For the want of a nail……

I had made up my mind…I would take interest in and develop surgery in cases of portal hypertension…These patients had a liver disease or a block in the portal veins supplying the liver…This usually lead to the development of very large veins in the esophagus leading to catastrophic bleeding….They would come to the hospital in shock following vomiting of large quantities of blood.

These were days before endoscopy. Now a days no one thinks of an operation, bleeding being controlled by either blocking these veins by an endoscopic injection or putting a rubber band around them….In the India of the seventies, surgery was the first choice….

I had opened the abdomen of a 35 year old man with portal hypertension…He had undergone a spleno-portogram wherein the spleen was punctured and contract injected to delineate the portal venous system…During the procedure the patient had a bout of coughing that lead to the needle tearing the spleen…The patient had gone into shock due to bleeding from the laceration of the spleen.

I looked into the abdomen in dismay…It was full of dark blood and clots…As I looked, the blood welled up more..I had to do something fast….The spleen had to be removed…The spleen itself was massive, as is usually the case with Indian patients..I could not see the hilum of the spleen, therefore unable to clamp the splenic blood vessels at the hilum…I tried packing the spleen with mops…bleeding slowed down a bit, but did not stop…If I made a wrong decision, there would be disaster and a death on the table….

“What’s up, Chief?” came a cheerful voice behind me….It was Dr Vilas, the Professor of Cardiothoracic surgery…He had joined Sion hospital only the previous months…He was rather young to be a Professor. In a very short time, he had become the favorite of all residents and lecturers…He had a ready smile and a quip and willingly helped you out…He had worked for five years with Debakey and that, in my eyes elevated him to a demigod status…The grapevine had it that he was shunted out of KEM hospital due his blunt behavior with his seniors…

“I see you have a problem. Do you mind if I scrubbed up and gave you a hand?” Did I mind! It was like a godsend…”Your problem Guru (He always got to know your first name and always addressed you by your first name) is that you cannot see the hilum.The huge spleen is obscuring it. A direct approach is not feasible. We will go between the stomach and the colon, yes, the lesser sac, identify the splenic artery near the pancreas and ligate it..The spleen will shrink and make it easier for its removal.”  Wow! that was brilliant! I opened the lesser sac, identified the artery and tied it up with silk. “Now inject some dilute adrenaline into the splenic artery. It will help in shrinking the spleen”The spleen had shrunk to a fifth of its size. I could see the hilum..From then on, splenectomy would a cakewalk..”I think you’ve got it. I will wait in the surgeons’ room till you close up”Prof Vilas said….

I finished the splenectomy and asked my registrar to close up…I badly needed a cup of coffee…”Closed the patient?” asked Prof Vilas…Registrar is closing, I replied…A shadow crossed his face. He did not reply.

Suddenly there was chaos in the OR corridor…The circulating nurse came running to tell me that they were missing a gauze mop….I sprang to my feet, scrubbed again and joined my registrar….The mop was nowhere to be seen in the abdomen…I was thinking of calling for an x-ray to look for it as all gauze mops are visible on x-rays…Suddenly the circulating nurse gave a cry of triumph..The missing mop was found under the OR table….I heaved a sigh, but made sure that I closed the abdomen, much to the chagrin of my registrar….

“So Guru, a storm in the teacup has been sorted out?” asked Prof Vilas. “Yes Sir” I replied…”The mistake you committed was not being present till the last stitch…..However qualified your junior, it still is your responsibility to be there till the very end. You could have assisted him and scrubbed out after making sure that everything was OK… Heard of the saying :For the want of a nail……?” I nodded wordlessly….

Author: drshirahatti

I am a surgeon, specializing in Gastrointestinal Surgery...I have headed the Departments of GI surgery, General Surgery and Medical Education.....I also was the Dean of two large government hospitals in Mumbai.....I like reading about cultures and like to travel....

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