Friday, September 18, 2009
Peyton Manning's modus operandi is to approach the line, stand there behind his center gazing over the defensive alignment, and then to start barking out commands in cryptic NFL-code. It seems to go on forever. Just run the play, you think. It's annoying as hell. Sometimes it seems as if he's just doing it for show, to draw attention to himself. What he's doing is he's changing the play at the line, he's calling an audible based on the defense's personnel and formation. A lot of times the Colts don't even huddle. Manning just lines the squad up and he calls a play based on what he sees.
In general surgery, we usually just "run the play". Patient has an inguinal hernia, we book the case, and go through the rote maneuvers, almost mindlessly, to repair it. Repetition is good. Muscle memory becomes ingrained. Laparoscopic cholecystectomy becomes an orchestral procession of unspoken movements and techniques. But the wonderful thing about general surgery is that every once in a while you have to improvise; you have to veer off the reservation a bit and change the play at the line of scrimmage.
I had a lady recently who presented with what seemed to be a classic case of gallstone disease. She had developed acute RUQ abdominal pain several hours after eating some chicken wings. The pain radiated to her back and was accompanied by nausea and copius emesis. Her physical exam also supported cholecystitis as the etiology---localized RUQ tenderness, positive Murphy's sign. An ultrasound done in the ER showed multiple stones in the gallbladder, but no typical finding of acute inflammation (wall thickening, pericholecystic fluid). Her blood work showed normal liver function tests and an elevated WBC to 15k. Because she had an acute abdomen, I booked her for a laparoscopic exploration, with intention of doing a lap chole.
We placed our ports, insufflated the abdomen, and started to look around. Her gallbladder was quickly visualized. It had that pearly white appearance that we often see with chronic cholecystitis, but it certainly didn't look acutely inflamed. That bothered me. She was exquisitely tender and had that leukocytosis. Things weren't adding up. So I hesitated. I took a look around. That's the beauty of laparoscopy; the whole peritoneal cavity is your oyster.
Sure enough, I noticed some edema and distortion of the hepatic flexure area of the right colon. The inflammation seemed to extend inferiorly toward the cecum. So I reconnoitered, put in a different port and started to examine the ileal-cecal region a little more closely. I ended up mobilizing much of the right colon from its lateral peritoneal attachments, rolling it over to expose the retroperitoneum. And there was the pathology--- a perforated, retrocecal, gangrenous appendix. The tip of this thing had extended up toward the inferior edge of the right liver. Hence the unusual presentation. But I found the sucker. And the gallbladder lived another day.
I suppose everything would have been easier if the ER had just done the usual, automatic thing and ordered a CT scan on the patient. But then it wouldn't have been nearly as fun. We surgeons like to call our own intra-operative audibles every once in a while too.....