Weeks 6&7 - Final Rotations

Since summer immersion is drawing to a close, I have been trying to fit all the different things that I have not seen before I leave while continuing to observe my mentor and his cases. On Monday, I went to office hours at Cornell with Dr. Grant as saw some pre-op and follow-up cases. On Tuesday, I also followed Dr. Grant for office hours and excisions at Columbia. It was a great day because I was able to see many of the patients I have been following throughout my time here. Laura came with me on Wednesday and had a very full day of seeing patients as well as a breast reduction, breast reconstruction, and wound closure.

On Thursday, I was able to see a prostatectomy done by Dr. Tewari who is the Director of Robotic Prostatectomy and Prostate Cancer-Urologic Oncology Outcomes. Dr. Tewari uses the Da Vinci robot to perform the prostatectomy and does around 600 cases per year (he had done 15 cases that week already!). It was very interesting to watch the robotic surgery and Dr. Tewari allowed me to look through the control console towards the end of the surgery. I was very impressed by the apparent dexterity of the surgical instruments within the body cavity and the precise control that Dr. Tewari had over every movement of the robotic arms and camera. The surgery only took 1 hour and I unfortunately missed the first 15-20 minutes so I plan to go to another surgery next week to see the whole procedure.

Afterwards, David and I went down to Greenburg Pavillion and watched a live donor kidney transplant performed by Dr. Kapur. We arrived in the operating room just before the kidney was harvested from the other patient. Upon arrival into the recipient’s room, the kidney was prepared for transplant by Dr. Kapur and his team. They removed the external fat and unneeded connective tissue and then isolated the renal artery and vein as well as the ureter. The kidney was then wrapped in a towel with ice and brought to the patient. The two renal arteries were connected to the iliac artery using an end-to-side anastomosis. The renal vein was connected to the iliac vein in a similar manner. Next, the ureter was connected into the bladder and a stent was placed within ureter to help it remain patent. It will remain there for 6 weeks and then be removed using a cytoscopy procedure. Soon after the kidney had been connected to the blood supply, it became a deep pink color and began to produce urine. Dr. Kapur said that the last transplanted kidney that he had done had produced 1.8 L of urine in the first hour and that the activity of the kidney he had just transplanted looked promising. Dr. Kapur was very helpful and allowed David and I to come to the operating table many times during the surgery to point out what he had done as well as what he was preparing to do—it was a fantastic learning experience!

On Friday, I was able to go on round in the Neonatal Intensive Care Unit (NICU) with Dr. Perlman and Fai. The doctors on this floor are much different than those on the other services that I have visited so far because the patients are unable to express themselves in any way except to cry. Many of the decisions made about the course of treatment are based primarily on the patient’s urinary output, heart rate, frequency of apnea, and willingness to accept food. Since the rounds didn’t begin until about 9:30 am, I was expecting many more of the parents to be present with their children and was surprised to see only a couple sets of families. Many of these children have been in the hospital for weeks and even months and the physicians discussed how it is difficult for parents to even get into the city sometimes. It was difficult to see so many sick babies fighting for their lives but it is amazing what technology has developed to allow these neonates to have a better chance to survive.

During my last week of immersion, I observed Dr. Spector, another plastic surgeon, use a rectus abdominus free flap to replace the tongue of a patient after a glossectomy (removal of the tongue). When I entered the operating room, the glossectomy had already been preformed and the lower part of the patient’s face and neck was completely open and exposed—it was quite startling to see. Dr. Spector dissected out the viable arteries and veins in the neck, removed the flap from the donor site, and began to anastamose the vessels. I was surprised at how the flap was used to form the tongue, a small piece of muscle and skin would comprise the tongue while the rest of the muscle was sutured into place. Although this man’s tongue would appear to be semi-normal, he would likely not be able to speak well or even eat orally again.

I was also able to stand at the head of the table to watch an aortic valve replacement surgery done by Dr. Girardi. During the procedure, the anesthesiologists monitored the heart using a trans-esophageal echocardiogram (TEE). From the TEE, I could clearly see the stenosis of the valve and the calcified lesions that were obstructing some of the flow and causing the valve to be less-compliant. The patient was put on cardio-pulmonary bypass and the heart was stopped using an injection of a concentrated potassium solution into the coronary arteries (so that the cells were unable to pass on the electrical signal). Next, the aorta was opened and the aortic valve was removed along with as much calcification the surgeon could extract. A tool was used to measure the valve size and a bovine magnum valve was prepared to be placed into the aorta. Watching the process of valve placement was very interesting because the surgeon first placed multiple sutures around the aorta and then connected those sutures to the aortic valve replacement. The sutures were then sequentially tightened and knotted so that the bovine valve was lowered into place within the aorta. After the aorta was closed and the TEE showed that the heart and valve were functioning properly off of bypass, the patient’s chest was closed using stainless steel wires. The wires were connected to large needles that can go through the sternum and the whole length of the sternum was prepared with the wires before the chest was closed. The whole process of closing seemed quite brutal but the wires have enough strength to hold the chest closed.