Under the Knife
Page 7
Pope John XXIII was canonised by one of his successors, Pope John Paul II. This popular Polish pope was, in surgical terms, the most interesting of all 305 pontiffs, in that he underwent the most operations.
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Stoma
The Miracle Bullet: Karol Wojtyła
HE WAS A media superstar, completely different from his Italian predecessors: young, fond of sports, enthusiastic, smart and enterprising, and he would play a significant role in the fall of Communism in the Eastern bloc. On 13 May 1981 his popularity rose to unprecedented heights when he survived being shot in the abdomen. It was the second time he had been shot at. As a child, a friend had accidentally fired a gun, just missing him. This time, he was severely wounded. He was saved by Italian surgeons who, apparently, fought not only to save his life, but also over the operation itself.
Around five o’clock that afternoon, standing in the back of a white jeep, Pope John Paul II drove across St Peter’s Square through a cheering crowd of some 20,000 people. The crowd included two Turks with guns and a bomb, Mehmet Ali Aǧca and Oral Çelik. At 5.19 p.m., twenty-three-year-old Aǧca fired his 9mm Browning pistol twice. He hit Ann Odre, a sixty-year-old American, in her chest, Rose Hill, a twenty-one-year-old woman from Jamaica in her left upper arm, and Karol Józef Wojtyła, the sixty-year-old pope, in his abdomen, from a distance of six metres. The Turk was overpowered by a nun called Sister Laetitia. Çelik did nothing. The popemobile raced out of the square through the screaming crowd. The severely injured pope was taken in an ambulance to the Gemelli Hospital, five kilometres away and the nearest university hospital in the city. On arrival, he was not taken to the emergency department, but to the papal suite on the tenth floor.
Duty surgeon Giovanni Salgarello found a small gunshot wound just to the left of the navel and other wounds on the right upper arm and left index finger. The patient was still alert for a short time and was given the last rites. When he lost consciousness and went into shock, the pope was moved to the operating department. He was placed under general anaesthesia at 6.04 p.m., three-quarters of an hour after being shot. While inserting a breathing tube via the mouth (intubation), the anaesthetist accidentally broke off one of the Holy Father’s teeth. Salgarello disinfected the abdomen and covered the area around it with sterile drapes. He took a scalpel and was about to start the operation when his boss, Francesco Crucitti, stormed into the operating room. He had been in his private practice when he heard the news and had jumped into his car and sped through Rome, to arrive just in time to start the operation himself.
From the sparse information that the surgeons gave to the Italian media and with a little surgical imagination, it can be surmised that the operation proceeded as follows. Crucitti and Salgarello made a long incision along the centre line of the pope’s abdomen from top to bottom. When the peritoneum, the membrane lining the abdominal cavity, was opened, blood streamed out. The pope’s blood pressure had fallen far below the normal 100mm Hg to 70mm Hg. The surgeons scooped the largest clots of blood out with their hands, removed blood with a suction device, and applied pressure to the bleeding wounds with gauzes. It was later estimated that the pope had lost three litres of blood, but he was administered no less than ten units of A-negative blood during the operation, which suggests that he lost much more. The abdominal cavity contained not only blood but also stools. The surgeons felt along the whole length of the intestinal tract with their hands and discovered five holes in the small intestine and the mesentery, which attaches the small bowel to the back of the abdomen. They then placed clamps on all the bleeding wounds they could easily get at, but the abdominal cavity continued to fill with blood. It seemed to be coming from below. The operating table was tilted so the pope was lying with his head downwards. Using all four hands, the surgeons pushed the bowels as far upwards as possible, so that they could see the bottom of the abdominal cavity. That is where the major blood vessels to the legs are to be found. Because of the bleeding, it was not clear whether they were damaged, but somewhere deep down, Crucitti felt a hole as thick as his finger in the ‘holy bone’ or sacrum, the triangular bone at the base of the spine. He pressed it closed with his hand and the worst bleeding seemed to stop.
Crucitti filled the hole with sterile wax, so that he could inspect the area around it. The major blood vessels to and from the left leg were immediately next to the hole, but had not been damaged. That was a good sign and everyone around the operating table must have heaved a deep sigh of relief. The bleeding seemed under control.
It was a good moment to consult with the anaesthetic team at the head end of the table. They, too, had been busy. The lost blood was feverishly replenished with fluid and transfusions, and the pope’s blood pressure and heart activity were closely monitored. There, too, everything seemed more or less under control. The patient was out of danger, for the time being.
So what happens next in such an operation? Usually, the surgeons would inspect the abdominal cavity again, make a plan, and set to work. First they would remove the clamps from the bleeding wounds one at a time and close them with absorbable sutures. The surgical assistant counts all the clamps, to make sure nothing gets left behind. Then the surgeons remove the gauzes one at a time from the abdominal cavity and check that the bleeding has stopped. In the meantime, a nurse counts and weighs the gauzes as they go in and out.
The surgeons examined the inside of the Holy Father’s abdominal wall. The bullet hole was on the left. They checked the organs in the upper abdomen – the liver, the transverse part of the large intestine, the stomach and the spleen – and found them all intact. Then they looked at the kidneys: these, too, were undamaged. And then the whole length of the intestinal tract was inspected, metres of small intestine and metres of large intestine. There, in the lower left quadrant of the abdomen, they found a long tear in the sigmoid colon, the last part of the large intestine (named after the Greek letter sigma, because it is ‘S’ shaped). Now they could reconstruct the trauma exactly.
All of the holes they had found so far fitted a single, simple trajectory – from front left in the abdominal wall, through the small intestine and part of the large intestine, to the sacrum at the back. Had the bullet gone any further? Had anyone seen a bullet hole in the patient’s back? ‘Damn, has no one checked el Papa’s back side?’ must have resounded through the operating room. It was too late to turn him around now. They decided to take an X-ray at the end of the operation to see if a bullet was still lodged in the pope’s sacrum or buttock.
They then removed the gauzes from the pelvis. It was reasonably dry. Though the hole in the sacrum was immediately next to the left iliac artery and vein (the large blood vessels to and from the left leg), they were undamaged. The left ureter, the tube that transports urine from the kidney to the bladder, was also intact. That was a stroke of luck. So now for the operation plan. The holes in the small intestine were no great problem. The surgeons decided to remove two pieces of small bowel and thus create two new connections. A small hole in the terminal ileum, the final part of the small intestine, was easily repaired. The tear in the large intestine was a much more complex problem.
Why the difference? The contents of the small intestine are fluid, consisting of food that is being digested, mixed with digestive juices from the stomach, the liver (bile) and the pancreas, all of which counteract the growth of bacteria. The excrement in the small intestine is therefore still relatively easy to deal with and not overly foul. The small intestine also has an exceptionally good supply of blood and a muscular wall with a strong outer layer of connective tissue. By contrast, the large intestine is packed with bacteria and compact stools, and has a much thinner wall with far fewer blood vessels. There is thus a greater chance of a surgical suture in the large intestine leaking than one in the small intestine, and with much more serious consequences.
In normal circumstances, the risk of a leakage in a large intestine suture is already quite high – around 5 per cent, or one in twenty. But that risk is e
ven greater if the abdomen is infected (peritonitis). There was therefore a very real possibility that this would happen to Karol Wojtyła after the operation, as the contents of his intestines had been leaking into his abdominal cavity for forty-five minutes. The surgical solution to this heightened risk is a stoma, an opening in the abdominal wall, through which the contents of the bowel can be diverted outside the body and no longer pass by the wound in the intestine. This prevents any further leakage.
The use of a stoma emerged out of necessity in the history of surgery. Until the nineteenth century, no one dared to cut open an abdomen. But if one had already been cut open by someone else – by a knife or a sword, for example – it gave the surgeon an opportunity to at least have a try. No one would blame you if the patient died. Theophrastus Bombastus von Hohenheim, one of the most renowned and successful surgeons of the late Middle Ages and better known by his adopted name Paracelsus, was the first to describe placing a stoma on the bowel before the wound as the only way to ensure some hope of the patient’s survival. The Latin term for a stoma is ‘anus praeternaturalis’, literally ‘beyond-natural anus’. There are various kinds of stomas: they can be temporary (reversible) or permanent (irreversible), be placed on the small intestine (ileostomy) or large intestine (colostomy), and can have one opening (end stoma) or two (double-barrel stoma).
In the case of John Paul II, the safest solution would have been the operation devised by the Frenchman Henri Hartmann in 1921. In what is now known as Hartmann’s operation, the affected last section of the large intestine (the sigmoid colon) is removed without connecting the two open ends back together. The lower one is simply closed off and the upper one is used to make a stoma. This makes it a safe operation, as it does not require a suture on the intestine, which might later leak. If the patient’s abdomen becomes infected (peritonitis), you can allow that to heal first before joining the intestine together in a second operation. That means that you can wait until the patient and his abdomen are in optimal condition to undergo an operation. The connection in the large intestine then has better chance of healing successfully than in an inflamed abdomen. That is the great benefit of Hartmann’s operation – the risk of a leaking suture in the large intestine can be reduced by postponing that part of the operation to a more favourable moment.
The Italian surgeons did something else, however. They stitched up the tear in the large intestine without removing the damaged part and constructed a stoma in the upper section of the large intestine, some half a metre before the tear. The advantage of this option was that it would make the second operation to remove the stoma easier than with Hartmann’s operation. It did, however, have the disadvantage that they took a risk by having to leave a large intestine suture behind in an abdominal cavity that contained bacteria.
The operation had been under way for several hours when it was the turn of Crucitti’s boss, Giancarlo Castiglione, to storm into the operating room. He was in Milan when he heard the news, had caught a plane to Rome and arrived at the Gemelli Hospital just in time to take over. Castiglione, Crucitti and Salgarello rinsed the pope’s abdominal cavity and inserted five drains, silicone or rubber tubes that remove the fluid from the abdomen. They then closed the abdominal wall and took an X-ray, which revealed no bullet. Later, an exit wound was discovered in the pope’s buttock and the bullet was found in the popemobile.
After they had also treated the wounds to the index finger and upper arm, five hours and twenty-five minutes had passed. Of course, it was not the real heroes of the hour Salgarello and Crucitti who spoke to the press but their boss, Castiglione. He had a highly developed sense of drama and suggested that the pope’s survival had been a miracle, saying, ‘If you look at an anatomy book, you cannot find a space wide enough for a bullet to pass through and miss so many vital organs.’ That is, of course, nonsense. The pope’s anatomy was perfectly normal and the two intestines, which together suffered six holes, and the large bone from which he lost three litres of blood most certainly qualify as vital organs. What he meant was that, if the bullet had passed slightly to one side, it would have hit the major blood vessels. In that case, the delay of three-quarters of an hour between the shot and the operation would have indeed been too long. The pope himself would later help to consolidate this myth. According to Karol Wojtyła, the projectile was guided through his lower abdomen by a ‘mother’s hand’, suggesting the direct intervention of the Virgin Mary.
Five days after the operation, the pope celebrated his sixty-first birthday in the Intensive Care department at the Gemelli Hospital. He went home again on 3 June. But he had developed a cytomegalovirus infection (CMV) as a result of all the blood transfusions and the wound left by the operation had also become infected. On 20 June, he was readmitted to hospital. Wound infections are not rare after emergency operations in which excrement has entered the abdominal cavity. They often result in the abdominal wall not healing properly, so that much later the scar can rupture to form an incisional hernia, requiring a new operation. This fate would also befall the pope. However, the peritonitis healed quickly and Wojtyła wanted to be rid of the stoma as soon as possible. On 5 August, less than ten weeks after the attack, Crucitti connected the ends of the large intestine back together – a short, 45-minute operation – and, nine days later, the pope was home again.
The popemobile was fitted with a bulletproof cabin. Aca – who later claimed to be Jesus Christ – spent nineteen years in an Italian jail, where Karol Wojtyła visited him on several occasions. After that, Aca spent a further ten years in jail in Turkey. He was released in 2010. The blood-smeared white T-shirt made by Swiss underwear manufacturer Hanro that John Paul II had been wearing at the time of the attack was kept as a relic in the chapel of the Daughters of Charity in Rome. The pope rewarded Salgarello and his colleagues by investing them with the Order of St Gregory the Great, the highest honour bestowed by the Vatican.
A year later, there was a second attack on John Paul II. A disturbed Spanish priest wounded him superficially with a bayonet. After spending three years in prison the priest, Juan María Fernández y Krohn, set up a lawyer’s practice in Belgium.
From 1984, Karol Wojtyła was regularly to be found skiing incognito in the mountains of Abruzzo. But in 1991, his health started to deteriorate. He developed Parkinson’s disease and, in 1992, was diagnosed with a precancerous polyp in the large intestine. The tumour was discovered in the sigmoid colon, precisely the part of the large intestine that Aca’s bullet had passed through. It is not very probable that the one had anything to do with the other, but if the surgeons had conducted Hartmann’s operation back in 1981 and had removed the torn section of the large intestine, then a tumour could not have developed there. Now the old man’s sigmoid colon was removed after all, and he recovered from this operation reasonably well, too. The operation was carried out by one of the same surgeons as eleven years previously, Francesco Crucitti. During the operation, the pope’s gall bladder was also removed to alleviate a problem with gallstones.
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Surgical team
During an operation, a modern operating room is strictly divided between a sterile (clean and completely bacteria-free) and a non-sterile (clean, but not completely bacteria-free) field. The part of the patient to be operated on is cleaned with disinfectant. The rest of the patient is covered with sterilised paper drapes. Everyone in the operating room wears clean surgical scrubs, cap and mask. The operation is performed by the surgeon and an assisting surgeon. They are aided by the scrub nurse, a surgical assistant who is responsible for the instruments and other materials used. These three people are ‘sterile’ – they wear gowns and gloves that have been sterilised and are completely free of bacteria. They have to ensure they remain sterile by not touching anything outside the sterile field. All instruments and other materials, such as sutures for stitching, have also been sterilised and may only be touched by these three people. A second surgical assistant – known as the circulating nurse or surgical technolo
gist – is not dressed in sterile clothing and supplies the materials to the operating team in a way that ensures they remain sterile. An important job for the circulating assistant is to count the gauzes used during the operation. At the head end of the operating table is the anaesthetist, the doctor who administers the anaesthetic, with an assistant. Six people are thus needed for each patient, three of whom are dressed in sterile clothing (in the past, too, surgeons could not perform operations alone – they needed four assistants to hold on to the patient’s arms and legs).
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In 1993, Karol Wojtyła fell down the stairs, dislocating his shoulder. In 1994, he slipped in the bathroom and broke his hip. He was operated on and given an artificial hip. In 1995, a third attack was planned on the pope, by Al Qaeda in the Philippines, but it was foiled in time. In 1996, he was operated on for a dubious case of appendicitis.
Pope John Paul II lived to be an old man, but kept his sense of humour. When, shortly after his hip operation, he rose from his stool with considerable difficulty, drawn with pain and stiff as a board, he mischievously and brilliantly quoted Galileo Galilei, mumbling ‘Eppure, si muove!’ – and yet it moves!
The deterioration of the aged pope was painfully and graphically reported in the media. In 2005, the now demented old man was given a tracheotomy, a breathing tube in the neck, because he was having difficulties with coughing. A month later, he died of an infection in the urinary tract. He had undoubtedly undergone more operations than any other pope in history. He was canonised in 2014.
He donated the bullet that had pierced his abdomen – and was supposedly guided safely past his major blood vessels by the hand of the Virgin Mary – to Our Lady of Fátima in Portugal, out of gratitude for this fortuitous intervention. It can be seen there in the crown worn by the statue, hanging above her head like a sword of Damocles.