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)

4 for the price of 1.

Scheduled for a lap. sleeve gastrectomy, a patient of ours was given accomodation in day care wards which is basically 4 beds in a room, fair enough for day care where you expect to leave the hospital in a day. The reason for this was that the class he had opted for which was a single room was full and so were the deluxe rooms. He was told that as soon as the room becomes available he would be shifted there. It is now his 3rd day in the hospital and he still lies in the 4 in 1 room. As luck would have it, his bunk mates consisted of the following:

The first came for a minor surgery and left the same evening.

The second was in for his chemotherapy. His relatives decided to wait with him till the chemo injections had run in. This was to be till 2 am which led to them watching tv till then to keep awake thereby keeping our patient awake as well.

Just when he thought it was finally done, in comes number three who had arrived from Iraq at 4.30 am and brought with him a bunch of relatives all speaking in arabic with their volume louder than the tv could possibly go. Our patient did not sleep very well.

The first thing he said to us this morning was not about his discomfort from the surgery he had yesterday, nor was it that he was hungry or thirsty (he was nil by mouth) neither did he say anything about the machine compressing his calves. All he wanted was to change his room. One that he had paid for. One that cost almost double. One that was not available when he got admitted. One that is not even available now as I write this.

The most innocent but relevant question was asked by his wife: If the room we wanted wasn't available, could we not have postponed the case? Could we not have waited till that class became available before admitting him and lastly could we not have discharged him if he didn't get the room he wanted?

I guess we all know that answer to that but I won't write it just yet!

SILS Sleeve Gastrectomy

On 14th September 2009, the CODS (Centre for Obesity and Diabetes Support) team of doctors created history at the hospital by successfully performing the first ever true single incision laparoscopic surgery (SILS) for sleeve gastrectomy in the whole of Asia. I was fortunate enough to be part of this team!

The SILS procedure is one of advanced laparoscopy wherein a single port of entry is devised using a special flexible port so that we can enter the abdomen through just one incision on the umbilicus and perform the surgery which would otherwise use 5 ports.

The advantages are immediately evident:

Single port (I can't emphasise this enough)
Less pain
Less recovery time
Obviously better cosmetic outcome
Done correctly the scar from the single incision hides within the umbilicus so virtually scarless!
Absolute boon for young women who need surgery but don't want it to be seen.

For the other side of the coin (and there always is one), it is marginally more expensive (should not be a problem for the kind of patients we're targetting) and requires a learning curve that would be greater than regular laparoscopic surgery.

It was tough, it required skill which my boss very capably handled and it required patience which I think came to the team knowing that we could become part of history.

We have had the company confirm that this was the first of its kind in Asia. We know that other surgical procedures have been carried out using the single port and have been published as well. We know that in the States this procedure is already on the way.

Keeping all this in view, We are all still quite damn proud to be the first in Asia to do what we did because we know that what we did was technically far superior to the other procedures done so far and its only a matter of time till we catch up with our compatriots in the States.

Bottom Line: We did it first!

This is a link for all those who can bear to watch.
Click here to You Tube It!

Squeamish people can stop reading here. Attached below is the picture of the port used and the final appearance on the umbilicus which will be difficult to find in about 3 weeks.