The Surgical Room

On the 4th of February, 2019, I got to watch a total knee replacement.this elective surgery was done on a patient who had severe osteoarthritis and had affectively no Articular cartilage left on the left side of her right knee. I met Dr Atrah in the theatre after changing into scrubs and boots and donning surgical mask and gloves. I helped the performing team gown up and get ready for their surgery. The patient, the lady of about mid 70s, was wheeled to the operating room, anaesthetised from the lumbar spine down. We made brief Eye contact, the drapes were put up to shroud her line of sight (as she was sedated yet conscious), The chlorhexidine was applied to sterilise her right leg, and the first incision was made to open the up and down to the bone.

Throughout the procedure, the would would be drained of blood, and bleeding venules were cauterised. Atrah prefers not to tourniquet the leg, as it causes a huge surge of blood post surgery and could potentially lead to emboli. A few holes were drilled, part of the bone were kept for sizing of the new tibiofemoral joint, Some angled cards were made and rounded off, and after the trial joints were put in place, the plastic patella and shiny steel femoral condyles and tibial head were cemented in place. The doctors gave me some of the excess cement from the joint to hold in my hand, and I felt it both create an exothermic reaction (helps bone regrowth and vascularity) and harden to a rock.

After the procedure, the patient was stitched up, and I was told that she would be able to walk on it tomorrow.the whole procedure was like watching an artisan work in his workshop, a carpenter building the new queen's throne. I was invited to see surgery performed again the following day, and gladly opted to do so. I was treating hip and knee patients as an Occupational Therapy student, and now, I was getting to see the procedures I was treating in real time with real physician and patient interactions.

For the hip surgery on 5/2, i had a quick lunch and straight down to theatre to meet Mr Atrah once more. Per the day prior, there was an airflow machine that cleaned the air of any pathogens, sterile surfaces, debridement and cauterising tools, a liquid drainer, and lots of sterile tools. The lady, previously having her opposite hip done, chose to not have sedation. The leg was draped in an iodine wrap to isolate and prevent infection, and the first incision was made. After severing the gracilis, tensor fascia latae, vastus lateralus, gluteus minimus, and glutus medius, the adipose tissue was separated and the femoral head was found. A bone saw cut the capsule from the trochanteric notch, and the acetabulum was reamed and bored out. The metal insert, after a trial run, was hammered into the acetabulum, followed by the polyethylene socket that emulates articular cartilage.

After this bit, a bit of debridement was done, and the surgeon malleted a wedge into the patient’s intertrochanteric neck to form an opening for the new head of femur (typically steel, chromium, or cobalt) to be inserted with a few more sledgings. I was called over to the surgical table to see the patient’s new, artificial hip flexing, extending, and rotating. Under spinal anaesthesia, the patient could feel these movements, but the sensations were dulled and painless. The severed muscles were stitched back together (they would recover in a few weeks, just as muscles recover post-workout), and the adipose tissue, dermis, and epidermis were sutured back together. Finally, the epidermis was stapled, a bandaged was placed over the area, and I followed the patient back to the recovery room, where she was desperate for a cup of tea (as is the English way, I suppose).

Comparing these two surgeries to another is like comparing oranges to tomatoes – one is a fruit, and one is sort of like a fruit. In both cases, old arthritically affected joints were sawed away, and shiny new metallic/plasticine parts were implanted. In both cases, the patients were anesthetised from the lumbar spine down. Surgical precautions were followed, and I saw a lot of similar tools (save the ones that aligned the knee or hip and allowed for measurement, angling, and/or the actual replacement). The surgeon was happily working his task, the team lead would suture and staple the patient’s affected parts back together, and the surgical assistant was deafeningly busy.

The major differences however lied in the surgical process itself. With the knee, three separate bones - the condylar surfaces, posterior patella, and tibial head - were sawed in places and eventually replaced with metal (save the patella, which was plastic). With the hip, there were only two; the head of the femur and the acetabulum (with it all being metal sans the articular cartilage, which was polyetheline). The hip was much deeper than the femur, and more muscles had to be severed and then stitched together for the surgery to be successful. The knee had to be properly aligned, and the trial process was much more intense. Just as well, knee surgeries typically use cementing, whereas hips do not. I also noticed that a lot more blood and marrow came from the knee operation than the hip, in spite of all of the muscles and fat that were severed.

Comparing surgical theatre between the USA (my homeland) and the UK, theatres in the US were more compact, had more equipment, and had a bigger team of clinicians present. However, in the UK, the infection control process was seemingly stricter. These differences may also very well be a product of the actual operation itself as well: I saw elective surgery in the UK, but the one in the states was done to save a patient’s life (bypassing the Left Anterior Descending artery of the heart using the Left Internal Mammary Artery).

The whole experience was exhilarating, to say the least. Most of my friends consider themselves squeamish; I am quite the opposite, save for a few bodily fluids. The bone cement sort of freaked me out with the exothermic reaction, and I had a few ‘oh my god’ moments under my breath during the procedures – namely when the bone bits started flying.  Being informed of different parts of the surgical process was also very exciting. I wish I had more time to develop and ask more questions; albeit, most were answered during the surgical process.

All in all, I'm very thankful the procedures I've been able to observe. Next up in this process is to learn more about redesigning the home and broadening my clinical knowledge. Catch you all soon!