My Day

I remember well from my residency days the post-vacation "power surge." It goes like this- I'm energized and ready to do more reading, exercise more, etc.  After all, I usually have several hours every evening to spend, right?  Then, after only one night of call and one long day of operating, I remember how exhausting being a surgeon can be. I am I'm too tired to read. It takes all of my energy just to make some pizza for my husband's birthday. My feet and shoulders ache. I just want to sit down and put my feet up. I sound old.

Why am I so tired? Perhaps because yesterday the inguinal hernia was huge...so was the hydrocele. And today, well, today was just full of surprises. Every day around here we find ourselves saying, "That is the biggest/worst <insert diagnosis> I have ever seen" or "I've never seen anything like that before"  several times each day.  Its exciting, interesting, challenging...

For those of you who have the interest/patience to read medical stories...this is how the day went:

It all started smoothly with an umbilical hernia repair in a child. No problem.

Then, I had three urgent laparotomies. The first was a young child with fevers for five days, obvious diffuse peritonitis, and a very distended abdomen. I made my incision, entered the fascia, then carefully cut the peritoneum. I thought. But I still wasn't in the abdomen. So I cut another layer and another. Still no pus, no omentum, no bowel.  Just a fluctuant mass under the fascia. Was I cutting in to bowel stuck up to the abdominal wall? I aspirated the mass with a needle. Air. So I cut through some more tissue...and finally after cutting throught a few millimeters of peritoneum, a liter of foul smelling pus poured out of her abdomen and her belly deflated like a balloon. She had the thickest peritoneum I have ever seen. Her bowel was inflamed, scarred, and everything was stuck together and bled if I tried to separate it.  She likely perforated her bowel some time ago and then sealed it off. I don't remember seeing patients in residency who had had several days of acute peritonitis before coming to the hospital, but here I'm quickly learning what that looks like.

Next, was a lady with a ruptured ectopic pregnancy. This was more straightforward (although, again, not something I encountered in general surgery residency).  I excised the ectopic/tube and evacuated old clot.  To add some interest to the case, her uterus was larger than expected. We're not sure what she had in her uterus, but I got it out with a D&C...

I took a break from the laparotomies to do a simple excision of a draining umbilical sinus in an adult. But the sinus kept going. When I followed the tract it opened into a cystic structure. Green/grey mucous gushed out along with chunky, yellow calcifications. After more tedious dissection, we followed the cyst down to the dome of the bladder where it was adherent (but no open connection).  I've never seen anything like it before...but I have read about urachal cysts and it fits the description...likely with a mucinous adenocarcinoma arising from it. Interesting.

After I finished that urology case, I proceeded with the third laparotomy. (As an aside, the turnover time here can be awesome. Today I had about 5 minutes between each case- just enough time to drink some water, do the paperwork, and wash my hands.)  Anyway, woman in her 20s with peritonitis, fevers, right lower quadrant mass on ultrasound. I cut through fascia and peritoneum and saw a huge mass? It looked like a pregnant uterus...but lumpy. It took me several minutes to define any anatomy. The uterus was large and bumpy. The bladder was draped over half of the uterus...the omentum was stuck to everything, and there were pockets of serous/green fluid scattered throughout the pelvis. For the fourth time today I was mystified. Finally, I freed some omentum from a big tubular structure stuck to the uterus that looked like thickened small bowel and found pus. Then I realized the tubular structure was her fallopian tube...3cm in diameter. The biggest fallopian tube I've ever seen. Mystery solved...tubo-ovarian abscesses. I aspirated and drained pus from both fallopian tubes and ovaries.  She should do well.

Last, but not least, I did a lateral internal sphincterotomy for an anal fissure. No problem.