Anatomy...

If there's one thing surgeons complain about it's the anatomy or lack there of in the medical schools these days. Yes, at some point in history (i.e. only several years ago) the medical school that 'teaches' me had a significant lack of anatomy in its curriculum. That was quickly sorted out and the volume of anatomy I learned in my first two years was much better than what I heard was standard back in the day. However, there are still issues. Nowadays, although surgeons complain to students about how anatomy is poorly taught in medical school, I must say that it is not entirely accurate - there are student factors.. and plenty of them.

This morning it was time to see a decent operation. We had only one operation booked in and I was determined to scrub into it. There was another medical student on the team and I did ask her if it was alright for me to scrub in and she said yes. What I did and she didn't know was that there was only one case booked in. The way I see it is: if I went through the trouble of finding out what's booked in, asking the Consultant if I can get involved and she merely was standing there - I don't see why I shouldn't be allowed to. Plus, she said go ahead and if she didn't know about the list, that's not my responsibility. It's not hard to work it out.

We had a 59-year-old gentlemen who had a colonoscopy for colorectal cancer screening after a faecal occult blood test came back positive. The registrar in gastroenterology performed the colonoscopy and concluded: There is a large polyp in the proximal aspect of the caecum, which could not be removed via hot snare due to its size. The location of the polyp was tattooed on the proximal and distal segments of the caecum. So it was up to the colorectal team to remove it; though just to be on the safe side, we'd remove some of the large bowel as well.

The surgical procedure planned was a Laparoscopic Right Hemicolectomy, which involved key-hole surgery to dissect the proximal colon and mobilise it up to the hepatic flexure, remove it and anastomose what was left, which would be almost 2/3rds of the colon. Thanks to the public hospital system, we had to wait 40 minutes scrubbed into the case for the technicians to rectify the poor lighting from the laparoscopic camera. There wasn't much success because I'm sure there wasn't money exchange for the fix. On with the surgery!

The operation went smoothly and it was amazing to watch, get involved and hold the laparoscopic camera. I am particularly interested in laparoscopic surgery and believe it is the future of surgery in the abdominal cavity. Minimally invasive, but the potential is nerve racking. Finally, we were able to extend the initial port incision to allow the colon out of the abdomen, so we could remove it. Dissection of the mesentery was smooth and then it was time to staple and seal the segments.

After we removed the large bowel in question, the resident and other medical student were asked to dissect the specimen to find the polyp. The problem soon became obvious - there was no polyp in the caecum or ascending colon, both of which were taken out.

Fuck. Shit. What the fuck is going on? Show me the colonoscopy report!


The anaesthetist showed the colonoscopy report to the three of us - consultant, registrar and I. We all read the same thing - proximal caecum.

Not happy. Surgical exploration is warranted - let's have a look laparoscopically to see we didn't miss anything.


We were back into the abdominal cavity searching for the tattoo the gastroenterology registrar left behind.

Oh my God is that the tattoo there?


The consultant was asking the colorectal registrar and he agreed. It was a bluish stain on the colon. The location: descending colon.

Oh I'm going to teach that girl a lesson in anatomy. We're going to have a nice, long chat. 


Tension grew in the operating theatre. What do we do now?


We must convert this to an open subtotal colectomy. Extend the ventral incision and dissect the transverse mesentery without laparoscopy. Fuck, this is going to be a while.


As we retracted, dissected and anastomosed, the room grew quieter and quieter. Dominating the ambience was the patient's slow heart rate. It is a sound we all subconsciously listen to and it comes to attention when the rhythm is irregular or very fast.

Today, the importance of anatomy emerged. It was always important to me - I loved it. But now it holds a special place in my heart; entire management plans are based on the anatomical involvement of disease.

If there is one thing that has stood the test of time in the context of change in medicine and surgery, it has been anatomy. Of course there is variation in size, shape and sometimes location - but all in all, we must understand anatomy very well, learn to use it and above all, never ever make mistakes describing locations of disease.

Heed my warning.