Gynecology = Surgery.

Friday I was able to help with surgeries all day long. I like the operating room. There seems to be no concept of time in the OR. You are not watching the clock, you forget about hunger or using the bathroom. When you finally do glance at the clock you realize several hours have passed in what seems to be a blink of your eye. There is this unexplainable sense of confidence in the air. That being said there is also the long hours and the unpredictability that goes hand in hand with surgery specialties. Sure you get to be the big man / woman in the OR but that is about the only place. You are a stranger at home, a memory to your children, and an ex-husband or ex-wife to your former significant other. 

I was able to help on a laparoscopic hysterectomy with preservation of the ovaries. It was a sad case. The patient was a 39 year old female (obviously) who never had a chance to have children. She had symptomatic uterine fibroids that had plagued her most of her menstruating life. Finally she had had enough and wanted the surgery. In this surgery 3 small holes are made in the abdomen / pelvic area. Through these incisions a camera and surgical instruments are passed to perform all of the work. You also have to fill the abdomen with air to open up the space so you can see and have room to work. 

The biggest risk with the removal of the uterus is the potential for massive hemorrhage. When a woman dies in birth it often was caused by massive hemorrhage of the uterus. The uterus has a large number of vessels that vascularize it and keep it healthy and well nourished. Most of the surgery is spent cauterizing vessels feeding the uterus. You do not want to miss any because this can cause serious bleeding when you pull the uterus out. My job was to hold and maneuver the uterus to help the other 2 doctors to find, cut and cauterize all the vessels. I accessed the uterus through the vagina. It was demanding to hold the uterus in the correct position and if you were to let it slip you run the risk of tearing a vessel that had not been cauterized which would cause massive hemorrhage. By maneuvering the uterus I could expose certain vessels that could then be cut. The patient's uterus was so diseased it was very large, about the size of a 16 week pregnant uterus. 

It took several hours to tie off all the vessels and then remove the uterus and cervix through the vagina. It was so big it seemed like delivering a small baby. This was a fascinating surgery. Many surgeons do this surgery open, meaning they cut the abdomen are completely open to expose the uterus. An open surgery is quicker and easier to preform but leaves the patient with a long recovery time and weakened abdominal muscles and a large scar. Laparoscopic is the way to go if possible. 

We did another surgery where we used a CO2 laser to ablate non-cancerous lesions off of a patients cervix. It was cool to use laser technology and the surgery was fairly simple and done with only an epidural and no general anesthesia. So the patient was awake through the entire surgery. There was no cutting involved. We simply exposed the cervix through the vaginal opening and removed the lesions with the laser. We had to wear protective goggles to avoid damaging our eyes if they accidentally entered the path of the laser. 

The final surgery we did was an open abdominal hysterectomy where the entire tract was removed; cervix, uterus, fallopian tubes and ovaries. It took less time than the laparoscopic surgery. It was also easier to see all the anatomy which meant the attending grilled me with a ton of questions. "What is this structure?" "What never innervates this structure?" etc. Some attendings will kick you out of the OR if you miss too many of the questions. Fortunately I had brushed up on the anatomy so I was ready for the pimping! 

Pimping is a term medical students use to describe the process of being asked questions in a quiz/test like manner by residents and or attendings. It is a common practice in our training and a crucial part of our learning. Some dislike being put on the spot in front of everyone but I think it makes you prepare more thoroughly. SOe doctors will continue to ask harder and harder questions until you finally miss one and then tell you that you do not know anything and are a disappointment. You can't take it personally and have to understand it is just part of the process. Other doctors are very nice about it and do on the spot teaching with each question.