Edition 124 of SurgeXperiences, the one and only surgical blog carnival, is up at Notes of an Anesthesioboist.

This is the last edition of the first season of this truly unique biweekly collection of blog post related to surgery. The season finale brilliantly sums up the great variation of subjects and writing styles SurgeXperienes collects. Be sure to check it out!

All 24 editions of the first season are collected here. If you’d like to host an edition, contact carnival founder Jeffrey. He will also be hosting the first edition of season 2, on July 6th at his great blog Monash Medical Student.

An English speaking reader sent me this question: 

How do you pronounce “Øystein”?

English speakers tend to go for something like “Oisteen”, but here is the correct pronouncation:

Ø like the U in Urge.
Y like in Yeti.
ST like in STone.
EIN like in EINstein.

Øy-stein with pressure on the Y. Øystein is an old norse name, and the original meaning is lucky stone/stone amulet. Øystein I was king of Norway from 1103 to 1123.

Today, seven videos I’ve made of diagnosis and treatment of sarcomas were published on www.oncolex.no. Working on these videos has been especially interesting, as sarcomas are a very rare form of cancer, and because of all the devoted specialists I’ve gotten to know.

The hospital where I work is the national sarcoma center, and all sarcoma patients in Norway sent there. All evaluation and decisions on treatment is done by a team which includes radiologists, pathologists, oncologists, orthopedic surgeons, gastrointestinal surgeons and gynecologists. Other specialists, such as head and neck surgeons and thoracic surgeons, are consulted when needed. A very efficient way to work which ensures the best possible treatment for all patients. In Norway about 200 people develop some form of sarcoma every year (160 soft tissue sarcomas, 40 bone sarcomas). That’s only about 1 % of all malignant tumors diagnosed yearly.

As usual the videos only have voice overs in Norwegian. But I think they’re quite pedagogically edited and should be interesting to watch for anyone with some knowledge of anatomy. In addition to footage of the diagnostic procedures and operations, all videos includes x-rays, MRI and/or CT images to visualize the tumor and its relation to anatomical structures.

Ultrasound-guided core needle biopsy [watch video]
A diagnostic procedure performed to establish the histopathologic diagnosis of a soft tissue tumor on the right flank of a young teenage girl. The radiologist uses ultrasound to guide the insertion of the core needle. I don’t know the result. After the biopsy you can see that the radiologist tattoos the area where he inserted the needle. As it can be contaminated with tumor cells, the surgeons will need to remove the biopsy channel if the tumor have to be surgically removed,.

CT-guided bone biopsy [watch video]
Also an image-guided diagnostic procedure. CT is used at intervals during the procedure to guide the insertion of a bone biopsy needle, in this case into a tumor of the left tibia of a young man. Both to establish if the tumor is benign or malignant and its histopathologic subtype.

I’ve written about the filming of this procedure before.

Wide excision of a liposarcoma of the thigh [watch video]
A video of an operation to remove a liposarcoma located in the vastus medialis muscle of the left thigh. The tumor have been biopsied prior to the operation. An eye-shaped incision is made around the biopsy channel and it is included in the surgical specimen. During the operation the femoral vein and artery and the saphenous nerve are exposed and dissected. The vastus medialis is cut at both ends, and the entire muscle is removed with the tumor left unexposed inside.

Excision of a chondrosarcoma of the humerus [watch video]
This was a patient with a large chondrosarcoma in the proximal end of the left humerus. Here too the biopsy channel is identified and included in the specimen. The different muscles covering the humerus are cut and the radial nerve is identified and dissected. The bone is cut about 5 cm below the tumor and the shoulder joint is opened.

The joint and proximal humerus is then reconstructed using a titanium prosthesis. I don’t remember why, but the joint was reversed with the cup on the humerus part of the prosthesis and the ball on the scapula.

It was a great challenge for me to try to identify all the muscles of the upper arm when editing. I expected I’d done a lot of mistakes, but on viewing the video, the surgeon found none! I guess I’ve learnt a thing or two along the way after all.

Resection of a sarcoma of the uterus [watch video]A radical hysterectomy to remove a leiomyosarcoma of the uterus. Performed as a normal hysterectomy except for the division of the vagina below the cervix. To avoid contaminating the pelvis and lower vagina with tumor cells, two rows of staples are placed on the vagina and it is then divided between them.

This is actually one of the first videos I made for this project, some three years ago, but not published until now.

Resection of a gastrointestinal stromal tumor (GIST) [watch video]
An operation to remove a large GIST of the stomach. The tumor originated in the cranial part of the stomach and grew laterally to the left, adhering to the spleen and the tail of the pancreas. There’s a characteristic fistula from the lumen of the stomach into the tumor. The tumor is dissected circumferentially. The spleen is included in the specimen. The pancreas tail is divided from the pancreas, using a TA stapler and knife, and also included.

I’ve written about the smell of this operation before.

Resection of a retroperitoneal sarcoma [watch video]
A large (⌀≈15 cm) tumor located in the left upper quadrant of the abdomen. The tumor grows through the mesocolon and shows a naked surface against the peritoneum. It’s close to the left kidney and pancreas but not adherent to any of them. Circumferential dissection of the tumor. Because the blood supply to the descending colon is involved in the tumor a left hemicolectomy is performed and the colon segment is included in the surgical specimen.

When the tumor is removed, the renal vein, splenic vein and abdominal aorta are exposed.

The picture at the top of the post is a microscopic image of a stained fine needle aspiration from a chordoma.

I haven’t been blogging much lately, but it’s not a planned break, blogger’s block or anything.

As the summer is drawing nearer I find myself spending the evenings outside with the kids or running in the woods (photo credit), and less time in front of the computer.

There’s a number of surgical videos that are scheduled for to be published in June, and I’ll surely post on that. I also have a few other posts I’m planning to write, and something that demands a post might of course happen, but I reckon I won’t be entirely back on track until the end of the summer.

The 22nd edition of SurgeXperiences is up at The Paper Mask, the blog of Australian surgeon Sheepish.

Sheepish offers a good tip:

My tip - never let a sound recordist into your theatre, and if they do, insist that they remove that hairy dog from their microphone, unless you are happy for your patient to have their wound infected with bizarre and rare bacteria or fungi.

I couldn’t agree more. A zeppelin shotgun mic (as they’re called) with a windscreen is the exact opposite of clean. They start to smell after being used for a while, and I never heard of a windscreen being washed. A windscreen should, however, be totally unnecessary in an OR, where there’s usually no wind.

SurgeXperiences is a biweekly blog carnival, collecting the best of the surgical department of the medical blogosphere. Check out the back catalogue here. Read this if you would like to host an edition (highly recommended! I’ve hosted two editions myself).

The next edition will be up at Israeli anesthesiologist QuietusLeo’s blog The Sandman, on June 8th. He’s chosen the theme “The Philosophical side of Medicine” and is looking for some introspective blogging. Submit your posts here.

A while ago I wrote a post about the smell of smoke from electrosurgery, wherein I said:

Opening the abdominal cavity does not emit any smells, unless there’s some infected parts, necrotic tissue, pierced bowels or gas present.

This week I filmed an operation where the bowels, or actually the stomach, was pierced on purpose.

This was an operation to remove a large gastrointestinal stromal tumor (GIST) of the stomach. GISTs are quite rare connective tissue tumors of the GI tract, and classified as a form of sarcoma. The large tumor (⌀≈20 cm) started in the right stomach wall and protruded laterally, adhering to the spleen and the tail of the pancreas.

To remove the tumor the spleen was first dissected and mobilized. Then the stomach was divided medial to the tumor, with good margins. The picture at the top shows a suction tube in the open stomach. You can see the rugal folds of the mucosa.

At this point the inner scents manifested themselves. I think I’ve never smelled a more dense and heavy smell before, spreading all over the OR very fast. Unsurprisingly it smelled like vomit. More than anything else it made me think of the sheer amount of chemical reactions going on in our GI tract. Takes a powerful process to produce smells like this. Sitting a few meters from the operation table, breathing only through my mouth, I didn’t even want to think about how it must be for those in the sterile field. They’re more used to it of course, but still - a very penetrating odour.

Finally, a small part of the tail of the pancreas was cut of, and the surgical specimen was removed. The stomach was sutured and the abdomen closed.

Surgical specimen of a gastrointestinal stromal tumor (GIST) of the stomach.
The spleen is adherent to the tumor on the right.

The workhorse of most video production - the professional camcorder - is also one of the best tools for shooting a variety of surgical operations. But it has its limitations and for some types of operations it is simply useless.

Next to exposure, access is the biggest problem in filming surgery. All specially designed camera systems, as I’ve written about before, try to overcome the problem of good access to the surgical field. The professional camcorder is however not designed for any specific purpose. It’s designed to be versatile. So access inevitably becomes the biggest challenge when using cameras like this to document surgery. But using the right camera support and choosing the best camera placement, the camcorder can deliver great footage.

Mobility and camera placement
A great advantage of the camcorder is that it’s not fixed to any structures, unlike for example the surgical light camera. It can easily be moved around the OR to find the best possible placement for any part of a procedure.

The number of possible locations for the camera is however restricted by the physical organizing of the OR. In a crowded OR like in the picture below, where are you going to place your camera? For operations on relatively superficial anatomical structures, like for example a thyroidectomy, there’s no problem to get good shots over one of the surgeon’s shoulder:

Laparotomies
For operations on deeper structures (like a laparotomy) however, shooting over the shoulder will not provide the desired access. The other options available is to place the camera at the foot or head end of the operation table. Both of these locations have some problems. At the head end the anesthesiologist and her equipment is usually placed. And a lot of technical equipment, like suction and electrosurgery units are placed at the foot end. This restricts both how close to the table you can put your camera and exactly where you can put it. Normally the head end will be the best choice. Anesthesiologists and -nurses tend to be nice people, and let you stand there.

The angle of the shot is determined by camera placement and distance to the surgical wound. Placing the camera at the foot or head end both results in quite steep angles.

This video still from a retroperitoneal lymph node dissection shows good exposure of the inferior vena cava and abdominal aorta with the camera placed at the head end of the table.

But as you can also gather fom this picture, anatomical structures located higher up in the body, i.e. the kidneys, is impossible to view from this angle. When filming a laparotomy, the angle of the shot is limited both by camera placement and distance to the surgical wound.

Either way the angle of the shot is quite steep. This is not a problem when filming a hysterectomy or bladder resection, but makes it hard to get good shots of for example kidney resections and esophagectomies.

Filming operations that are done through smaller incisions, like for example a lobectomy of the lung is especially challenging with a camcorder. For these operations the camera needs to be placed more directly above the wound.

Camera stand
A standard professional camera tripod will not get the camera high enough relative to the wound. To get good shots it will have to be placed above the surgeons’ heads. To achieve this I use a body-mounted camera rig, as can be seen in the picture at the head of this post. This rig rests on my shoulders and a waist belt, distributing the weight and making it possible to keep the camera from shaking. The camera can be placed above eye height and tilted down. This requires a camera that is not too heavy and has a LCD monitor, as you will not be able to use the viewfinder with this configuration. Using a rig like this makes it easy to constantly adjust the framing to avoid heads and hands in the picture.

I am quite happy with this rig, but a body-mounted solution is of course not ideal for longer operations. But with good planning, I’ve been able to film operations of 10 hours using this rig. Going through the procedure with the surgeons in advance, identifying the interesting parts, you can take frequent breaks and avoid fatigue.

Conclusion
The professional camcorder delivers better video quality than most smaller cameras. It also offers the best control for the cameraman. So for “superficial” surgery, especially in the head and neck area and on the extremities, it is outstanding - the weapon of choice. For operations on deeper structures however, it is not the best camera solution.

This is the fourth post in a series about different ways to shoot surgical videos. First post: Surgical light cameras. Second post: Headlight cameras. Third post: Swan neck camera.

Welcome to the 21st edition of SurgeXperiences - the one and only surgical blog carnival - collecting the best from the surgical department of the medical blogosphere. I chose to call this edition “Tools of the Trade”. So what are those tools, and what exactly is the trade? I think the great variety of posts collected here shed some light on the many challenges encountered by surgical people everyday, and the different instruments - be they of steel or grey matter - utilized to overcome them.

As I am no ancient mariner, I won’t attempt to rhyme. But as recent studies show that a picture says exactly the same as 1014 words, I’ll stick with what I know - visuals. I’ve decorated this edition with some photos I’ve taken of aesthetic surgical instruments. Enjoy.

We start off with some hands-on, physical instruments. A steady provider of informative blogging, Suture for a Living brings us a post on barbed sutures - a type of suture that don’t need tying. From the same blog comes a post on dermatomes - a device used to cut thin layers of skin for grafting.

The guys over at OpNotes offer some news on the latest gadgets in minimally invasive surgery, including the EndoBarrier, AnchorPort and NeatStitch. GreatInventions or just DisposablePlastic?

A lot of surgical instruments are beautiful and exquisite in their design. I am especially fond of the hemostat myself. Professor Thomas Söderqvist of the blog Biomedicine on Display has been to a medical history museum turned art gallery in Paris where the instruments are presented as little works of art.

Sid Schwab’s Surgeonsblog has featured several great posts on the use and abuse of different surgical instruments. In two of my favorites he writes about surgical clips and electrosurgery/diathermy.

Talking about abuse - this is what a retained surgical sponge looks like on an x-ray, as brought to us by the fascinating blog Radiology Picture of the Day. It’s mission is simple and effective: a new medical image daily, with a brief description.

As we’re about to move from physical to more metaphysical instruments we turn to eye surgeon David Korram and his blog Marianas Eye. As a young student he found himself about to be seduced by a stethoscope. Fortunately he was saved from committing the cardinal sin of gadgetry. As the blood rushed back into his brain he realized the patients make appointments with doctors, not instruments.

T at Notes of an Anesthesioboist also had a realization about meeting patients. Interpreting the human Rorschach test we’re put to everyday correctly is an all-important tool in handling patients.

Being able to concentrate on the moment can be challenging in a busy workday, but is vital to really see the person before you. From Dr. Bruce Campbell comes a post on smoking that captures two of these moments clearly.

Surgical first assistant, and self-declared ambulance chaser (or trauma slut if you will) makeminetrauma at IntraopOrate uses an unconventional instrument to get a head start on trauma calls. Keep on chasin’!

Buckeye Surgeon questions if restricting more and more sub-specialities of surgery to “Centers of Excellence” is such an excellent idea. Maybe an exam is a better tool to ensure operations are handled by competent surgeons?

I reckon nobody has come up with a special forceps to remove what’s causing the bowel obstruction monash medical student Jeffrey Leow presents in the post a rare cause of SBO. Talk about stomach wrenching guts…

In the end, education and practice is perhaps the most important tools of them all. Bongi shares two stories from his surgical training. Being thrown into an operation he’s trained for but haven’t actually performed, he finds himself very alone. To some (professors) doing an operation by the(ir own) book is more important than a succesful operation. Though not alone this time, Bongi found himself being skewered for saving a patient’s life.

Aggravated DocSurg compares his medical education to drinking wine from a fire hose. Must have made him wet, but did it whet his appetite?

I’d like to end this edition with what is without a doubt the most interesting surgical blog post I’ve read in a long time. Respectful Insolence discusses, in a very detailed post, the ethical and practical problems with clinical trials in surgical intervention. A critical view on the tendency of surgeons to adopt new procedures before studies show it to be safe or more efficacious than the procedure it’s designed to replace. Highly recommended.

That concludes the “Tools of the Trade” edition. Did you learn anything? Go here to find out. The next edition will be hosted at The Paper Mask on May 25th. Submit your posts here by May 23rd. All previous and upcoming editions of SurgeXperiences are listed here.

Oh, I almost forgot to mention - there’s a new plastic surgeon in town:

I was tagged by rlbates who was tagged by Midwife With a Knife for the six word memoir meme.

The instructions? Write a 6 word memior and tag 6 others. Leave a comment on the tagged blogs with an invitation to play.

rlbates - My life is full of stitches.

MWWAK’s - Catch a baby, watch the floor.

Scanman - Aiming for accuracy in grayscale images

And here’s mine:

Marveled at inner and outer landscapes

Which sums up my love for nature and anatomy, two important aspects of my life. Lots of other things are and have been important to me, but it’s simply impossible to distill them all into 6 words.

I really don’t like pushing stuff on others, but this somehow comes across as more meaningful than other memes. Makes you think. But as I’m running out of possible blogs to tag, I’ll break the rule and tag just these four: Øystein in Antarctica , Kariknapp, Jeffrey and makeminetrauma,

The Sterile Eye is 6 months old, just learning to sit on its own and getting its first teeth. It’s also delightful to see that it has more than doubled it’s birth weight.

At this first milestone it is time to take a step back and review the past. Here are the posts that are my personal favorites of each of the six months this blog has existed.

November 2007: Different shades of red
About the problems involved in rendering our inside’s different shades of red on video. Read the post.

December 2007: Bright spot puncture
The little boy who was excitedly looking forward to a lumbar puncture.
Read the post.

January 2008: Makes a grown man writhe
Treating skin cancer with light can be heavy for some. Read the post.

February 2008: You’re not recording sound, are you?
What does it sound like in an OR, and why don’t I record these sounds?
Read the post.

March 2008: Paean to the pean
The story behind a common surgical instrument, and why I think it’s an artist’s tool. Read the post.

April 2008: Diagnosis and aspiration
Some thoughts on the “mystical knowledge” about people, possessed by healthcare workers. Read the post.

I’d like to dedicate this review to my better half. Thanks for reading (most of) my drafts. You’re the best editor!

Illustration created using Websites as Graphs