Doing Harm (10 page)

When patients recover after surgery, they’re mostly healing from the damage done to them during the surgery itself, not from the disease that prompted the surgery in the first place. The goal of minimally invasive surgery is to speed up recovery by doing as little damage as possible. In traditional surgery, we make big incisions so we can stick our hands inside patients to operate. In minimally invasive surgery, we make small incisions through which we insert long, thin surgical instruments shaped like oversized chopsticks. Minimally invasive surgery is a much more precise way of operating than traditional surgery. I think of it as high-tech robbery, stealing valuable objects out of patients without touching anything else, making clean getaways from the insides of their bodies as if we’d never been there. It’s also a lot like playing video games: Because we can’t directly see the tips of our instruments, which are inside the patient, we instead stare at a video monitor mounted over our heads, using the images transmitted by a camera placed through one of the incisions to guide our movements.

Some researchers believe that my generation, the first truly video generation, has been naturally trained to do this kind of surgery from childhood. I’ve been cranking on joysticks ever since I could crawl, and there’s no doubt in my mind that my gaming skills have crossed over to my surgical skills. Larry recognizes this, too. As we begin, he stands next to me, holding the video camera, intently watching the video screen, letting me do most of the work. Larry is partial to Led Zeppelin, so as I start poking around Mrs. Samuelson’s abdomen with the oversized chopsticks, “Kashmir” from
Zeppelin 3
thrums from the speakers of Larry’s iPod. Luis, interested in learning about this operation, soon joins us, taking control of the video camera from Larry so that he can follow my movements like a cameraman for an NFL game.

We find the tumor right away: a big, bright yellow ball pushing its way out from underneath the liver, just above the kidney. It looks completely out of place among the normal organs in Mrs. Samuelson’s abdomen, a suspicious stranger skulking around an otherwise good neighborhood. Using the electrocautery, I begin to gently peel normal tissue away from the tumor and cut it away from the organs sitting next to it.

Today is a good day.

I’m in the Zone, baby.
Definitely. I’m in that place where I know I can do no wrong. It feels great. Better than great. It’s absolutely exhilarating. My hands seem to know where to go, to have taken on a sentience all their own, to consider multiple moves, then act without my even thinking. It’s like I’m standing there, staring at the screen, a spectator in the room, watching my own hands operate. I barely have to think as I steer my instruments through her abdomen. What a rush.

Mrs. Samuelson has what we surgeons like to call a
virgin belly.
This means that she’s never had an abdominal operation before and that her internal anatomy is absolutely pristine, just like a textbook, undistorted by scar tissue caused by prior hands probing inside her in search of appendixes or gallbladders or uteruses to remove.

Larry stands next to me with his arms folded, at turns coach and cheerleader. He otherwise doesn’t help. He doesn’t need to. I make steady progress and, chipping away at the tumor like a sculptor working a piece of marble, carefully cut the attachments holding it in place inside her body, one by one. After an hour of meticulous work, I’ve released most of those attachments, and now the only major portion still anchoring the tumor to the rest of Mrs. Samuelson’s body is the one that’s sticking to the IVC. It’s the same part Larry was worried might be tougher than the rest to cut out. It’s also the part where, more likely than not, the main blood supply of the tumor is located.

Larry tells me to stop. He darts over to the video monitor on the other side of the table. He squints at the image, pressing his face up to within inches of the monitor, tilting his head—first one way, and then the other—before nodding approvingly.

“Okay, okay. Good, Slick, good. You’re doing a great job. Keep going along that plane there”—he points to a spot on the screen—“but now I want you to start marching this way”—he draws an arrow in the air in front of the screen with his gloved finger to indicate direction—“
carefully.
We’re not sure where the adrenal vein is yet. Okay?”

“Okay, boss. No problem.” I’m sure it won’t be.

Larry returns to my side of the table, and I start operating in the direction he indicated. But a few minutes later, Larry gets a call from one of the other ORs. The chairman of general surgery has unexpectedly run into trouble and needs some help. Immediately. And he wants Larry personally for the job.

This kind of thing happens a fair amount. Larry’s so good that, whenever another surgeon at University gets in the weeds during a difficult operation, Larry’s often the one they call for a hand.

Although I’m sure there’s a part of Larry’s ego that secretly loves it, and revels in being the go-to guy for some of the most important surgeons in the hospital, for the most part today he’s annoyed. The patient is in an OR located in a different area of the hospital, and he’ll lose several minutes just walking back and forth, not to mention however long it takes him to solve the other surgeon’s problem. But this isn’t a request, really—it’s an order. So he sighs heavily and steps away from the table, ripping off his sterile gown and gloves while muttering obscenities.

“Okay, Slick,” he says. “I need you to fly solo for a while. It should only take a few minutes. I’ll be close by if anything happens. Keep going along that tissue plane I showed you. But once you get to the medial aspect of the tumor, where the adrenal vein is, stop and wait for me. I think it’s going to be a really tough dissection in through there, and we may run into some serious bleeding. I don’t want you trying it by yourself.”

Fair enough.
“No problem, Larry.”

“I’ll be right back.” He leaves the room.

I turn to the video screen and stare at the tumor: big, fat, and a grotesque shade of puke yellow.

It glares back defiantly, as if taunting me.

Well, what are you waiting for, Slick? Are you scared now that Daddy’s not here anymore to hold your hand?

I think about my next move. In my left hand, I’m holding a pair of forceps: essentially a pair of metal pincers, like pliers, used to grasp and hold on to things. That’s fine. But I need something for my right hand, which is empty.

“Sucker, please.”

The scrub nurse hands me the sucker. I slide it through the plastic port and into Mrs. Samuelson’s body. Its magnified tip appears on the video screen next to the forceps. The purpose of the sucker is exactly what it sounds like. The technical term is
vacuum suction device.
But everybody I know calls it a sucker, which is pretty descriptive, since it sucks blood and other bodily fluids away from the operative field so that surgeons can see what they’re doing. Since being able to see what you’re doing is one of the more obvious components of a successful operation, it’s an immensely important surgical instrument, but it tends to be underrated because it’s not as glamorous or sexy as the other ones. But I also like to use the sucker to dissect things during an operation, a habit I picked up from Larry. Now I put the sucker to good use, gently sweeping the tumor off the other tissue as I slowly but steadily march along the path Larry marked for me.

Sweep, sweep, sweep.
Using the sucker, I delicately brush the tumor away from the tissue that’s holding it in place. Things continue to go very well, and I begin to wonder what Larry was talking about. After all, this part of the dissection isn’t so bad. Certainly not as bad as he thought it was going to be. My confidence swells, and I pick up the pace, swinging the sucker in ever-more-aggressive arcs that increase the speed of the operation and take me closer toward the area around the as-yet-unseen IVC and adrenal vein.

The area Larry told me not to work on by myself.

That last thought gives me pause. I stop to survey my handiwork. I’m now very close to the most dangerous part of the operation, and I really should stop and wait at this point for Larry to come back. I’ve never done anything like this before. But a large portion of the tumor, previously trapped in place, has peeled away in response to my work, curling away from the healthy tissue to which it was previously clinging. I imagine that separated edge of tumor flapping in an imaginary breeze, begging me to keep going, to keep taking it off, to march ahead and finish the operation.

In my head, the tumor starts mocking me again.

You ain’t no pussy, are you, Slick?

I decide to keep going. A little more progress before Larry gets back in the room won’t hurt anything. Besides, I know what I’m doing.

Luis isn’t so sure. “Steve. Shouldn’t you stop and wait for Dr. Lassiter to come back?”

“No. We’re okay. We’ve got some great momentum going with the dissection, and the exposure is perfect. If we stop now, we’re going to lose our momentum
and
our exposure. I’m sure of it. That’s a good teaching point for you, Luis: If you’ve got momentum going during an operation, try not to lose it. Besides, do you know what surgeons say about asking permission to do something?”

“No, what?”

“‘It’s better to beg forgiveness than ask permission.’ Remember that.”

“‘Better to beg forgiveness than ask permission.’ Roger that.”

Sweep, sweep, sweep.
I keep teasing the tumor away from the healthy tissue with gentle sweeps of the sucker. It’s coming off perfectly now, as easily as peeling a self-adhesive postage stamp or sticker off the backing once you’ve worked off that stubborn first corner. Just a little bit more, and I’ll have the tumor out before Larry’s even back in the room.

“It’s tough sometimes being so good,” I say, sighing. Luis guffaws, jerking the camera. The image on the video monitor momentarily bounces up and down. The motion reveals a hint of blue at the bottom of the screen.

“Hey,” I say, my excitement growing, “is that the IVC? Luis, zoom in on that blue patch.” He does. It’s the IVC. It’s perfect, exactly the location where I want to be.

I rule.

“Yep. That’s the IVC all right. Excellent. So if we push on it up in this direction…” I push upward on the tumor with the sucker. In response, the tumor slides smoothly away from the IVC. “We should be home free.”

I push again in the same direction, and then again, and then again. Each push separates the tumor from the IVC a bit more. The tumor starts to move up and away from the IVC in exactly the way I predicted.

Then, suddenly, it stops.

I push some more, but the tumor won’t budge.

“Hmmm. It seems to be really socked in right here,” I narrate to the rest of the room. Surgeons do that sometimes to help them think. “There must be some desmoplasia from the tumor making it stick a little bit. No big deal. I’ll just have to push a little harder right about … here.”

I move the sucker to a different spot on the tumor and push again.

Nothing.

“Maybe try the scissors here?” Luis asks.

“No … I think I’d rather stick with blunt dissection for now. I wouldn’t want to stick the scissors directly into the IVC. The tumor’s just putting up a little bit more of a fight now. No big deal. I’ll get it.”

I pick another spot on the tumor and push against it again with the sucker, a little harder this time, with steady and firm pressure, trying to coax it off the IVC just a little bit more.

It gives a little.

Bingo.

The tumor is stubborn, but so am I.

I push again.

The tumor gives a bit more, and suddenly I can feel that it’s almost there, that there’s just one more small spot that’s still holding it to the IVC, just one more point to release before I’m home free and the hardest part of the operation is over. I can feel it. I know it. So I keep pushing up on the tumor. Up, up, up.

The edges at the sticky spot separate. The tumor starts to peel away again.

Yes! I imagine Larry walking back into the OR, checking out my progress, duly impressed at my having done such a difficult dissection all by myself, slapping me on the back, recognizing Slick’s skills.

Almost there …

The tumor stops peeling. Again I push a little harder, up and up with steady, firm pressure, confident now that the sticky spot will give the same way it did before.

Suddenly, sickeningly, it does give.

It gives the way a stuck window that’s been shut all winter gives during spring cleaning, after you’ve pushed against it with all of your might for several minutes, grunting and gasping and wheezing in the dust, until it slams upward against the top of the frame with a loud crash.

The resistance,
all
of the resistance, disappears.

My hand holding the sucker jerks forward.

Bright red fluid jets upward like a geyser.

Blood.

Before I have time to react, the jetting blood envelops everything on the screen. Tumor, kidney, liver, IVC, my instruments—all disappear underneath a bright red sheet of blood. It’s as if a thick red curtain has dropped over the entire operating field. I can’t see a thing. Everything is gone, lost in a disorienting, monotonous field of redness.

I feel my stomach drop through the floor.

Fuck.

Sweat instantaneously materializes over every square centimeter of my body, my heart starts hammering away at the inside of my chest, and my breath feels like it’s been knocked out of my body by a two-by-four.

“Oh,
shit,
” Luis gasps.

Behind me, I hear the scrub nurse sharply suck in her breath.

I frantically sweep the sucker back and forth, trying to part the red curtain and figure out what’s going on, to figure out where the bleeding is coming from so I can put a stop to it before Mrs. Samuelson bleeds to death.

But nothing happens. The screen remains a perfect, unblemished scarlet. There is only the red. There is nothing else. I can’t see anything. And because I can’t see anything, I can’t do anything. I’m absolutely helpless.