Surgeries

Another interesting aspect of anesthesia is seeing the wide range of surgical operations. General surgery involved typical cases like hernia repair and laparotomies. I saw a handful of orthopedic surgeries; we did hip replacements under spinal anesthesia and knee surgeries with regional nerve blocks. I saw a cataract surgery (anesthesia is simple sedation), a robotic prostatectomy done by the Da Vinci system, and cystoscopies.

However, the most amazing surgeries I saw were the heart surgeries. I saw two bypass surgeries (CABG) and one aortic root repair for an aortic aneurysm. At the beginning of the surgery, the resident begins harvesting the bypass vein (saphenous for both of the surgeries I saw) while the attending does a median sternotomy. This vertical midline incision involves sawing through the sternum or breastbone. We adjust our ventilation settings to allow the surgeon to work in the chest cavity and dissect out the pericardium to examine the heart.

Seeing the heart is beautiful. I love seeing the dynamic pumping, the anatomy, and the pathology. All the surgeries I saw were done on cardiopulmonary bypass where they stop the heart, remove blood from the body to oxygenate it and remove waste products, and return the blood to the body. In order to do so, they have to cannulate the aorta and superior vena cava. We bring down the blood pressures to allow the surgeon to cut into the aorta, put in a tube, and suture it down. We then heparanize the patient to thin the blood for bypass.

Finally, the perfusionist starts the cardiopulmonary bypass, and the surgeon cross-clamps the aorta. The heart is stopped with ice and medications. I always feel apprehensive watching the heart bathed in ice and watching the EKG show hypothermia, then arrhythmias, then asystole. After the heart is still and empty of blood, the surgeon can begin the procedure, sewing the graft onto the heart in the CABGs or sewing an artificial mesh into the aortic root repair. After the repair, we take the patient off bypass, reverse the heparin with protamine, and watch tensely to see if the heart regains function. In some surgeries, I've seen the heart go into ventricular tachycardia and then fibrillation, a life threatening condition. While the surgeons shock the heart directly, we gave resuscitation medications. I unfortunately also saw an intraoperative myocardial infarction ("heart attack"), all risks with such large procedures. The surgeons finally insert chest tubes to prevent cardiac tamponade and wire the sternum together.

Image is in the public domain, from Wikipedia.