Herniation

In the simplest sense, a hernia is when something goes where it shouldn’t. This requires a breakdown of the usual barriers in the body. Sometimes these barriers are simple, and sometimes they are quite elaborate. The consequences of a hernia, as you therefore might imagine, range from mildly irritating to rapidly fatal. As general surgeons we deal a lot with inguinal hernias, or hernias that arise in the groin area. This a place of natural weakness in the body – especially in males – and therefore has a predilection for herniation to occur. The bowel pushes through the floor in this region and can cause pain, or even a true obstruction of the gut. If there is enough pressure on the bowel it can become ischemic and die – off hand, I can think of one person who died under these circumstances. As trauma surgeons, we deal a lot with traumatically injured brains. When the brain is injured – from assault, or a car accident – blood forms inside the skull. When the condition worsens, there is too much pressure that then expels the brain downward through the base of the skull – the foramen magnum – on its way to the spinal column in a vain attempt to relieve the pressure. This kind of herniation is rapidly fatal. The other day I saw a hernia unlike any I have ever seen. This woman had her uterus removed several years ago. The remaining cuff – that is, the portion where the uterus opens into the back of the vagina – is either sutured or stapled. This particular woman had recently undergone chemotherapy, and as a result that cuff opened. As luck would have it, her intestines worked there way through that opening – she eviscerated her intestines through her vagina. By the time we got her to the operating room, that portion of her small bowel was dead and needed to be removed. It’s a miracle she didn’t die. It’s safe to say that none of us – neither me, nor the colo-rectal surgeon on call – had ever seen anything like this before. But we were all in agreement: nothing we had ever seen just looked so wrong and obviously in need of repair. The body has countless built-in defensive barriers, and when they fail the consequences are too-often catastrophic. Something things are just supposed to stay put. As we look towards the new year, let us assure the barriers in our own lives are solid, and that we don’t herniate where we’re not supposed to. Let us stay where we belong, wherever that is.

Between Two Worlds

The other night on call I was presented with a very sick patient. A woman in her early 70s had been admitted with abdominal pain. After a couple days of testing and retesting a CT scan of her abdomen ultimately revealed an ominous finding: pneumotosis colitis, or air in the walls of her colon. It likely meant that she had infracted part of her intestine and would need urgent and massive surgery. If she didn’t, we feared, she would die very quickly. Unfortunately what was required was a resection of whatever portions of her intestines were dead. Sometimes just a little, but often quite a lot – either way, it’s the type of operation that can kill you because it’s such a stress on your body. And so she had to make a choice. Spend a few quality hours with her family and likely be dead by morning, or take a chance at a massive operation which she might not survive. I hated pressuring her, but every moment we waited we risked more of her intestines dying. She looked at me with wide eyes – “I’m not ready to dye tonight.” A part of me wanted to tell her that that decision had likely already been made for us, but I resisted – she needed to find hope in the surgery I was offering. She signed the consent form. And so she was there, stuck between two worlds – so delicately in this world, and so close to entering the next – I could see her closing her eyes and wishing all this were a dream. But it was not. We put her to sleep and cut her open. With my scalpel I took long swipes over her abdomen revealing her damaged bowels. It wasn’t as bad as we thought – I’m haunted by the notion that she might have made it ‘till morning after all. I’ll never know. And so it is often in this work – we make decisions and live with them. But we get to live. Others, not always. The choices are ours; the consequences, theirs. All we can do is our best. And at this Christmas time I am reminded that long ago in Israel someone stood between two worlds, this one and the next. And then too decisions were made, decisions that ended in death. It is all so fragile. The family thanked us for our efforts. I pray we did right.