The Art and Science of Surgery: Angeli in SLMC Week 3

Halfway through already? :) Can’t hardly believe it! It’s been such a great experience so far. Yet up to now, the nurses are still at a loss whether to allow me inside the OR or not. Haha! Thankfully, I finally got my visiting clerk ID – better late than never, I guess.

Day EIGHT: Tuesday, july 14, 2015

Inguinal Herniorrhaphy with Mesh. Mastectomy. Breast Reconstruction. Oooh, an inflatable breast! :)) #PlasticSurgery

AM – I got to accompany Dr. Siozon on yet another one of his ORs – there never seems to be a day when he isn’t in the OR. haha! – this time, an indirect inguinal hernia. And it wasn’t just a hernia. It was a HERNIA. A really big inguinal mass was clear to be seen from the moment I entered the OR. It seemed like the entire sigmoid colon was herniated into the defect – thankfully it didn’t strangulate! Lolo Boss did a classical bassini repair along with the mesh placement. From what I understood, both techniques were done to ensure the return of strength of the floor so as to avoid recurrence, especially since there was that big of a hernia to begin with.

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Me and Dr. Siozon, head of SLMC-QC Institute of Surgery, after that herniorraphy || Galing talaga mag-opera ni Lolo Boss! :D He’s one of the living proofs of how surgery is definitely a combination of science and art. 

PM – Another breast OR with Dra. Macel. This time, we got to do the OR with Plastic Surgery. The GS team did a skin-sparing mastectomy + sentinel node biopsy (which turned out positive from the histopath, making it so they also had to do axillary lymph node dissection); afterwards, the Plastics team went in to perform immediate breast reconstruction using this really cool breast implant that mimics the breast contour really well, versus the old rigid implants. Due to the possibility of having radiation therapy in the future, they didn’t inflate the implant all the way; it can readily be collapsed should RT be needed to be done to the patient.

DAY NINE: WEDNESDAY, JULY 15, 2015

Laparoscopic Cholecystectomy – re-appreciating my anatomy. First hand try – Mammotome at the Breast Center.

One of the mainstays of any general surgeon is the surgery of the gallbladder. And today, I finally got to observe a laparoscopic cholecystectomy with Dr. Gigi Garcia and Dr. Edward Oliveros. The procedure almost didn’t push through on account of the patient’s premature ventricular contractions. Monitoring was done, Cardio was called in, 12-lead ECG was done. Eventually, since the patient was asymptomatic and had a stable blood pressure, the green light was lit! I’m still so amazed at how minimally invasive surgery is done. I got to re-appreciate my anatomy (It’s so, so, so true, especially for an aspiring surgeon like me. You always go back to the basics) with Dr. Oliveros taking time to teach me the pertinent structures as well as important points.

I hope I remember this correctly! :) 
The 5 Key Structures to Identify in Doing Lap Chole
- Hartmann's pouch
- Left fissure of the liver
- Right fissure of the liver
- Common bile duct
- Common hepatic duct
It is very important to search for and identify 
the cystic duct and the cystic artery.

My most important takehome point from the whole thing is probably SAFETY FIRST! :) From the patient’s ECG (always important to make sure that the patient’s stable enough for surgery) to the identification of landmarks and the blunt dissection (watch out for the vessels! find and cauterize all bleeding points. know which is “garbage” i.e. just fat, and differentiate your safe and danger zones!), it is always about taking caution much for the benefit of the patient as well as yourself.

Afterwards, it was back to the Breast Center for me, where I got to assist Dra. Macel in doing breast biopsy using the Mammotome. Guided by ultrasound and performed under local anesthesia, the Mammotome probe is inserted through a small incision (around 1/2 inch) and directed towards the breast mass, which it cuts and vacuums portion-by-portion until the entire thing is removed. The tissue samples obtained are the ones submitted for biopsy and are practically as accurate as the ones obtained from surgical excision. This technique can be done for lesions up to 3cm and it definitely beats having to go to the OR for excision as it can be done right at the doctor’s clinic. Cooool. I got to assist by administering the anesthesia – they use the spinal needle used in epidural anesthesia – and even got to operate the Mammotome myself (with much guidance, of course!) Way awesome! :)

To make this day of learning complete, I also got a crash course on Breast Cancer 101! Dra. Macel discussed the must knows – common clinical presentations, risk factors, benign vs malignant findings, the different biopsy techniques (FNAB, core needle, Mammotome, stereotactic, excision), the mainstays of local treatment: mastectomy vs breast conservation, adjuvant (or neoadjuvant) treatment with radiation,  and systemic treatment (chemotherapy, hormonal, and targeted). My brain got quite the workout today! What a rush! :)

 

DAY ten: thursday, JULY 16, 2015

a trip to St. Luke’s Global City ~ Hospital Tour: so sosy! Breast Center: Mammotome and Stereotactic Biopsy

They weren’t kidding when they said it was a hospital-hotel! I finally got to visit St. Luke’s Medical Center – Global City, after catching the 10AM shuttle bus service from the QC hospital (Thank you, Kuya Ernest!). The place is huge and, as I expected, extremely sosy! :)) Haha! Such a pretty hospital. While Dra. Macel finishes up with her countless patients in the clinic, Nurse Gwen showed me around the hospital. We went to see the special patient rooms, the Presidential Suite and the Ambassador Suite, both very impressive set-ups with a receiving area, a dining area, a kitchen, a study – complete with a full desktop computer set, and a huge patient room. The Presidential Suite even has a separate room for the relatives/watchers! And of course, the prices for these suites are also likewise impressive. I could pay for a semester’s worth of tuition for a day’s charge! 

That afternoon, I accompanied Dra. Macel at the Breast Center, where I assisted in another Mammotome procedure as well as get to perform the specimen harvesting during a stereoscopic biopsy. So cool! It’s really a wonder what the advancements are capable of doing these days.

The stereoscopic biopsy procedures makes use of the same instrument as the Mammotome, the only difference being you take imaging shots (x-ray) of the breast so as to determine your location. This particular procedure is mostly used for microcalcifications, the kind you can’t usually palpate, and using the imaging as a guide, you get to accurately pinpoint the location of the microcalcifications and harvest a specimen for biopsy. The patient is positioned prone over a platform with the target breast suspended over an opening on the platform and into the imaging device.

I also got to learn a bit about breast imaging from the Breast Center’s own Radiology team – thank you to Dra. Perez and all the fellows/residents! :) I was taught the basics of mammography and breast ultrasound (they have 3D ultrasound!), and got to appreciate microcalcifications, fibroadenomas and cysts on imaging, as well as how to identify whether a particular imaging finding appears benign or suspicious. Yay~!

Dra. Macel treated me to a delicious mixed berries cheesecake + chocolate tart cake at Paul’s afterwards. Medyo nakakahiya na talaga! Hehe! Ako pa yung pinapakain. >.< Libre ko naman next time, Tita! Then, we braved the intense traffic jams as we made our way back to the QC hospital. Took us 2.5 hours! We got to talk about a lot on that intense road trip! :))

Huhu. I forgot to take pictures at Global. Wala pa kaming picture ni Dra. Macel. 

Week 3 over, and it’s down to my last week already! This elective went by so fast! :( August is also almost upon us and with it, the real clerkship begins! Ahhhh!

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