Week 7: It's Been A Long Day

On Wednesday, I observed two surgeries, one after the other, that lasted eight hours combined! Talk about experiencing what it is really like to be a surgeon...

The first was a right upper lobe resection (lobectomy). The patient had a cancerous mass in the upper part of their right lung, and Dr. Patel removed the lobe to be sent to pathology for staging and therapy options. When performing a lobectomy, an incision is made superficial to the affected lobe of the lung. The surgeon can access the lung through the ribs in order to remove the lobe. It is also important to remove a few enlarged lymph nodes as well, because if they contain a tumor, the cancer therapy process can be properly outlined.



The second procedure was an aortic valve replacement. This was especially exciting to observe because it was the same procedure I saw for my first time in the OR. I blogged about it in detail in my post titled "Week 1: Get Pumped." This time, I had better visualization of the aortic valve while Dr. Patel removed the diseased valve and replaced it with a tissue one. This is what the valve looks like when sewn into place:

Week 6: You Guessed It, More Surgeries!

Hi all! I hope everyone had a terrific spring break!

This week is going to be a bit of a game changer... literally. But before I get into that, I want to talk a bit about the surgeries I watched this week. This post is going to be quite short, but the next two will not disappoint, trust me.

This week, I watched an on-pump CABG and a right thoracotomy. I want to talk about the process of harvesting the left internal mammary artery (LIMA) for use in bypass.

The LIMA supplies the anterior (the front) chest wall and breast to the left of the sternum. It originates at the Subclavian artery right under the clavicle and runs down right past the sixth intercostal space (space between the sixth and seventh ribs) before it splits into two terminal branches.

Subclavian Artery

This particular artery can withstand being used as a graft for a vessel as important as the left anterior descending coronary artery. It is a better choice for the LAD because it can support blood flow at a higher pressure. This is why a saphenous vein graft may not be the best option.  

Removing the LIMA

Once the desired length is achieved, the distal (further from center of body)
end of the artery will be clipped off and the proximal part will be used as a graft for the LAD.

In my next post, I will talk briefly about the independent research project that I mentioned in previous posts. Next week (finally!) I will go into detail about what the next six weeks have in store for you all! 

Empyema Returns

Today, I observed a left chest empyema. Again, empyema is a condition where pus builds up in the chest cavity due to an infection (usually pneumonia). This procedure was the same as the one I described in my last post, but in this case, there was less pus in the pleural space and the infection was on the left side. Dr. Patel removed the pus and the patient was given antibiotics to prevent the infection from returning.

Here is a less graphic picture in case some of you did not particularly enjoy the one in my last post :)

Now, lets talk a little bit about monofilament nylon sutures. Nylon sutures pass through tissues easily and hold knots reliably. These sutures also have excellent tensile strength, and maintain their strength over time. While polypropylene can be used to secure grafts in the heart, nylon is generally used to secure chest tubes and close incisions.

Monofilament Nylon Suture

Next week I will go into the details of how I will carry out my suture project, talk about braided polyester sutures, and describe the materials I will be using.

Week 5: Home Is Where the Heart Is

Hey guys! The first procedure I observed this week was a redo surgery and on-pump mitral valve repair. This was the first open heart case that I have observed since week 3 and it is so exciting to be back at it again! Don't get me wrong, thoracic cases are very interesting, but it is just thrilling to see beating hearts in all of their glory every week! 😃

This on-pump MVR was a little different from the one I described in my second post from week 3 because it was a redo surgery. Also, the patient had a coronary artery bypass surgery in the past, so there are risks associated with doing another surgery such as hemorrhaging, graft injuries, and scar tissue adhesions. Thus, this mitral valve repair was performed with extreme caution and different techniques to avoid these problems.

The cardiopulmonary machine was still necessary in this surgery, but instead of stopping the heart with cardioplegic solution, Dr. Patel shocked it into an abnormally fast sinus rhythm (atrial fibrillation) in order to prevent air embolism. Air embolism occurs when a blood vessel is blocked by pockets of oxygen in the blood, and can cause a stroke if they travel to the brain. This was also avoided during surgery by flooding the thoracic cavity with carbon dioxide because it dissolves faster than oxygen does in the blood. Thus, it is less likely to occlude blood flow and cause a stroke.

In order to access and repair the mitral valve in a bloodless field, Dr. Patel induced atrial fibrillation where the electrical signals in the heart fire rapidly, causing weak, fast, and irregular contractions of each chamber in the heart. In this state, the heart moves so fast it just slightly wiggles, making it easy to access the valve. Also, blood flowing through the cardiopulmonary machine was cooled to around 25 or 30 degrees celsius to sustain fibrillation, lower the body's demand for oxygen, and protect the heart.

In atrial fibrillation, each chamber of the heart will beat rapidly and irregularly as shown by the photo above.

Other than shocking the heart into fibrillation and sustaining a state of hypothermia, the procedure was carried out the same way as the one I described before. Dr. Patel fixed the annuloplasty ring into place around the mitral valve to pull the walls of the heart closer together and prevent regurgitation.

In my next post, I will talk about the surgeries I will see in the next two days and the advantages and disadvantages of monofilament nylon sutures. Until next time!

Change of Heart *graphic photo*

So far in my project, I have been observing open heart surgeries, but since Dr. Patel is a cardiothoracic surgeon, I have the privilege to watch his thoracic procedures as well. For those of you who may be confused about the difference between cardiothoracic and thoracic, thoracic surgeons manage the conditions of anything in the chest cavity except the heart while cardiothoracic surgeons manage everything in the thorax with a focus on the heart. This week, Dr. Patel changed things up a bit and focused on thoracic surgeries rather than open heart surgeries. I observed three thoracotomies, procedures in the pleural space in the chest.

There are many reasons as to why someone may need a thoracotomy. To name a few, a surgeon may need to access the lungs and diaphragm in order to remove a portion of the lung, treat trachea or esophagus disorders, remove blood clots and pus from the chest, or diagnose a lung or chest disease.

In this post, I will briefly discuss the thoracotomy I observed today and touch on the general uses, strengths, and weaknesses of monofilament polypropylene sutures to begin my suture project.

Today, Dr. Patel performed a right thoracotomy with decortication. Decortication is the removal of the pleural membrane surrounding the lungs, and may be necessary if the patient has empyema, which was the case. Empyema is a condition where pus builds up in the pleural space between the lungs and chest wall. The pus is a product of infection of the lungs usually caused by pneumonia, and can cause breathing problems since the lungs can't fill with air completely.

Decortication

Empyema (arrow pointing to pus build-up)

To begin my suture experiment, I will spend the next two weeks explaining the advantages and disadvantages of each suture I will use. Today, I will talk about monofilament polypropylene sutures. These sutures are specially made for cardiac surgery because they can easily pass through cardiac tissue and induce a minimal tissue reaction. Also, they have a higher tensile strength (resistance to breaking under tension) than nylon sutures and may be easier to handle due to their ability to slightly stretch when passing through cardiac tissue. However, polypropylene sutures don't have the most reliable knot holding security.

The blue color of Polypropylene allows for easy visualization during surgery

Next week, I will briefly talk about monofilament nylon sutures and the surgeries I will observe! 

Week 4: Life After Surgery

On Tuesday, I visited Dr. Patel's office and met with pre-op and post-op patients. I have been spending the majority of my time in the operating room for this project, so I want to stray from the topic of surgery in this post and discuss what happens during post-op visits.

Dr. Patel meets with his patients a few weeks after their surgery to make sure their incisions are healing correctly and their quality of life has generally improved. Once he asks how they mentally and physically feel after surgery, he will take a look at their incision to ensure there is no sign of infection anywhere along the cut. The incision site must be kept dry and clean after surgery because moisture and warmth are perfect conditions for bacterial growth. It is also important to press along the edges of the incision to ensure that the sternum is in place and healing correctly. There are many precautions that patients must take to prevent re-injuring the sternum since it is being held together by wires as it heals. Patients should avoid lifting or pushing anything heavier than ten pounds for about six to eight weeks after surgery, because this is usually how long it takes for the sternum to heal. However, walking for at least 2 hours a day and doing easy household chores once patients start to get their energy back is extremely important to keep the blood circulating and prevent swelling in the legs. This light exercise will also prevent blood clots from forming in the feet, traveling up to the heart or lungs, and causing a heart attack or stroke.

Recovering from open heart surgery should never be an independent journey. Of course, it is the patient's responsibility to maintain and form good habits, but they should have support and help from their family to get around and stay healthy mentally. Patients will experience temporary physical limitations and may be dependent on others for performing tasks that they didn't need to think twice about such as walking to the restroom or lifting a package. Thus, it can be easy to fall into depression in the early stages of recovery if the mind is not being constantly stimulated or if the patient doesn't receive the encouragement and support they need. There are medications that can help in this situation, but a family effort to help the patient and the doctor's recommendations should minimize stress during the transition in lifestyle.

Meeting with post-op and pre-op patients at the office was very interesting, and it is extremely gratifying to see how immensely someone's life can improve after one surgery. More to come soon!