The Long Case

One day as a "late call" resident staying until midnight, I got assigned to the longest case I've had so far. A patient with BRCA positive breast cancer was scheduled for bilateral mastectomies, a salpingo-oopherectomy, and breast reconstruction with abdominal tissue flaps. The anesthesia was unremarkable, but the surgery was interesting. The gynecologists started by removing the uterus and ovaries (due to the increased future risk of cancer). Then, two simultaneous surgical and nursing teams started. Above the arms (which were out by the patient's side), the surgical oncologists were removing the breasts (first the healthy one, then the diseased one to avoid contamination). Below the arms, the plastic surgeons were dissecting out the abdominal tissues with which they would reconstruct the breast. There were two scrub nurses and two circulating nurses as well. After several hours, the breast surgeons had finished and the pathologist confirmed negative cancer at the margins. Then the plastic surgeons got to work. The length of the surgery was really a result of the microdissection required; the plastic surgeons had to hook up the tiny arteries and veins from the abdominal tissue graft to the ones in the chest wall. Then they had to optimize symmetry and appearance. The procedure took a total of around 16 hours from start to finish. The anesthetic challenges for this sort of case include fluid management and positioning. The incalculable fluid losses from an open surgery of this length are considerable, yet too much fluid can cause tissue swelling that will impede the plastic surgeons. And for positioning, anyone leaning on a cord or having a joint at an odd angle for 16 hours will wake up uncomfortably. Luckily, the patient did well.