Tuesday, April 13, 2010

28. Enterotomy, enterectomy, gastrostomy practical

To excel in veterinary surgery, one must have lots of practice. In human medicine, surgery is a post-graduate study and specialty but vets after 5 or 6 years of undergraduate studies are expected to be competent in veterinary surgery. There are veterinary specialists in surgery but he or she will not be able to earn a living in Singapore or in many countries.

Therefore, it is good to know that the 4th year students are given hands-on experience on intestinal surgery in the pig. 3 in a group. One would be a surgeon, one would be an anaesthestist and one would be a recorder at any one session. Anne was the one doing surgery yesterday. She had the short stick of the draw.

I did advise her to practise a lot on stitching pig intestines prior to the test. Reading notes and watching video may give the theory. But in the real McCoy, she needed to demonstrate competence if she was to get HD (High Distinction). For this high-achieving student, failure is not an option. Failure means having to repeat the test but I doubt that the University would be funding a pig for this repeat. It must be expensive and time-consuming. So, yesterday would be her trial by fire.

I discovered that she was a high-achieving student when her mother told me. It is rare to meet high-achievers doing internship in my practice and in veterinary medicine and surgery. There are around 70 graduates per year. 150 students might have started first year. The drop-out rate is high. In 70 students, only one veterinary graduate may get the University Medal for being amongst the top 7 in the whole campus. I presume the winner will be from the crop of the top 2%. It is not easy.

Veterinary medicine and surgery is a very tough subject unlike human medicine where only homo sapiens is the only species being studied to death.

A vet student has to study so many animals and each animal has its own diseases and various medicines to treat them. It is a wonder how the undergraduates can memorise and pass the examinations.

"How's the practical test on your intestinal surgery today?" I phoned Anne who was the surgeon in a group of 3. I had advised lots of practice on pig's intestines prior to the test if she wanted to get high marks. No 4th year student or even new graduates can demonstrate competence in stitching up the intestines because of the Western model of veterinary education which prohibits practices on live animals due to animal welfare concerns.

I was surprised that Anne accepted my advice and sourced for pig intestines from the butcher's shop to practise surgery. A butcher told her that pig intestines are never sold in Perth. Yet she found one selling at Northbridge. So, she practised and the vets and nurses at the vet surgery she stayed helped out.

I had many questions to ask about how she did the surgery on the pig. I don't do pigs. "Enterectomy, enterotomy and gastrostomy," she said. "How long did it take? Around one hour?" I asked optimistically. "The total surgery including stitching of the linea alba and skin stretched from 1.30pm to 4 pm."

I was just interested in one result regarding intestinal anastomosis. "Did the intestines leak after joining the two parts of the cut intestines?" Performance counts. You fail if your appositional sutures did not close the defect. The patient would suffer peritonitis and there will be a need to operate again.

"Did the intestines leak?" I asked again. This was her first intestinal surgery and she had diligently practised. "In a live pig, the intestines are mobile," Anne said. "It is not easy to stitch (unlike the dead specimens from Northbridge. The mucosa is hard to stitch up."

"So, did the intestines leak?" I asked patiently again. I could not afford to talk too long in international phone calls and this was the answer I wanted to know. You can have beautiful stitching. But the life and death issue is whether the patient's intestines, uterus, bladder, heart, blood vessel leak contents after your stitching.

"Yes," Anne explained to me that it was hard to stitch interrupted appositional sutures to join the two intestines. The sutures should not evert or invert. They should just close up tightly as in simple interrupted sutures in the skin. "Why don't you use inverting sutures on the serosa?" I asked. "Fine 4/0 absorbable sutures inverting the serosa as in gastrostomy?" Anne said, "The professors said that only one layer of appositional sutures would do as there may be intestinal blockage."

Well, I did read the lecture notes which taught what Anne just did. It also said wrapping of the omentum and tacking it to close the anastomosed area. Or a serosal patch after intestinal anastomosis.

This anastomosis of intestines is a rare surgery in a general practice. Practice on Caesarean sections would help a vet hone his skills. Unfortunately, there are not many Caesearean sections unless the vet has lots of dog breeders and provide dirt-cheap surgeries attracting them. "Why was there a leak?" I wanted to know. "Didn't you check after stitching?"

It is easy to criticise when one is not on the hot seat.
"It was closing time," Anne said. "I had to rush." Failure is really hard on high performers. Nobody wants to talk about the pains of failures. "Do you know your marks?" I asked. "No," she said. I think she would not get a HD for this surgery. And after all her hard work.

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