THIS CAN HAPPEN VOL XII
This can happen vol XII
Dr. Gangadhar Sahoo
It is an interesting incidence which had occurred in 1978-79 during my PG carrier.
A middle aged parous lady was admitted for a case of huge ovarian tumor. Only imaging technology available at that time was X-ray. Three conditions were to be differentiated:
- Pregnancy .
- Ovarian tumor.
- Massive ascites.
Clinical diagnosis was Ovarian tumor. X-ray excluded pregnancy. It was difficult to differentiate between massive ascites and huge ovarian cyst. Cytology report of aspirated fluid was inconclusive. A single time tested age old clinical method was taken as gold standard for confirmation of diagnosis. On percussion of abdomen from center to the back , if one finds a band of resonance on the custo-vertebral angle , then it is clinically diagnosed as ovarian tumor. The explanation is very simple. In ascites the intestines will be found floating at the top . So when percussion is done on supine position, it will be resonant at the top where as in huge ovarian tumor , the intestines will be pressed by the mass and percussion node will be resonant at the back .
Operation date was fixed. Dr. Mishra , Associate Professor was the main surgeon and assistant professor Madam Panigrahi was his assistant . I was the second assistant . Under general anaesthesia operation was started. After opening the peritonium when the whitish glistening surface was seen the diagnosis of OVARIAN CYST was confirmed. Operation of ovarian cyst is a simple operation. So Dr.Mishra left the case to Dr. Panigrahi and went to the second table to start another case.
On exploration Dr. Panigrahi found it difficult to deliver the tumor. On examination of the wall of the tumor she found typical criss-cross distribution of capillaries which aroused suspicion of a retroperitoneal cyst . She called Dr. Mishra for help. Dr. Mishra was already ready for the other case . So he directed Madam to open the visceral peritonium and deliver the retro peritoneal cyst. While doing so , Madam came across a long tubular structure below the visceral peritonium loosely attached. She had never encountered such a scene before. She again called for help. Dr. Mishra again came and asked Madam to clamp and cut that tubular structure. Madam seriously asked Dr.Mishra, " Sir ! Can it be ureter ? " Dr. Mishra confidently told, " It's the uterine artery stretched over the tumor. It can never be ureter. Blindly clamp and cut .
Don't worry. I am here . Have faith on me ." Madam did so .
After cutting there was no bleeding from the tubular structure from either or both ends. Only drops of water was seen dribbling from one end . It was the URETER bisected through and through. Madam could not believe herself. A blunder was done . Dr. Mishra came and consoled her . In lighter vein he quoted the quote of the legendary Gynecologist Prof. Jeffcoat, " One cannot be rated as a complete gynecologist without cutting an ureter in his/her life time. Today you got that distinction. Congratulations. "
The urologist was called. He did the end to end anastomosis , kept the ureteric catheter. Then the operation of ovarian tumor was completed.
Lesson: Every patient is a teacher and every medical problem is new chapter.
While operating any case simple or difficult, every protocol should be followed meticulously.
Over confidence is the main cause of complications during surgery. Had Dr. Mishra given a thought to the suspicion of Dr . Panigrahi this iatrogenic complication could have been avoided.
I always teach my students, " SURGERY IS NEITHER EASY NOR DIFFICULT. IT'S EITHER MADE EASY OR MADE DIFFICULT. "
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