SCREW IT, LET"S DO IT!!

When you learn how to swim, there’s usually a process that’s followed. You place your feet in the water, you just bounce about in the shallow area, then you practice beating your legs and floating while holding the railing, then you learn to float around, use your hands, go to the deeper parts, and then you work on your stroke. If surgery was swimming, it would go something like this- you read about how to swim, you look at a lot of different people swimming, you place your feet in the water one day, you hold the railing the next day, then you dive into the pool from high above and hope you can surface fast enough to breathe. Only, the water you dive into, isn’t always the one you practice in, it maybe murky , dirty with things swimming around at the bottom that you never noticed. Knowing all this, there comes a point in every surgeons practice, time and again, when he has to take a deep breath and just dive in.

That’s what happened when I performed my first minor surgical operation independently. A hydrocoele is a collection of fluid around the testes (commonly called a man’s balls), that can grow to enormous sizes. Decompressing this collection and making certain it doesn’t recur is one of the first minor operations a surgeon learns.

Even in this, there are many variations. Some open the sac (the part that contains the fluid) early and then dissect it out while some do the dissection first. Some don’t believe in using electric coagulation, while others consider it a necessity. Some take more bites of their suture, others take fewer. I had seen them all. So one fine Operation theatre day, when a patient with a large classical right sided hydrocoele was posted for surgery and every other person other than an intern of ours was busy, I said to myself- screw it, let’s do it.

It was all going well. The intern was a good assistant. The local anaesthesia worked well, so the patient didn’t make a sound, and I began with a good incision. Then I deepened it. The fluid filled sac should’ve shown itself as a nice white surface. But it didn’t. I deepened it further. Nothing. Maybe I had missed it. That’s a stupid thought, how could I have missed it? It’s a water filled balloon. When you cut open a balloon, the water has to flow out. I cut deeper. Next layer, then another, then another. What? Where was this damn thing? Then sac rotated a bit in its place and I found my mistake. My assistant hadn’t fixed the sac properly, it kept moving left and right. Plus the local anaesthetic I had given had infiltrated some of the deeper layers, causing them to swell and distorting the anatomy of the layers. I had kept making incisions at the same layers repeatedly at different points. I had him fix the swelling in place. That’s it. Just a few layers deeper and I’d reach the sac. So I placed my scalpel on an incision I had made earlier, and bang, a spray of fluid hit my face.

I had incised the sac early and without knowing it, I quickly caught the edges of the incision with artery forceps. My face mask was wet, and it was a bad feeling. But I had to get this done. On my own.  I widened the incision on my sac with a scissors, careful to visualize that the testis underneath doesn’t come in the way. It didn’t. phew! Cutting the testis would’ve been a bleeding disaster. I drained the rest of the fluid. And the testis popped out of the scrotum (the skin and other layers covering the balls). But wait a minute- the testis wasn’t in the sac. It was outside it. That, was unexpected. The testis was supposed to be inside the sac. What had I cut? Was I in the wrong plane? The sac was just a blind fluid filled cavity. Was this even a hydrocoele? It said so, according to the seniors who had seen him.

I had had enough. I called my second year post graduate. She said it wasn’t just a hydrocoele. It might even be a hernia. That thought scared me. I had no idea what to do with a hernia. One of our consultants just happened to walk about around that time, so I called him. “It’s a hydrocoele of the cord you idiot”, he said. Just excise it and stitch the edges. I did, and he helped me, and the patient went home with normal sized balls. But somehow, my dive hadn’t gone too well.

The next week, I got to do another hydrocoele. The same intern and I shifted the patient, again while the senior resident was stuck up. This time, I incised the planes in one line. I opened the sac, so that the fluid didn’t hit my face. This time the testis was in the sac, where it usually is. I everted the sac and fixed it. I closed the incisions, making sure there was no bleeding. By the time my senior resident came to check up on me, I was dressing the patient. A week later, when I removed the patient’s stitches, and found no complications, somehow I just felt a sublime happiness. I wasn’t ecstatic. I just felt satisfied, and more capable.

I saw these moments in surgeons at all levels after that. No matter how many years of practice you have, there are always procedures that you have just started to learn. Only the difficulty rises as you progress. That’s the excitement of being a surgeon- the moment when you look at a problem, you know you have what it takes, but you’ve never done it alone. And then you say- what the hell, screw it, let’s do it.