Indexing Title: JPINGUL's Medical Anecdotal Report  [04-4]

MAR Title: My Third Eye

Date of Medical Observation: June 29, 2004

Narration:

It was twelve midnight and it was raining hard outside with the occasional distant sounds of thunder.  I was in the operating room about to start an exploratory laparotomy on an obese female who was diagnosed with a perforated appendix with generalized peritonitis.

I sat down at a corner and recalled the last time I had wound dehiscence after a midline exploration back when I was in second year.  Since that time I was careful and cautious while closing the fascia to avoid wound dehiscence.  Every suture bite was carefully planned and placed, along with continuous judgment  and self-criticism, “Was my bite adequate enough, am I on the fascia, was it properly spaced out?”  These are the questions that keep running in my mind.

But I think, the success of the closure depended on the incision.  If the abdomen was opened midline through the linea alba, there would be no problem.  However, just a few millimeters deviation will open the rectus sheath, problems occur when closing, only one layer may be closed, leading to a high risk of wound dehiscence.  I was taught to find the midline, look for the crisscross pattern on the fascia.  I took this advise and most of the time, as I opened the fascia, the rectus muscle came into view, meaning I ended up not on the midline, resulting in a wavy fascial opening.

In an operation before this, I saw the orthopedic consultant palpated first the bone landmarks, the fractured part, and then carefully placed markings on the skin for the incision site.

That night, before I made the incision, I tried to palpate for the linea alba of the patient, making a picture in my mind of its approximate location.  As I cut through the thick fat, my left hand guided my right hand as to where the fascia was located.  And as I opened the fascia, I made a clean midline.  The patient tolerated the procedure, and was eventually discharged.

Insights (Discovery, Stimulus, Reinforcement)

It is very important for surgeons to develop their third eye, their skill of palpation.  Through this maneuver we can make clean midline incisions with high accuracy, even for resident surgeons who are still developing their skills.  It is by palpation that a hard to find appendix was found, or a 3 cm sigmoid mass was noted, which turned out to be cancer. 

With such a simple maneuvers, morbidities like wound dehiscence can be lessened.