By Sid Schwab
Never, after doing thousands of operations, did my awe and amazement at the human body diminish. Nor did I ever take for granted the gift I’d been given: Trusted by another to breach, in the most literal sense, the boundaries between us. From the simplest office procedure to the most complex of operations aimed at defeating some horrible disease, it was hard not to stop in the middle and wonder at it all.
Nor did I think being a surgeon conferred status higher than my patients. I had the opportunity to learn to operate and to take care of surgical patients, and I committed to it (at the expense of family time) above all else. Many of my patients could have done the same. Recognizing how rare is the privilege, how great the responsibility, granted entry to the body’s secret spaces, I’ve tried, on my surgery blog and elsewhere, to share it.
Modified below is one of those efforts, respite from the compulsion to address the political horrors to which we’re being subjected daily; from the frustration that pointing it out is invariably greeted by Trumpists as fake news, responded to with absurdities (“It was warmer millions of years ago, libtard!”) Revisiting my surgical writing reminds me there was a time when it made a difference. So:
The inside of a vein is perfect. No matter the state of the rest of the body, when you open one it’s smooth and shiny. The inner wall glistens, lavishing the eye with a creamy khaki surface. Not that it’s common to get into one on purpose, but for things as minor as a cut-down (directly opening a vein to insert a large IV), or as major as a portal vein decompression (a finger-in-the-dike procedure to stave off the effects of cirrhosis of the liver), the lumen of a vein seems impervious to the ravages going on around it. It’s like searching a house stacked full of junk and finding a hidden closet, empty, clean, sparkling. A private, preserved space, kept pristine against the odds. (Arteries, not so much.)
Bile ducts, too, if less certainly. When there’s obstruction, or with infection, they get swollen, sticky and thick, the inner surface knobbly and cobbled. Mostly, though, it’s a similar wonder: crisp and shiny on the inside. There’s something about these specialized tubes that fosters their own brand of admiration. Springy and soft, yet turgid and tough. Sewing a vein, unlike anything else, (as long as it’s not during a mad rescue attempt) is almost meditative. Their thin, fragile walls demand particular concentration. It’s quiet work. The suture is finer, the instruments more delicate than typical needle-holders. Sewing requires the perfection of needlepoint: evenly-spaced bites, close, careful, exact. With such concentration (true of all surgery, but especially here) the rest of the world drops away for a while.
There’s rubbery resistance to the needle, which gives way with a little recoil. No tissue is quite like it. If creating, say, an arteriovenous fistula for dialysis, or sewing a vein patch onto a narrowed artery, you go through the vein first with the needle, and the textural difference is striking. Sometimes you hold the slender suture between thumb and index finger of one hand, propping the pinkie for stability, gently tugging upward to tent and approximate the edges, while suturing with the other. Or maybe your assistant holds the suture, and you a pleasingly extra-fine forceps. When you release flow, the vein bulges, and holds. It’s satisfying.
With a bile duct, you might be closing a previously-made access hole, sewing edge to edge. More often it’s to make a connection between duct and bowel, and the two couldn’t be more different. (If they were, you probably couldn’t connect them at all.) Then, it’s more of a puzzle: putting together two structures of entirely different thickness and texture, one of gross and separating layers and another of imperceptible ones. It’s a challenge with its own rewards, but not the quiet kind that veins provide.
A vein, laid open but stilled of flow. A silky surface even when lying next to corporeal corruption. It’s not a big thing, really; but seeing it on those rare occasions is somehow reassuring. A signal that things might be made right. If one place in this person is still OK, maybe we can help the rest to get there.
Email Sid Schwab at columnsid@gmail.com.
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