Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  The treatment for groin hernias thus advanced step by step. There would be one final step. Bassini had been wounded by a bayonet passing right through all the muscles of his abdominal wall. Although the healing of such a gaping wound must have been extremely painful, it was clear to young Bassini that you would also have to cut through all of those layers to perform a groin hernia operation. How else would you get at it? That was, of course, a serious disadvantage not only to the original Bassini procedure but also to later methods using a mesh: there was always the risk of the operation wound causing chronic pain, just as if you had been pierced with a bayonet. About a century after Bassini, that problem was also solved.

  All you have to do is make sure that the mesh is fitted in the right place between the layers of the abdominal wall: above the peritoneum and below the muscle layer. It makes no difference to the outcome whether you do that via a large wound from the front or by making a detour. Thanks to laparoscopy, it is now possible to reach that point with keyhole surgery through the navel, reinforcing the abdominal wall with a mesh from the inside, without having to cut through all those seven layers. Keyhole surgery cannot, however, be conducted using local anaesthesia. But that does not have to be a disadvantage any more, thanks to the fast-track concept. After general anaesthesia, the patient can just as easily go home the same day. Groin hernia repair is currently the most frequently performed surgical procedure – and a laparoscopic operation with a mesh and a fast-track recovery is the best way to do it.

  23

  Mors in tabula

  The Limits of Surgery: Lee Harvey Oswald

  DR MALCOLM PERRY was still on duty. He was the young surgeon in Dallas who, two days previously, had experienced the most terrible moment of his short career. He had fought to save the life of President John F. Kennedy, but the horrific wounds caused by the assassin’s bullets gave Perry not even the slimmest chance of success. Kennedy had died in his hands and the whole country had descended upon him.

  He had not withdrawn from the limelight, not taken leave or switched shifts with his colleagues. He had just carried on working. So he was still the duty surgeon when two days later, on Sunday 24 November 1963, that strange little man – the alleged assassin himself – was brought into the same emergency room. He had just been shot and was unconscious when he arrived by ambulance. Witnesses said that he had been hit by one bullet. A breathing tube was inserted into the man’s windpipe through the mouth, and he was administered blood and fluid.

  There was one bullet wound visible, on the lower left side of the chest. A thorax drain was placed in his chest, a tube alongside the left lung, but no blood came out. The patient was thin and, on the opposing side of his chest, at the back and to the right, a bullet could easily be felt just below the skin. It had passed right through the upper abdomen. He still had a weak, rapid pulse of 130 beats per minute, but there was no measurable blood pressure. The man was quickly moved to the operating room, where three surgeons would fight to save his life.

  The whole of America had been sitting in front of the television. They watched as the coffin of the late John F. Kennedy was driven to the Capitol in Washington, where he was to lie in state so that they could say farewell to their president. The scene switched to a garage under the police station in Dallas, where the suspected assassin was being taken to a prison van. The viewers saw a thin young man, handcuffed and led by two policemen in large cowboy hats. Suddenly, a man emerged from the throng of reporters. He approached the thin man, shoved a pistol into his ribs and shot him. It was the first murder in history to be seen live on television. The gun had been aimed at the man’s heart, but he had warded off the shot and it had caught him lower in the body. With so many reporters on the spot with television and photographic cameras, the shot was recorded from several angles. Some of them can be seen on YouTube.

  The gunman, Jack Ruby, was immediately overpowered by the reporters and taken to the cell that the young man had recently vacated. Amid the uproar in the garage below the police station, the cameras continued to roll. A few minutes later, an ambulance drove in and the man, clearly unconscious, was put in the back on a stretcher. There were cheers among the crowd in front of the Capitol in Washington when they heard the news of the shooting in Dallas on their transistor radios. Lee Harvey Oswald had been shot.

  Oswald was taken to trauma room 2 at the Parkland Memorial Hospital in Dallas. Everyone knew the thin man’s face and Malcolm Perry must have thought: ‘Here we go again.’

  * * *

  There is a difference between elective and urgent surgery. Elective operations can be planned and do not necessarily have to be performed. In the case of urgent operations the patient has his back against the wall; it is a matter of life and death. That difference is even a little subtler: with an urgent operation, no matter how great the immediate risk of operating, it is always smaller than that of doing nothing. With an elective operation, the immediate risk of operating is always greater than doing nothing, but that gap must be acceptably small to justify operating anyway. In modern surgery, it is considered an acceptable risk if an elective operation causes complications in no more than 10 per cent of cases and the risk of death is no more than 1 per cent. Complications obviously vary widely depending on the severity of the operation, but generally serious complications occur more often with severe operations. Of course, serious complications can occur with less severe operations, but not as frequently.

  The occurrence of complications after an operation is known as ‘morbidity’ and is expressed in percentages. General complications include wound infections, haemorrhaging, bladder or lung infections, thrombosis of the legs, a heart attack, bedsores, vomiting, constipation or an inactive small intestine. The risk of death, also expressed in percentages, is called ‘mortality’. You don’t die simply because of an operation or a complication. Complications are only life-threatening if they get out of hand – if they are not treated in time, or if one complication leads to another, causing a chain reaction.

  Complications, even lethal complications, are a calculated risk in all operations. The patient must of course be informed of these risks in advance. Surgeon and patient reach agreement about the surgical procedures to be followed, based on the principle of informed consent. The surgeon must inform the patient about the four aspects of the operation, the patient must understand them, and they both have to agree on them. These aspects are the indication (the reason for the operation), the nature and consequences of the operation, alternatives for the operation, and all possible complications of the operation.

  A complication is certainly not the same as an error. It can only be considered a surgical error if it can be attributed to incorrect action by the surgeon. If an operation is conducted lege artis, literally ‘according to the rules of the art’ (in other words, as it should be) and a problem occurs nevertheless, that is called a complication and is not an error. A complication is also different from a side effect. The first is unintentional, while the second can be expected. Side effects of an operation include pain, a high temperature, nausea, tiredness or psychological stress.

  Complications in surgery relate to the skill of the surgeon, the severity of the operation, the surgical method used, the care of the patient before, during and after the operation, simple coincidence and bad luck and, last but not least, the patient himself. Not every patient is the same and the differences between them are very important in the development of complications. Complications occur more frequently with patients who are obese, who smoke, are malnourished, or have a higher biological age (not their calendar age), and where there are serious co-morbidities, that is high-risk diseases like diabetes, high blood pressure or asthma. Patients themselves can therefore reduce the risk to a certain extent themselves by, for example, giving up smoking, reducing their weight to healthy level, eating sufficient protein before the operation, and getting other diseases treated as far as possible beforehand.

  Surgeons are expected to keep their own
record of complications. A good complication record is a form of quality control. And yet, you cannot simply compare the results of different hospitals and surgeons. After all, a surgeon who mainly operates on cardiac patients who are old, overweight smokers is more likely to encounter complications than one whose patients are usually young and healthy.

  It is a myth that surgical complications primarily occur during an operation (intra-operative). They mostly arise after the operation (post-operative). It is during an operation that a surgeon has most control over his patient and thus over a good outcome. At that moment, he holds the risks almost literally in his own hands. Because complications mostly occur later, a surgeon has to operate wearing four-dimensional glasses – the fourth dimension being time. He must be able to imagine what he now sees, dissects, reconstructs and stitches up will look like an hour, a day or a week later. If an organ, for example, is now just about receiving sufficient blood, it is not only a healthy pink colour now, but still will be in an hour’s or a week’s time. But if it is a little too pale, the surgeon must be able to predict whether, after a few hours, it will be black and mortified. And loss of blood can seem minimal during an operation but if it does not stop completely can accumulate over a few hours to a life-threatening level. When stitching up a hole in the intestines, the surgeon’s prediction needs to be even more accurate. A repaired intestine immediately provides a watertight seal. But if the tissues of the intestinal wall around the stitching do not receive sufficient blood to heal, cells will die off in the hours or days after the operation and the intestine will leak after all.

  So a surgeon has much more control during an operation than afterwards. Therefore something must go terribly wrong for a patient to die on the operating table. That is a surgeon’s worst nightmare, mors in tabula, ‘death on the table’.

  * * *

  The record of the surgery on Lee Harvey Oswald is a public document. It is part of the report by the Warren Commission, published in 1964, and can be found in Appendix 8 ‘Medical Reports from Doctors at Parkland Memorial Hospital, Dallas, Texas’, as ‘Commission exhibit number 392’, under ‘Parkland Memorial Hospital Operative Record – Lee Harvey Oswald Surgery’. The operation was performed by surgeons Tom Shires, Malcolm Perry and Robert McClelland, and chief resident Ron Jones.

  They performed a xipho-pubic laparotomy, which entails opening the abdomen with the largest possible incision, along the mid-line from the point of the sternum (the xiphoid process) to the pubic bone (pubis). On opening the abdominal cavity, they immediately removed three litres of blood, including fresh clots. As the patient was in danger of bleeding to death, time was of the essence. Most of the blood seemed to be coming from the right side of the body.

  In the upper right abdomen, there are five important structures in front of each other. First, the large intestine makes a bend in front of the liver, known as the hepatic flexure (literally ‘liver bend’). Carefully, but as quickly as possible, they dissected that free, so that the liver was visible, with the duodenum beneath it. The large intestine and the duodenum seemed to be intact, while the liver was slightly damaged. To investigate further, the liver had to be moved aside and the duodenum dissected free. Behind that was the right kidney, which appeared at first to be seriously damaged, bleeding severely from the top. But when the surgeons dissected the kidney free to examine it more closely, they saw that most of the blood was coming from a large structure even deeper in the abdomen, the inferior vena cava, literally the ‘lower hollow vein’. That is a blood vessel as thick as a thumb, with a very thin wall and directly linked to the right atrium of the heart. As all the body’s blood passes through the right atrium, a hole in this major vein means that the circulatory system can literally run dry. The surgeons quickly placed a curved clamp on the blood vessel to close the hole and packed the upper right abdomen between the back, the liver and the kidney with gauzes to stem the bleeding temporarily.

  It was clear to the surgeons that this was not the end of the story. There was an enormous haematoma (a localised collection of blood) in the retroperitoneum, the tissues behind the abdominal cavity. The swelling in the back of the abdomen was so extensive that the intestines were pushed out. The surgeons wanted to find out what was wrong there and decided to approach the area from the left.

  In the upper left abdomen, the structures are also located in front of each other. First, the large intestine makes a bend in front of the spleen (the splenic flexure). Carefully, but as quickly as possible, the surgeons dissected this free. The spleen was then visible next to the stomach. They could see damage to the top of the spleen and, near to that, they saw a hole in the diaphragm. They dissected the stomach free and moved it aside, in order to see the pancreas, which appeared to be severely damaged. Further to the centre, they felt around deeper in the abdomen to find the aorta, the large main artery. That, too, had been hit by the bullet. The superior mesenteric artery, the large artery that branches off from the aorta in the upper abdomen to supply the small intestine with blood, had been shot off. Perry closed the hole in the aorta with his finger and clamps were placed around it and on the detached intestinal artery. It was a complete mess, but the loss of blood seemed to have been stemmed for the moment. If you read the operative report, you can feel the relief of the entire surgical team at this point. The patient’s blood pressure rose again to an acceptable level.

  And yet, they must have known that they stood little chance of saving Oswald’s life. The risk of death from acute combined injury to both the inferior vena cava, the body’s largest vein, and the aorta, the largest artery, is exceptionally high (more than 60 per cent). That sombre prognosis is of course attributable to the enormous loss of blood from both injuries, from the aorta due to the high pressure and from the hollow vein due to the direct connection to the heart. The difficult access to these hidden structures and the many organs in the immediate vicinity that can also be damaged do not help increase the likelihood of a successful outcome. On the battlefield, where injuries are mainly caused by high-velocity fire, victims with severe damage to the major blood vessels rarely make it to the operating table alive. It is different in the case of civilian bullet wounds, which are mainly caused by handguns, as was the case in Ruby’s attack on Oswald.

  The anaesthetist during the operation was Dr M. T. Jenkins. The reports state explicitly that the entire procedure was performed without anaesthesia. The patient no longer responded to the pain from the very start, and was therefore only administered pure oxygen. Dr Paul Peters, a surgeon who was present in the operating room, said later in an interview that he recalled three men in green scrubs who clearly did not belong to the operating team. Although Oswald had a breathing tube in his windpipe that would prevent him from speaking, had been unconscious for some time, was on the point of death and had three surgeons poking around in his abdomen, the men still stood at the head end of the table, yelling into his ear, ‘Did you do it? Did you do it?’ This led Peters to conclude that the authorities had not yet obtained a full confession from the suspect.

  The clamps held and the loss of blood seemed under control. A total of nine litres of fluid and sixteen half-litre units of blood were administered. Yet, still the pulse became weaker and slower, and suddenly stopped altogether. This complete absence of a heartbeat is known as asystole or flatline. Was the patient still bleeding somewhere else? In his chest perhaps? Had his heart been hit? The surgeons continued the fight, performing an immediate thoracotomy – making an incision in the left chest cavity between two ribs. They opened the chest, but found no bleeding. Then the pericardium: also no bleeding. Perry, McClelland and Jones took Oswald’s heart in their hands in turn to perform open-heart massage, rhythmically squeezing it. As they kept that up for some time, Shires cut out the bullet from just below the skin on the right of the body, as evidence.

  Calcium, adrenaline and xylocaine were injected directly into the heart, but to no avail. The heart was by now hardly refilling itself; the circulatory system ha
d practically bled empty. Then the heart started to fibrillate. Instead of contracting rhythmically, the heart muscle made chaotic, uncontrolled movements. The surgeons performed defibrillation, increasing the charge in steps to 750 volts. The heart stopped fibrillating but did not resume beating. Not wanting to give up, they inserted a pacemaker wire, but that too failed to stimulate a strong heartbeat. Jenkins, the anaesthetist, established that the patient no longer responded to stimuli, was no longer breathing independently, and that his pupils no longer contracted when light was shone into them. The surgeons ceased their efforts – Oswald was dead. When they closed up the abdomen and the chest cavity, they were two gauzes short. The operation had lasted eighty-five minutes. The loss of blood was estimated at almost eight and a half litres (a human body contains no more than six litres of blood).