“Well, shit. We can’t see a thing.”

My glance slipped over to the attending surgeon, the one in charge, weighing her expression. Two blue eyes peered over a mask at the high-definition conundrum displayed on multiple monitors before us. Over our surgical field, over our anesthetized patient, the images hovered like the terse assessment she had just delivered. And for just a brief moment, I caught the brows that capped both eyes straining inward in scrutiny. The moment was just barely so, and as it passed, I sensed and even took comfort in perhaps the slightest hint of a smile—though I never could distill with confidence which expressions dance safely beneath a face mask and which twirl only in the onlooker’s imagination.

I restored my focus to the task ahead. To the floating monitors and the rhythmic refrain of steadily beeping vital signs. Smile or no smile, the digital displays continued to broadcast a landscape, twisted and uninviting, from within the patient’s abdomen.

We had assembled in the operating room to remove a gallbladder. Yet, with the laparoscopic camera aimed in its direction—that of the bile-filled sac tucked just beneath the liver—we were greeted instead by a dense and disorienting web of scar tissue. This matrix of fibrous scar, termed “adhesions,” caused organs and tissues within the abdomen to cling to one another with a chaotic kind of tenacity. These adhesions obstructed our view of the patient’s anatomy. They obliterated our space to operate. And they gave us considerable pause.

“That ruptured appendix from when she was a kid is coming back to haunt us,” the attending surgeon remarked, referring to the likely source of the patient’s adhesions. “I’m going to take the camera for a bit.”

She took the laparoscope from my hand and maneuvered it to dissect away layers of pearly scar tissue, unfolding ribbons of intestine, and teasing them apart from the glistening, yellow curtains of intra-abdominal fat. My eyes shifted to the smooth exterior surface of the patient’s abdomen, weighing our options for the insertion of our first instrument port. From the outset of the operation, we had enshrouded the patient in a sterile blue drape, leaving only her abdomen—our surgical field—uncovered. The brown skin on the dome of her exposed belly glowed under the lights of the operating room, detailing every bump, pore, scar, and stretch mark from sternum to pubic bone. A midsection that had perhaps grown gradually fuller over the years was now tensely distended as we instilled gas into the abdominal cavity to facilitate the procedure.

I pressed my finger against the exterior of her insufflated abdomen and watched on screen as the camera captured a corresponding impression from within her body. “I think we can get our first port in here,” I proposed. My attending nodded slowly. “We’ll see… if we can’t free this up, we may not have enough room to do this…” She trailed off.

We moved on. “I’ll take the scalpel,” I announced. A scalpel was delivered to my outstretched fingers. I made a small stab incision in the skin. “Knife coming back. I’ll take the five millimeter port.” I placed the port through the incision, through the abdominal wall, and watched on screen as the tip of the port entered the insufflated abdominal cavity. “Grasper.” I slid the laparoscopic grasper into the newly placed port.

With the introduction of our first instrument, we slowly developed a working plane until eventually, two additional instrument ports could be placed. The process of setting up the camera and the three standard surgical ports, a process which usually takes fifteen minutes, had taken us ninety.

As the lights in the operating room dimmed, the glow from the screens produced colors and shadows that danced in reflection off of our eye shields. We proceeded in a coordinated calm, punctuated only by the occasional order or obscenity. Strand by strand, adhesions were divided and intra-abdominal contents were shifted out of the way until finally, a clear view of the gallbladder came into focus.

After more dissection was completed, after key structures were identified, and after the vessels that were meant to be clipped were clipped and the ducts that were meant to be divided were divided—after a few more frustrations were vented, and a few more beads were perspired, and only after the time that had to be swallowed was swallowed—we extracted the gallbladder in a plastic bag through a small incision at the belly button.


“Um, what the hell, Jay. No, no. Take that off and redo it.”

My attending had already scrubbed out and was looking over my shoulder as I finished dressing the last incision. I cracked my knuckles, “What’s wrong?”

She pointed with only her eyes. “That one’s wrinkled and that one’s crooked.” My gaze fell on the noticeable crease in the adhesive film covering one incision. I scanned the remaining square tiles of gauze, identifying the one that had been fixed at an angle not quite parallel to the others.

“Redo both of those,” she stated. “We just spent three hours in this woman’s belly. And all she will see—all she will judge—are those four tiny incisions. Make them pretty.”

Unnoticed beneath my face mask, I measured a single breath out into a sigh. I asked the circulating nurse for another set of dressing supplies and re-dressed both incisions. Prettier.

The sterile drapes were removed, and the woman who had offered me a warm smile and sincere handshake before the operation began, was now resting quietly in front of me under the fading haze of anesthesia. Glossy black hair, strong cheekbones, and soft freckles. Mother, patient, and 37 years of memories and experiences that stretched far beyond the range of our laparoscope. As I waited for her to awaken, I considered how rare our perspective was, surveying the inner workings of her abdomen, yet at the same time, how intimately superficial.

As we wheeled the patient out of the operating room, we glided down a hall and past a mirror situated above a scrub sink. I noticed my surgical cap had shifted during the case, allowing tufts of black hair to flee its confinement, and I paused to readjust. I examined the bags beneath my eyes and wiped away the dry flecks collecting at the corner of my mouth. I slid my fingers down the stubble over my chin. For a brief moment, I weighed my own reflection as if staring at the familiar face of a stranger, trying to gauge my impression of the man staring back at me. Yet there was no space for this moment to stretch into anything beyond a moment. And knowing this, I dressed myself in a smile and turned down the hallway toward the recovery suite.

Posted by:jayzmd

Full-time resident surgeon and part-time tolerable millennial

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