“Way down deep, we’re all motivated by the same urges. Cats have the courage to live by them.” – Jim Davis

The Scar

Mercedes n. – Spanish origin; mercies

Ch. 1

They called it the Mercedes-Benz. This was no premium German automobile; it was a surgical incision measuring nearly two feet. It is an upside down version of the Y-shaped incision used in an autopsy. It is defined as a bilateral subcostal incision with a midline extension. In layman terms this translates to a cut that is beneath the ribs affection both the right and left side of the body with a straight cut in the middle going towards the sternum. Sir Roy Calne coined the name for the incision after using it in a number of liver transplants. In truth, it does strangely resemble the Mercedes emblem, well, except for the fact that it’s carved into human flesh.

Imagine for a moment being twenty years old, one year from graduating, ready to get married, with the world at your feet. Then everything comes crashing down. It happens like a hurricane, slowly curving into a storm, vicious and destructive, eventually gathering power and pain to become an all-encompassing force of death. Then everything changes.
In a hospital, waiting is the worst. You wait for them to bring your medication. You wait for someone to answer your call light. You wait for the night to end so you can have company again. You wait for the doctors to finally tell you what’s going on. It’s all a huge exercise in patience. I used to say “Patience is a virtue, but not one of mine,” so you can imagine how well that went over with me.
This particular waiting didn’t bother me so much. I felt relieved, actually, during my surgery prep. I looked forward to the sleep. You never get a chance to sleep in a hospital. The majority of my tests required me to stay awake, so the opportunity for anesthesia sounded enticing and painless.
“Are you, Katrina?” This began the round of routine questions.
“As far as I know.” Sarcasm made me feel better.
The little nurse paid no heed to my bitterness at seven a.m. She just smiled with motherly understanding. “Do you have any allergies?”
“Bactrim and medical adhesives. So use this tape,” I pointed to the clear one.
“Have you ever had any adverse reactions to anesthesia?”
“No.”
She scribbled my answers down on a notepad. “The anesthesiologist will be with you in a moment, dear.”
I waited. I tried to concentrate on the awkward floral wallpaper instead of the constant gnawing pain. The thick smell of alcohol wipes made me want to be ill on the waxed tile floor.
A thin, freshly-shaved man leaned on the railing of my bed and smiled a toothpaste commercial grin at me. “Hello, Katrina,” he greeted me congenially.
I didn’t answer. Most of my well-mannered upbringing had been carefully preserved in a foggy-layer of sleep deprivation.
“It says here you are allergic to Bactrim and medical tape.”
“Yes.” Translation: Wow! You can read.
“No problems with anesthesia in the past?”
“Nope.”
“How are you feeling?”
“Terrible… That’s the reason for the surgery, you know.”
He looked at me and laughed. I immediately felt less irritable. “Who’s this?” he asked. He motioned towards a brown stuffed animal at the foot of the bed.
“That’s Tom. I named him after my first anesthetist.”
He raised an eyebrow. “Really?”
“Yup. The teddy bear didn’t have a name, so Tom made a deal with me. I promised to name the bear after him if I didn’t have any pain during my procedure.”
“I assume he succeeded.”
“It was great,” I nodded
“Well, you ought to give him my name, too.”
“That’s a little redundant, don’t you think?” I replied.
“Well, I suppose he is your bear,” replied the doctor, laughing. He handed me the paperwork to sign. It said that I wouldn’t sue if I woke up in the surgery or died or anything. Then he gently patted my wrist. It felt like everyone tried to be gentle with me that morning.
“I will meet you in surgery,” he promised, and disappeared.
One of the young transportation personnel showed up and wheeled me to the operating room. Dr. Karim was already there waiting. He was a tall, aging gentleman. His skin was tan and slightly wrinkled and his hair mostly white. He smiled at me like he always did. “Good morning,” he said with his Egyptian accent.
Everything went quickly from there. I remember him explaining to me that I would go into ICU after the surgery and who could visit, etc. but it mostly came across as a blur. Then the anesthesiologist stuck a needle into one of the ports in my PICC. The last thing I remember is how cold I felt.

Surgeon’s Log:

I stood outside the operating room before they wheeled the patient in. I knew her history and I knew how difficult this operation would be. I expected to open her and do whatever I could to stop the problems, if I could anything… but if I didn’t find some way to fix her, she would die. Maybe not today, maybe not tomorrow but this clot or the next would kill her, presently. I told her family that the surgery would last four hours, but truly, I had no idea what to expect. I hoped I would be able to see something, anything, to fix the problem.
The lights in the operating room shone blue and cold down onto the table. The patient was carefully covered in small, round, white circles coated with a sticky adhesive. These were placed on her chest and back to hook her up to the EKG. An IV was hooked up to her PICC, a peripherally inserted central catheter that hung out of her right arm. Through this line the anesthesia was administered.
Once the patient fell asleep, another central line was inserted into her jugular vein. The nurse placed an arterial line into her left wrist in the radial artery so we could keep a constant watch on her blood pressure. Then we put in a catheter. Through her nasal cavity, an NG (nasogastric) tube was inserted to keep her stomach drained. Then a plastic tube was wrapped around her head with a hole for each nostril, this device administered a steady stream of oxygen to the patient. To measure her O2 levels, a pulse oximeter was taped to her left pointer finger.
After we entubated the patient, we draped her. Long blue sheets like thick paper towels were placed across the patient chest and the lower parts of her hips, leaving her stomach open for the surgical procedures. Once everything was ready I made the long Mercedes incision, tracing my scalpel across her stomach and watching the blood well up around the blade. Once I cut through the layers of fat and muscle, I pinned open the wound.
First, we removed a thin layer of fat covering the areas we needed to work on. Not much of this protective covering was left because during her hospital stay the patient had consistently lost weight to the point of looking unhealthy. Then I entered the abdominal cavity. The constant beeps and whirrings of the medical equipment in the background completely faded away as I concentrated. I assumed the patient had a partial obstruction in her bowel. I intended to remove it, but that turned out not to be the case. Just removing the blockage would not fix the deeper problems and she would have other severe problems again if no solution could be found.
This patient had a unique history and a rare birth defect even I had never worked with. The case intrigued me and as I carefully controlled the blood-stained tools I realized this surgery would end up more monumental for me than I had anticipated.
First I looked at the overall digestive system. Every organ looked as though it was covered in small, slender worms, each one pulsing and purple. It was if they were trying to take control of her body by swarming over every internal surface. For years this girl’s body had been trying to save her by creating a completely new circulatory system between all her organs.
I discovered upon closer observation that the proximal jejunum loop of her small intestine looked swollen but instead of discovering the supposed blockage I found that the bowel had completely ruptured, separating into two pieces. I stopped my examination to ponder this discovery. A normal person would die within twenty-four hours of a full rupture but from what I could see, the rupture looked about two weeks old. The lower portion of the large intestine wrapped itself around the two separated sections. This created a bubble around the split, holding everything together. “Miraculous,” I muttered under my breath. I called my college over and the nurse too. “In all my years of practice”—which were quite a few—“I’ve never seen anything like this.”
My assisting physician stared at the girl on the table. “She’s very lucky,” he added in his South American accent.
“I doubt luck has anything to do with it,” I snapped at him. He was still young.
I carefully unraveled the colon from the small intestine. Five centimeters of the bowel had become necrotic. I removed the dead pieces with my scalpel. I took the two separated parts of the intestine and sewed them together with tiny silk stitches. Then slowly we took the entire small intestine and physically felt along all twenty feet to check for any other perforation or illeus. Every section of the small intestine was pulled out gradually and squeezed. This part of the procedure took hours of full concentration, much longer than the anticipated four. After that I felt satisfied that no other problems existed with the small bowel. This amazed and even baffled me. The girl’s mesenteric artery had completely clotted off a month ago, nearly killing her entire bowel. This should have made her bowel completely unusable and caused her death. The fact that we found only one rupture just added to the miraculous circumstances of the case.
I moved up and slightly to the left to consider the gall bladder. The poor organ had taken the majority of the heat while the small bowel was inoperable. The small structure was full of sludge, which is bile that has started to become thick and crystallized. The patient’s gallbladder had been over-producing bile in tremendous amounts that the patient had been vomiting up for a few days prior to the surgery. The strain upon the organ was apparent. I decided that the best course of action would be to remove it. The problem was that a normal gallbladder would be simple to move, but this particular’s patient’s circulatory system presented a unique problem. An extensive number of extra blood vessels swarmed all over her digestive system including her stomach and gallbladder. Some of these tiny veins were clotted off but a number of them could be easily severed. Already a high risk surgery, the gall bladder removal would need to be done carefully to avoid a bleed. The patient’s low platelet count would make even a minor cut disastrous and lead to death. With every ounce of concentration I moved and detached the myriad of miniature vessels from the organ and laboriously removed it. I tried very hard to leave as many collaterals available to the liver as possible and to avoid other unnecessary cuts that could cause fatality. I then delicately tied off everything where the gallbladder had been. After that I examined the circulation around the liver. It looked slightly smaller than a twenty-year old girl’s should be. I carefully removed a piece of the liver for a biopsy.
Finally, I examined the truly spectacular abnormality in the patient. Her spleen, a vessel usually about 4 inches long was enlarged to 7 inches and a number of extra-collateral veins had grown in on account of it. This unexplained defect, probably existing since birth, was the root of all the patient’s difficulties. Her spleen literally ate her platelets, keeping them at a lower than normal level. When the patient was six months old, it was discovered that her spleen was enlarged and a number of thin collateral veins, spread out from the vessel to create the line from the spleen to the liver. Now imagine trying to squeeze gallons of blood through a straw through what should be a one inch pipe day after day. The amount of blood lying stagnant in the spleen eventually became old and the platelets died. This also lowered the blood flow to the liver and pancreas causing them to be underdeveloped. After a hemorrhage into her esophagus in grade-school the patient was carefully watched. Later a sonogram showed what we thought was a natural shunt created by her body, pushing that extra blood to her kidneys to relieve some of the pressure off the spleen. This blood could then take another route to get to her starving liver.
At some point in time a surgery had been suggested that might correct the problem. Of course no one wanted to perform a possibly pointless procedure, especially on someone so young. Also that procedure would run into the same problems I was, every cut was dangerous a single mistake would end her life almost immediately. But since she was already filleted on the table, the opportunity lay in front of me quite literally.
First I trimmed back some of the extra veins covering the stomach. I did so around the pancreas as well which was tiny and underdeveloped. Each time I removed the extra veins it was a huge risk, at any time she could begin to bleed uncontrollably and die on the table. Every movement had to be made with grace and precision since her young life was caught in the balance of each cut.
Huge collaterals extended up above the small pancreas which seemed to connect to her coronary system. I continued to preen away extra veins in the retroperotoneal region, the area behind the abdominal cavity. As I did this I could see the enlarged adrenal vein. I was stunned at finally seeing the exceptional case up close. It was different from what we expected. This adrenal vein was so much larger in her than in a normal person that it was easy to see how her sonograms were misinterpreted. There was no shunt between her spleen and kidneys, only the massive adrenal vein. This gave me an idea, one that could possibly alter the current downward course of her life.
I turned to the spleen itself. The vessel looked as though it was drowning in the superfluous vessels. It also appeared not to be receiving adequate drainage from the coronary system. The veins of the stomach and pancreas were ligated or joined together and then the spleen itself was used to create a natural shunt to her kidneys. This was a fortunate situation, keeping me from having to add an artificial shunt to correct the clotting of the mesenteric artery. Since the shunt we thought existed wasn’t really there I had an opportunity to create what her body had failed to fix.
As soon as the shunt was complete, the spleen visibly reduced in size. It was like all that backed up blood suddenly escaped to where it needed to go. The consistency changed to something much softer and the strained color shifted to a more normal maroon. I watched with satisfaction knowing that the immediate results would produce a positive outcome for my young patient. I hadn’t felt the slightest bit tired until this point where I realized the truly hard part was over. But now, the heaviness of a ten-hour surgery started to weigh me down. We had taken no breaks.
Now we flushed the abdominal cavity with antibiotics. There would be many infections inside due to the steady leak of the ruptured intestine. I closed the wound with surgical staples along the Mercedes line. I then inserted two drains through a small hole on the patients left side just beneath the incision. Then we wrapped her swollen abdomen in a thick white bandage and transferred her back onto a movable bed.
I deliberately removed my gloves and told the nurse to remove the patient to the Intensive Care Unit. I walked through the hall, cracking my neck and rotating my shoulders to release some of their strain. I reached the waiting room. The patient’s family was grouped together looking nervous, they had been waiting the entire time, expecting some kind of response hours ago; I could see the fear etched in each face.
I smiled widely as way of consoling them. “Good news. The surgery has been successful.” I started to explain to them the complexity of the procedure and the good fortune of the patient. “I’m a great surgeon,” I stated flatly. It was true. Even after the thousands of small bowel transplants I had done, this was one of the most interesting cases of my careers. I had gotten to be extremely creative with the procedure and see something most surgeons could not even imagine. Then I added. “But God is the only reason she lived.”