It’s been a while since my last post, but things are starting to wrap up at the hospital. Well, for my SRP, but not for anyone else. One of the pediatric neurosurgeons, Dr. Ruzicka, has performed multiple brain surgeries in the past week, all tumor resections, and he’s been kind enough to let me watch some of them. Brain tumor resections are very long cases, as they can last for more than 8 hours. Even the set-up is much longer than most of the surgeries I’ve observed. While watching these surgeries, I was particularly fascinated by two pieces of equipment:

            The first is a technology called Stealth. To use Stealth, doctors must take an MRI of the patient pre-operatively. Then, in the operating room, the equipment technicians place a sensor next to the patient, and connect it to the Stealth machine. The surgeon can then use a tracing needle and place it in the patient, and the sensor will pick up the tracer’s position, relative to the patient’s anatomy. The screen on the Stealth machine will show where the tip of the tracing needle is with multiple angles of the MRI that was taken earlier. So during surgery, a surgeon can figure out what exactly he or she is looking at by using the Stealth technology.

            The second is the microscope that Dr. Ruzicka used during the tumor resections. It was an incredibly complicated device mounted on a 7-foot tall arm. There were 4 different pairs of eyepieces and buttons on every side of it. Before the surgeon could use it, the entire arm had to be wrapped in a sterile covering, so he would remain sterile while working with it. The equipment technicians connected it to a 3D screen, so everyone in the room could wear 3D glasses and see the surgeon’s work more clearly.

            In other news, we had a fire drill in the clinic building today. With only a couple days left of my SRP, the problem at hand is trying to fit the whole experience into a relatively short presentation.

Two Surgeries I Didn't Know Were Surgeries

This week was a pretty short one for me, as I was only at the hospital on Monday and Tuesday. I was out of town for the rest of the week, so I wasn’t able to do as much as in previous weeks. I spent most of my time in the OR during those two days, but I did reach my goal of having at least 6 participants do timed anastomoses.

On the other hand, I watched some surgeries that I didn’t even know existed before Tuesday. The first case was on a person whose costal cartilage was protruding on the right side of his sternum. This excess cartilage was causing his chest to have an abnormal ridge to the left of his midline, since his left ribs were normal. To correct the problem, the surgeon, Dr. Greenfeld, had to cut through the patient’s chest until his costal cartilage was exposed. He pointed out to the rest of us in the room that the cartilage from separate ribs was overlapping and building up, only making the problem worse. Dr. Greenfeld pulled the cartilage out of the kid’s chest from about 4 different ribs and kept the pieces to the side. This left a gap in the patient’s chest, which the surgeon closed with some of the pieces of cartilage, so the cartilage would heal without the prominent ridge. The patient was in his late teens, so his ribs and his cartilage were very mature, making it much harder to pull the cartilage out. Another effect of the age is the amount of pain that the patient would have during the healing process of a few months. Any excision of the actual ribs would be more effective in removing the ridge, but would be more painful during recovery, so Dr. Greenfeld only took cartilage. Before completely closing the wound, the surgeon placed a drain in the kid’s chest to address any internal bleeding.

Another surgery (that some people may react more sensitively to) that I watched was on a baby that had just been born 2 hours earlier. The baby was tiny, and weighed less than 2 kilograms! His limbs had about the same girth as my thumb. In order to explain why he was in the operating room so early, here’s some background:

While in the womb, a human’s intestines are developed outside the fetus’s body, and when the fetus is big enough, the bowels fold into the abdominal cavity, following a specific pattern. In some cases, including this one, the bowels do not enter the abdominal cavity, and the baby is born with its bowels outside its body (not a pretty sight), although the ends are still connected to the stomach and the abdominal wall. However, this baby was too small to fit the bowels back in immediately, as most babies with this condition are. So the surgeon, Dr. Cox, placed the bowels in a special bag, in which the opening enters directly into the baby’s abdomen. Every day, the bag will be taped, and the bowels will slowly enter the baby’s abdominal cavity, until the opening can be closed surgically.

Things are starting to wrap up at the hospital, now that there are only three weeks left in my project. I’ve had almost everyone in the office, surgeons and their assistants alike, come in to do at least one pair of anastomoses to compare to each other. As a reminder, each participant is doing one anastomosis with smooth sutures, and one with barbed sutures. One external variable that could possibly affect the results is the fact that a task or procedure will almost always be easier the second time a person does it. Since the participants cannot do both anastomoses at the same time, we had to find a way to minimize this effect. So everyone completed a practice session to get the first simulated anastomosis out of the way, while getting used to the tools. This way, the participants would have started moving along the learning curve before they were timed. To further minimize the effect of the learning curve on the data, some of the surgeons have thankfully been able to set aside enough time to do a second round of time trials. So far, both surgeons and physicians’ assistants have been suturing more quickly with the barbed sutures.

However, the material and length of the barbed sutures have been a bit cumbersome for some of the surgeons. For example, some suture material has more “memory” than other material, which means it maintains its shape if it is bent, similar to how a piece of paper will remain bent if it is folded in half. This can cause annoyances while using the suture, because it will bounce back to its previous position if one lets go of it. The length of the suture can also be an issue when using it laparoscopically, since one always wants to keep the material and tools within the camera’s field of view.

In other news, I was able to watch Dr. Workman, the pediatric plastic surgeon, during some of her cases this week. On Friday, she had a surgery on an infant who had been born with radial deficiency. Radial deficiency is a congenital condition in which there is a lack of length in the radius, one of the bones in the forearm. The shortened radius causes radial club hand, in which the wrist is angled toward the radius, usually accompanied by a deformed or missing thumb. In order to straighten this baby’s wrist, Dr. Workman first opened up the wrist and moved all the tendons and ligaments out of the way. She then drilled a rod all the way through one of the metacarpals, entering the bone in the wrist and exiting it near the fingers. She then switched to the other side of the rod and drilled it into the radius. To finish, Dr. Workman cut off the extra part of the rod and closed the muscle and skin. Now, the rod is acting as a longer radius, effectively keeping the baby’s wrist straight. She also said that, in 6 months, she would be able to make a new thumb for the infant from its index finger. 

This has probably been the busiest week of the Senior Research Project so far, which is why the blog post is so late in the week. I’ve spent a lot of time in the OR and in the office, gathering data, so here’s what I’ve been doing:

On Thursday, I had the opportunity to watch a neurosurgery case! But in order to explain what the case was about, I need to give a little background. When humans are developing, the spinal cord forms all the way into the tail bone, and as the fetus develops more, the spinal cord shortens, so it ends before it reaches the sacrum. In some babies, however, the spinal cord does not shorten, so it extends into the tail bone even after birth. In some cases, babies are born with tails that they can move, since the spinal cord extends into the tail. The baby being operated on did not have a tail, but did have a spinal cord that extended into her tail bone. So the surgeon, Dr. Ruzicka, made an opening in the baby’s back, exposing the spinal cord, which looked like a silvery, translucent cord. He then used a microscope to cut the spinal cord, and only the spinal cord, where it should have ended. He then used the smallest needle the scrub tech could find to stitch the dura mater (the outermost layer of the sheath covering the spinal cord) back together. By watching this case, I also learned that it is imperative that the surgeon has the tools he originally asked for.

While I was in the office, I had the surgeons start doing time trials with the smooth and barbed sutures. Here is a comparison of the two different suture designs:

Both of these sutures are monofilament sutures, so they are made up of only one strand of material (as opposed to multifilament sutures, which are braided). 

Hey followers! This is a fairly unrelated topic of discussion, but some of you may have heard about a shooter in the Phoenix area. It turns out the shootings were really close to Cardon Children’s Medical Center, my research site, so the hospital is on lockdown as I’m writing this post. Believe it or not, we didn’t turn the lights off and sit under our desks. All but 3 of the hospital’s entrances and exits are locked, while the 3 unlocked doors are accompanied by security guards. On the inside, however, everything and everyone is working as if nothing had changed, which makes sense, because there are still patients that need medical attention.

Update:  The shooter was caught just down the street, and he was actually taken to the emergency room at the same hospital.

In other news, at the beginning of this week, my advisor gave me a small cactus and told me that it is my responsibility to maintain and water the plant every week. Here’s what it looks like:

I came in during spring break to watch one of Dr. Vegunta’s laparoscopic surgeries. This particular surgery was a nissen fundoplication, in order to correct a hiatal hernia. A hiatal hernia is the protrusion of the upper part of the stomach into the thorax, which is the area between the neck and the abdomen, in which the thoracic cavity is located. The stomach enters the thoracic cavity through the hole between the two cavities, which the esophagus goes through. Dr. Vegunta and his colleague, Dr. Truong, created several openings in the patient’s abdomen for the camera and the rest of the laparoscopic tools. During the surgery, which lasted 7 hours, Dr. Vegunta pulled the stomach back into the abdominal cavity, then stitched part of it around the esophagus, so the same movement doesn’t happen again. Here’s a cartoon of what the surgery looks like:

Before I go, here’s some trivia for you:

What’s the difference between pain and tenderness?

What’s the difference between a symptom and a sign?

Write your answers in the comments, and I’ll give you the answers in my next post.

Hey followers! The research part of my SRP has started to become more concrete, as we’ve obtained all the materials we need to start running trials. We were able to buy pig uteri from a local supermarket. I was really surprised (and a little grossed out) that they were selling pig tongues and even pig hearts in the meat section. Thankfully, I didn’t have any need for those.

My research is dealing with laparoscopic anastomosis, which is the joining of two tubes by stitching their openings together. This will be done in laparoscopic simulators with the pig uteri, which will be pinned down so the material does not move around as much when being handled. As I mentioned earlier, I’ve been learning how to use sutures when I’m not in the OR, and now I’ve started practicing anastomoses on the pig uteri outside the simulators. But it’s extremely important that anything the pig meat touches is sanitized, because raw meat has a significant chance of carrying salmonella. I’m not supposed to let the cleaning wipes touch my skin, because their chemicals are harmful to it.

As one may imagine, laparoscopic tasks are much more difficult than regular tasks, and here are some of the reasons:

1.      The tools are extended, so the user must be very steady with his or her movements

2.      The tools must be placed through small openings that restrict their movement, so they cannot approach the material from the opposite side of the user

3.      The 3-dimensional material is being displayed on a 2-dimensional screen, so it is more difficult to determine depth

4.      The user cannot use his or her hands to tie knots or correct the suturing needle

These restrictions can make for a very long, very tiresome laparoscopic anastomosis. But that’s what practice is for.

Hey Guys! So this last week, I’ve spent a lot of time in the operating room, but I’ve also been learning a lot outside the OR. Since I’m conducting research on sutures, Dr. Vegunta and his PAs have been giving me a crash course on how to actually use them.

            First, I learned how to tie knots with sutures, which can become particularly frustrating, but after a while, tying knots almost becomes second nature. And it’s very necessary that knot-tying is easy for a surgeon. For example, Dr. Vegunta and his colleague, Dr. Greenfeld, had to tie sutures in the thoracic cavity while the lungs were expanding and contracting, while the heart was beating, and while there was water and blood coating their gloves. They had been working on the same patient for about 6 hours. Speaking of working in undesirable conditions, Dr. Vegunta had to return to the OR in the middle of the night to perform on a patient who needed immediate attention, and then he came back in the morning as he does every day. Surgeons can have very tiresome jobs, to say the least.

            Anyways, after learning how to tie knots, I started learning how to suture with needles. To close an incision, you need forceps, a needle holder, and, of course, a suture with a needle at the end. Here are some pictures of the needle holder and the suture’s needle:

As you can see, there are notches on the handle, so the user can click the needle holder into place, and it will hold the suture’s needle until the user pulls it back open. The suture I used in this picture was not barbed, as I was practicing knots as well, and barbed sutures do not require knows. However, my research is focused on laparoscopic techniques, so suturing will be fairly different when performing anastomoses in the laparoscopic simulators. For instance, the tools are much longer, since they are designed to be inserted into the abdomen, and you must look at a screen to see what you are working on. Here’s what the simulator and its tools look like:

If you've got any questions, feel free to leave them in the comments!