosed red assed creep who is the only one working and the only one who is busy and can't call!!!


You know what........ inspite of all this I've had to endure I loved every minute of cutting open all these people and removing some of their organs!!!!