anonymous

THE LIMITS OF SURGERY 4

 THE LIMITS OF SURGERY 4

DR R.H. KARMARKAR

Howsoever diligently and skillfully a surgeon may operate, he is still likely to meet with an occasional complication following or during an operation. This occurs despite the knowledge of possibilities of such events-a knowledge which a surgeon must acquire by reference to books and journals before doing any surgery—major or minor. As the maxim goes, books are your best friends. They never hide anything from you. This valuable advice was given to me by my father who himself very religiously followed it.

This story is about a patient who lived in spite of my surgery! He was a member of the staff of a well-known industrialist. He had developed hydronephrosis, i.e. an enlarged kidney due to obstruction by a stone at the lower end of a ureter near its entry into the urinary bladder. The stone was removed by gentle dissection and the ureteric wound sutured. I particularly emphasize that it was a gentle extraction because the end of the ureter is relatively fragile and vulnerable to injury. For a week, the patient passed urine freely and on palpation it was noticed that the size of the affected kidney had diminished, thus indicating that the kidney was now effectively draining into the bladder.

Unfortunately one day, suddenly the urine began to leak from the sutured abdominal wound, leaving no doubt in my mind that the lower end of the ureter had necrosed and sloughed off. Intravenous Pyelography confirmed my suspicion. Here I had done my utmost to be gentle and careful, but fate had destined otherwise. This complication was so bad that it could upset any surgeon, there being no easy solution for its cure. My distress and anxiety knew no bounds, because the patient was referred me in good faith and I had done my job with all possible care. I had done my job with all possible care. I had to keep the morale of the patient high by assuring him that the needful was being done. I also had to maintain my cool as I could not afford even a trace of my mental turmoil to other patients. Still, the grim picture of losing reputation and having a setback in practice was constantly haunting my mental canvas, as I was still only in the fifth year of my private practice.

In the meantime, the patient was getting bouts of high temperature every day. This story relates to a period when Achromycin was the only available alternative to Penicillin. It proved to be of some use in controlling the fever.

Day and night, there was hardly any other thought in my except the spectre of a gloomy future. However, soon enough, the advice of my father, given in the past, that books are your best friends, came my rescue. I purchased a copy of the latest edition of the Year Book of Urology which gives reviews of the most recent articles. Therein, I luckily found a reference to what is now known as Boari's Flap. In this technique a rectangular flap of a bladder is raised, hinged near the ureteric orfice and it is then converted into a tube which is joined to the lower end of the ureter after cutting off the necrosed terminal portion. I rushed to the College Library to read the article of Dr Boari in an American Journal and collected some more technical details. I operated according to Dr Boari's plan with perfectly good result. My joy knew no bounds.

In those days we had established a very good tradition of holding clinical meetings every weekend in the K.E.M. Hospital under the chairmanship of our beloved and revered teacher, Dr R.N. Cooper. I presented this case in one such meeting and was complemented by Dr Cooper who asked me about the source of my information. I had gathered that he burnt the midnight oil before retiring to bed, so that he was ready for the lecture to his students scheduled for the next day. So his acknowledgement was ample reward for me.

Compilation of professional reminiscences of specialists - edited by M.V.Kamath and Dr.Rekha Karmarkar