Cutting for Stone - Abraham Verghese [214]
Deepak insisted that I be on the patient's right again. It took just seconds to remove the drapes, swab his skin, and pop open the towel clips that held the skin edges together. I removed the packs.
Deepak guided my fingers to the stalk of vessels that led into the liver. “Okay,” he said. “Squeeze there.” This was the Pringle maneuver. I squeezed, choking off the blood supply to the liver, while Deepak removed the last pad and lifted the liver forward. Blood gushed out at once, turning the dry clean field into a sopping red mess.
“Okay, you can let go,” he said, pushing the liver back. “That's what I was afraid of. The vena cava is torn for sure. That's why, even with the Pringle maneuver, it still bleeds.”
In some people, the inferior vena cava barely indents the back of the liver. In our patient, the vena cava was swathed by liver like a pig in a blanket. When Junior went airborne, then hit the pavement, his liver kept traveling; its momentum tore the short veins that anchored it to the vena cava, leaving a jagged rent.
Deepak asked for a suture on a long needle holder. At his signal I pulled the liver forward, and he tried to put the needle in one end of the tear. But before he could even see it, the field was awash with blood.
“God,” I said, violating a cardinal rule about keeping quiet when assisting, “how do we fix this?”
Deepak said, “Oh, it's easy to repair the cava—it's just that the liver is in the way.” It took me a second to realize this was as close as Deepak came to joking during surgery.
He was silent for a good while, almost in a trance, and I tried not to make a sound. At last, like a priest finishing a prayer, he moved. “Okay,” he said. “It's a long shot. Let's switch sides.”
I was unprepared for what followed. All I could do was marvel and be the best second pair of hands that I could be. Deepak swabbed Junior's chest, then cut vertically down over the breastbone from top to bottom, then ran an electric saw in the same groove. The smell of burning flesh and bone hung in the air. Suddenly the chest popped open like an overstuffed suitcase.
I didn't ask what he was doing. He didn't explain. My exposure to chest surgery had consisted mostly of draining fluid collections outside the lung or, rarely, watching Deepak resect a cancerous lobe. Three times during my internship we had cracked the chest and oversewn a stab injury to the heart. One of the three survived. This was one of the deficits in our program, one of the reasons we were being shut down: we had to ship off much of the thoracic surgery, not to mention much of the urology and plastic surgery, to other hospitals.
Junior's heart, a fleshy, yellow-streaked mass covered by the pericar-dial sac, was exposed, pumping away, as it had done for all his nineteen years. It had never been more threatened. Deepak cut open the pericardium.
I was aware of activity in the operating room behind me and in the scrub area that was shared. At one point, I looked around, and through the three sets of windows, I saw a crowd of white faces around the other operating table.
Deepak put a purse-string suture around the right atrium, the upper chamber of the heart that received blood from the vena cava. He took a chest tube and cut side holes in it with scissors. Now he made a nick in the atrium of the heart, in the center of his purse-string suture. Then he slid his newly fashioned tube into the atrium, using the purse string to cinch the tissue around the tube which he pushed down through the orifice of the inferior vena cava, and down to where our problem was.
“Tell me when it reaches the level of the renal veins,” he said.
I saw the inferior vena cava distend, like a garden hose filling with water. “Now,” I said.
“The tube serves as a stent for the inferior vena cava,” Deepak said, leaning over to look from below. “It's