The Doctor: Incision with precision

The first time I assisted in a laparoscopic operation, it was hard to see what was going on. In a real theatre my seat would have been classified as “restricted view”, one of those seats with half a pillar in front of it or offering an aerial view of the actors’ hair.

The operation was a laparoscopic salpingectomy: that is, we were going to take out a Fallopian tube using tools inserted through small incisions in the abdomen, rather than making one big cut. My role was to sit on a stool between the unconscious patient’s legs and keep her uterus at a helpful angle by exerting pressure on a pair of forceps. My sideways view was cut off by the patient’s blue-draped knees. In front of me I could see the consultant and the registrar as they operated, or at least the underside of their chins. The screen showing the operation was directly above my head; if I swivelled until my neck popped I could just make it out. It was half past midnight on a rainy night, and even in theatre the light seemed grey.

The registrar made a nick in the patient’s tummy button and pushed a trocar – a hollow surgical instrument – through the hole. “Gas please,” she said. Inflating the abdomen – insufflation – creates room for the surgeon to manoeuvre and separates the organs from one another. (Insufflation works like inflating a bouncy castle – everything uncrumples.) We use carbon dioxide, as it is relatively inert and, given time, the body can absorb any leftovers. Sometimes, when a little gas gets left behind, it irritates the nerve that supplies both the diaphragm and the skin covering the edge of the shoulder – hence the common post-laparoscopic complaint of “shoulder-tip pain”.

The screen went white as the registrar examined her gloved hand with the camera, checking the light and the focus. Then there was a flash of the consultant’s face as the camera waved past him, on its way in. I looked back up the table, resting my neck. The consultant was finicking over one of the incisions; the registrar was holding her tools still, waiting for him. “OK, go now, go now!” the surgeon said. When I looked back at the screen, we had arrived in a sea cave. The light source in laparoscopic surgery is both cool (you can’t put a hot bulb in a confined human space) and bright: it spreads a glow like a scuba diver’s torch. Under the inflated dome of the anterior abdominal wall, the Fallopian tube was bulging like a sea anemone. “Intact,” said the registrar. “Good.”

Ectopic pregnancy is the main reason for emergency salpingectomy. The fertilised egg is meant to waft along the Fallopian tube until it reaches the uterus, where it implants. In an ectopic pregnancy it settles elsewhere, most often in the Fallopian tube. As the foetus grows, it stretches the walls of the tube, which are likely to rupture if left untreated. This can cause disastrous internal bleeding.

Earlier in the evening, the patient had felt a terrible pain in her pelvis. Her husband called an ambulance; the couple were taken to A&E and then sent to the gynaecology department. The woman hadn’t known she was pregnant – the positive test was a shock; the scan that followed was a worse one. Within three hours she was in theatre; half an hour later, the consultant had bagged up the ectopic and was extracting it through the trocar and into a waiting dish. Back on the ward, her husband sat next to his wife’s bed, surrounded by sleeping women.

Sophie Harrison is a hospital doctor in South Yorkshire. This column appears fortnightly.

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