Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.


I remember doing a case with one of my favorite attendings. This person was a colo-rectal surgeon who would talk through out the case. I was an intern at the time but I remember him saying that his talking was just “venting” and that he hoped it wouldn’t bother me.  I looked at him with amazement because his “venting” was putting to word, many of the thoughts that I was having as we went through the case.  I had felt honored to be able to scrub this case with him because usually, one of the chief residents would have taken this case but everyone was tied up and thus I asked if he would mind if I scrubbed with him. He said that he was happy to have me there.

The Teaching

He explained the fine technical points from skin to skin allowing me to mirror many of the things that he was doing. He pointed out anatomy and explained why he loved mobilizing the rectum and why colo-rectal surgery was always a rush for him. I was mesmerized by how fascinating going through this case was.  In short, I was being treated to the first of many one-on-one mentor-trainee sessions with this young colo-rectal surgeon. His enthusiasm for his craft and his ability to teach me what he found amazing was delightful. From that point on, I always held a special reverence for colo-rectal surgery.

He marked out the incision line for me and handed me the scalpel. He showed me how to make sure I had just the proper amount of tension and counter tension as we entered the abdominal cavity. He showed me how to explore the abdominal cavity and how to palpate the liver for cancer mets. He pointed out the fine points of living anatomy as we located the tumor that we knew we would be able to resect.

His next lesson was how to put two ends of bowel together. Today, he said, we would do a hand-sewn anastomosis. Sure the stapler is nice to use but once in a while, a hand sewn anastomosis is a good thing to do. He showed me how to resect the section of colon leaving plenty of margin and the fine technique of location the numerous vessels that fed this wonderful organ. Again, the living anatomy is a wonder to behold and being able to see how this tumor would be removed was great.

We carefully sewed the remaining ends of  the colon together using Lembert stitching. He talked, he vented and I watched and listened. Together we completed the case and at that moment, I understood why operating on the colon is both fun and something of a challenge. I had to always keep the anatomy in mind, the technique perfect and move in an efficient manner. I remember laughing at him describing the “big honking vessels” that we would be ligating and why one doesn’t want to even think about ties not holding. He said that when he started residency, he would lose sleep over thinking that his ties were not secure.


One of the great things about doing a case with an attending like my colo-rectal professor is that he does vent the things that go over and over in my mind. Are my ties secure with every knot? Are my hands going in the right direction? Have I identified the vessels correctly and ligated them using proper technique? After all, surgery is a practice which has to take place over and over for years. Even now, year’s later, when I don’t have to think about every suture or every tie, I still mentally revisit some of the cases that were turning points in my training for various reasons.

There isn’t anything magical about surgical technique but there is something magical about having the knowledge, background and education to use that technique properly. This is what I learned across the table from my colo-rectal professor. He vented and I listened to all of those pearls that he would verbalize. For me, his venting was golden and some of the best teaching that I ever encountered. He was an extraordinary teacher and he would often tell us that if he was in our position, his venting would drive him crazy. Well, that was never the case for me. His venting made me see the artistry of colo-rectal surgery and why having impeccable technique was paramount for these patients.

The best teaching

It’s no accident that the lessons that I remember best came from my first two years of surgery. By the time one reaches third year, there is a comfort level with being in the operating room. The lessons of my first two years were magical and have not left me. Those late night cases with the chief residents, moving through the abdominal cavity on a laparoscopic case or the first time I was able to close the abdominal cavity and feel confident that I had done this correctly, were memorable for me.

I was fortunate to be exposed to some of the greatest professors of surgery under a variety of circumstances in addition to having some of the best chief residents who were willing to give me their best too. There is much joy in this type of learning and a great amount of joy in venting.


28 December, 2008 Posted by | colo-rectal surgery, general surgery residency, intern | , | 7 Comments