Indexing Title: JMDEGUZMAN’s Medical Anecdotal Report [05-09] 

MAR Title:  

Date of Medical Observation: October 2005 

Narration:

            Our Thursday duties usually start with the routine, conference and ward rounds. I am not expecting that this day would be any different until I received a barrage of paging calls from the operating room. Hurriedly, I called and learned that the Ob-Gyne had an intra-operative referral. The patient was a relative of one of the senior Ob-Gyne residents. She is 64 years old and was diagnosed with Ovarian New Growth, Bilateral probably malignant. I remembered that this patient was previously referred to our service for evaluation if there were gastro-intestinal involvement.  Since on history and physical examination there were no signs and symptoms of intestinal obstruction nor any findings suggestive of intestinal involvement or pathology with the whole abdominal CT-scan, we cleared the patient. They plan to do bilateral oophorectomy on this patient. The patient having underwent multiple laparotomies in the past for cholecystectectomy and hysterectomy, the senior Ob-Gyne resident (relative) requested if I can help them intra-operatively if they encounter any problems. And as expected, I said yes.

             As I got back to my senses and dragged myself to the operating room, things played on my mind as to what were the most commonly encountered causes of Ob-Gyne intra-operative referral from simple to complex. Much to my surprise, the patient was not yet opened up. They were still about to start when I went in. But what can I do? I was already there. It would be impolite to leave and ask them to call me again. I stayed. The relative senior OB-Gyne resident was assisted by a consultant and two other senior OB-Gyne residents as I remained a spectator on the side waiting but not wanting to be called upon. The patient had two separate previous midline incisions, a supra-umbilical and an infra umbilical. No need for prophetic abilities, I witnessed their difficulty of going intra-peritoneally due to massive adhesions of omentum and intestines on the previous incisions. Finally, with much persistence and uncanny ability of using the knife they have entered the temple of surprises. Surprise indeed, they could feel the masses but they could not grossly identify them due to adhesions. After a few tries I was called in. Consultant scrubbed-out as I scrubbed-in. Assessing the jungle I was into, I pointed out that there were now seedings on the intestines and omentum giving a hint that it was too late for cure. The risks that could be incurred could surpass the benefit to be gained. I asked their protocol. They usually do tumor debulking if complete resection is not possible then chemotherapy. I was asked to complete the adhesiolysis for them to fully assess the masses.  As I proceeded, I was able to free adhesions from the right ovary however its posterior side was markedly adherent to the retroperitoneum specifically to the side of right iliac, a complete resection was too dangerous. The left ovary was markedly adherent to the ileum and there is no way of removing the left ovary without sacrificing a length of the ileum. I explained the options: stop, close the patient; resect the left ovary together with a part of the ileum, leave the right ovary. Still, I let her decide. First, she is the attending and second she is a relative. The verdict was go on with the resection of the left ovary together with a part of the ileum even when I explained that I have to do it with an ileostomy. I was not confident of doing a primary anastomosis on this case, we were already in a prolonged operation, the patient’s condition was not stable, the bowels were edematous and I’m not sure of the blood supply to the bowels. We have already incurred a lot of blood loss enough to warrant multiple blood transfusions intra-operatively. I left the right ovary on their care which they did tumor debulking. It proved however that this procedure was not easy either. We had difficulty of controlling the bleeders afterwards but with persistence we finally did. The patient ended up with resected left ovary with ileum, debulked right ovary, and ileostomy for a bilateral ovarian tumor with intra-peritoneal seedings. Amazingly, she survived that 6-hour operation and went through an uneventful post-operative course.

Insights: (Discovery, Stimulus, Reinforcements) (Physical, Psychosocial, Ethical)