surgery observation 3

8/8/2019 Surgery Observation 3

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The morning lecture was about… who I’m kidding. I arrived around 7:15 and it had

already started. I picked up some big words, jolted them down and tried to connect the

dots. With some internet help, I think , the morning lecture was about tumor in the adrenalglands. I did a little research; you guys might find it helpful too.

Adrenal glands: Sit on top of both kidneys. They secret corticosteroids (cortisone,aldesterone) and cathecolamines (e.g. epinephrine/adrenaline, norepinephrine/

noradrenaline, dopamine).

Aldosterone: Increases rate of reabsorption of Na and water and increases secretionof potassium. Its production is effected by pituitary gland and the rennin-angiotensin-

aldosterone pathway-- Do you remember? Overproduction of aldosterone can lead to low

level of potassium, high blood pressure, weakness, tingling, thirst, etc., a condition calledConn’s syndrome. Cause: Usually benign tumor in the adrenal glands.

COMPARE:

Pheochromocytoma: Tumor in/outside the adrenal glands (arisefrom different cells) that causes excess production of epinephrine or

norepinephrine, NOT aldosterone.

Then they went into diagnosis and treatment. Common diagnosis includes CT scan and

MRI scan. If tumor doesn’t show up in the scans, alternatives are urine metanephrines(to rule out pheochromocytoma) or to measure the amount of sodium and potassium

in the blood (to detect hyperaldosteronism), but sometimes blood samples from the

adrenal glands are tested to determine the source of the hormone. Usual treatment isinterventional surgery to remove the tumor.

1st surgery: AICD thoracotomy

What a coincidence, this patient was the same one I saw about 2 weeks ago! Due toabnormal right subclavian vein anatomy, she had to come in another time for alternative

(open heart) pacemaker placement. If I remember right the patient had left ventricular

systolic heart, which is characterized by left ventricular dilation and hypertrophy,

results in decreased lower ejection fraction, or 13% in this case. The pacemaker to be implanted is called biventricular, whose name suggests that in addition to the

traditional pacemaker lead placement on one side of the heart, there are leads to pace both

ventricles. Also, there was a transparent plastic pad placed on the right side of her heart.

An incision (Incision A) was made on her right chest, a wire (J-wire, because of its shape

when it’s down in the right ventricle) was introduced into the subclavian vein. Drs. usedfluoroscopy to advance the lead as far as possible to the apex of the right ventricle, and

then mechanically adjust the head of the lead (from outside the patient’s body) to make it

bend upward and form a letter “J”. The lead appeared to be hooked somewhat below thetricuspid valve, at the septum.

Another smaller incision (Incision B) was made on her upper right quadrant. A tube was



inserted from B to A, through subcutaneous layer, and the end of the J-wire was tunneled

into the tube and guided down B. Incision A was stitched up.

Incision C was made below patient’s left breast, diagonal, about 5-inch long, deepenough to expose rib 4 and 5. A cut was made along the intercostals space in between rib

4 and 5. A pliers-looking cutter was used to cut rib 4. O-M-G, my heart was squealing

when I heard the crackle. Lungs were exposed. They looked rather small. As Dr. Harken

pointed out, patient was a long-time smoker; hence the dark tar spots on the supposedly pink lungs. Lying behind the lungs was the pericardium, which they cut through to

expose the beating heart. Drs. stitched the pericardium to the skin so it didn’t fall back

and block their view on the working area.

Drs. put on all the lead on the right side of the heart. Then, they took out an orange

tube and stuffed all the leads in it. They then pushed the tube across the abdomen

subcutaneously and it exited at incision B. They released the leads from the tube andconnect them to the generator unit of the pacemaker.

Right below incision C, another incision about 1 inch long was made. A clear tubewas inserted into the pericardial space for chest tube. The purpose is to remove excess

bleeding and pericardial effusion that usually occurs after heart surgery.

2nd surgery: Posterior C5-6 foramenotomy, a surgical intervention to remove pressurecaused by spinal discs protrusion that compresses the nerve and causes tingling sensation

and numbness on the patient’s right fingers.

X-ray of the patient shows that part of the spinal disc between C5-6 seems to be “leaking

out” and according to the surgical PA, Jen, patient had a trauma from an assault on his back years ago. Patient was put under on his stomach; his head was extended a little

beyond the bed. A clamp, holding at his temples, supports his head from under the bed.The Drs. put a needle on the possible locations of the disc protrusion. A few X-rays and

trials later, they finally got the right spot and went on to cut open on his back.

This is the anatomy of a cervical vertebrae, followed by another figure depicting the

fragment removed to enlarge the foramen to release compression on the nerve.



Even though my view was very limited, I heard that there was some drilling going on.

Once it was within sight, the Drs. continued the operation with a microscope. PA Jen

was really helpful by ordering a video cam so I could see what the Drs. saw through themicroscope. Honestly it was quite hard to tell the orientation and the depth of the image

so I just watched patiently and threw a few questions every now and then. But I could

tell that the Drs. are picking up some “black stuff” out from the opening. Sometimeshe would put in white foam-like cubes for coagulation. Okay, I admit it’s kinda hard to

articulate what I really saw. But I found this picture, hope it helps. What was different

was that instead of the lumbar spine, the surgery was done on the back of the neck,

around C5-6.

surgery observation 3

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