between two clamps. He'd surrounded the area with gauze to protect the rest of the abdomen from the contents and now he sliced it open with a scalpel.
'Merrin, do you see what we're doing?'
'You're going to join that up with the other end,' she observed, fascinated. 'Have you already taken out the tumour?'
'It's in the bowl over there.'
The scrub nurse tipped a kidney dish towards her and Merrin saw the segment of bowel he'd removed. 'What about his liver?'
'Clear. Lymph nodes feel clear.' In the few moments she'd been watching he'd managed to insert a stapling machine into each end of the bowel and now she saw him start to draw them carefully together, using a piece of blue thread that he'd clearly stitched into place earlier to secure the hold. 'Do you understand what I'm doing here?'
'You're stapling the bowel together, instead of sewing it,' she confirmed, watching, fascinated, as he. prepared the machine, closed the two ends together then stapled. 'Does this mean he won't need a colostomy?'
'There's enough of a clear margin between the tumour and the ends here to make a successful join,' he said, nodding briefly as he unclipped one end of the stapler to reveal a circular piece of tissue which the machine had removed.
'But how can you be sure that it's safe?' Merrin asked.
'I'm sure.' He sent her a quick, almost half-amused look, then lowered his head to his task again.
'But what if it isn't?' she persisted, genuinely interested. 'Wouldn't you be better hand-sewing the ends to be safe?'
Lindsay sent her a look which suggested that the SHO questioned Merrin's sanity, but the professor didn't seem particularly bothered. 'In experienced hands, a stapled anastomosis is as safe as a hand-sewn one,' he told her calmly. 'I'm experienced. This anastomosis is fine.' He showed her the small piece of bowel he'd removed. 'We call this a doughnut. If it's an intact circle then the join is complete.'
'The join might be fine,' she accepted, 'but what about in the future?'
The Prof looked up at her again from his work, his pale eyes solemn this time. 'There isn't going to be a problem, Dr Ryan. Mr Wilson's going to recover normally and in about a week's time he's going to go home.'
'But I thought that experimental studies showed that if bowel ends were stapled there was a higher risk of tumour recurring around the staple line,' Merrin protested.
'You're right,' he conceded, nodding. His fingers moved quickly as he spoke. 'I'm sorry. I was simplifying things for you and I shouldn't have. But what you've read about are experimental studies conducted in laboratories and not in patients. Lab studies have shown increased tumour recurrence around staples, true. But in practice it doesn't happen. In practice, current evidence is that tumour recurrence is seen less often in stapled joins than in hand-stitched ones.'
Above his mask his eyes sent her what looked like a quick smile. 'Have I relieved your worries?'
'You have,' she said firmly, feeling her pulse rush a little at his apparent approval. 'Thank you.'
'You're welcome.'
'I haven't read anything recently about staples and tumour growth,' Lindsay said uncertainly.
'I've some references in my office,' the professor said quietly, his attention back on the wound. 'I'll give them to you later.' Moving quickly, he extracted Merrin's retractor, passed it to his scrub nurse, tucked the bowel they'd been working on back into the abdomen, uncovered the gauze-covered remainder of the bowel and small intestine and directed it all back into place.
He swiftly inserted a drain through the skin and threaded it down around the surgical field then pulled the abdomen closed.
'Closing, Chris,' he announced—Merrin assumed to the anaesthetist because the man beside her raised a lazy hand in response. 'Vicryl to close, please. Lindsay, swap places. We've been fast. You can finish here.'
'Thanks, Prof.' Beside her, Lindsay moved, walking around the scrub nurse's trolley to the other side
'Merrin, do you see what we're doing?'
'You're going to join that up with the other end,' she observed, fascinated. 'Have you already taken out the tumour?'
'It's in the bowl over there.'
The scrub nurse tipped a kidney dish towards her and Merrin saw the segment of bowel he'd removed. 'What about his liver?'
'Clear. Lymph nodes feel clear.' In the few moments she'd been watching he'd managed to insert a stapling machine into each end of the bowel and now she saw him start to draw them carefully together, using a piece of blue thread that he'd clearly stitched into place earlier to secure the hold. 'Do you understand what I'm doing here?'
'You're stapling the bowel together, instead of sewing it,' she confirmed, watching, fascinated, as he. prepared the machine, closed the two ends together then stapled. 'Does this mean he won't need a colostomy?'
'There's enough of a clear margin between the tumour and the ends here to make a successful join,' he said, nodding briefly as he unclipped one end of the stapler to reveal a circular piece of tissue which the machine had removed.
'But how can you be sure that it's safe?' Merrin asked.
'I'm sure.' He sent her a quick, almost half-amused look, then lowered his head to his task again.
'But what if it isn't?' she persisted, genuinely interested. 'Wouldn't you be better hand-sewing the ends to be safe?'
Lindsay sent her a look which suggested that the SHO questioned Merrin's sanity, but the professor didn't seem particularly bothered. 'In experienced hands, a stapled anastomosis is as safe as a hand-sewn one,' he told her calmly. 'I'm experienced. This anastomosis is fine.' He showed her the small piece of bowel he'd removed. 'We call this a doughnut. If it's an intact circle then the join is complete.'
'The join might be fine,' she accepted, 'but what about in the future?'
The Prof looked up at her again from his work, his pale eyes solemn this time. 'There isn't going to be a problem, Dr Ryan. Mr Wilson's going to recover normally and in about a week's time he's going to go home.'
'But I thought that experimental studies showed that if bowel ends were stapled there was a higher risk of tumour recurring around the staple line,' Merrin protested.
'You're right,' he conceded, nodding. His fingers moved quickly as he spoke. 'I'm sorry. I was simplifying things for you and I shouldn't have. But what you've read about are experimental studies conducted in laboratories and not in patients. Lab studies have shown increased tumour recurrence around staples, true. But in practice it doesn't happen. In practice, current evidence is that tumour recurrence is seen less often in stapled joins than in hand-stitched ones.'
Above his mask his eyes sent her what looked like a quick smile. 'Have I relieved your worries?'
'You have,' she said firmly, feeling her pulse rush a little at his apparent approval. 'Thank you.'
'You're welcome.'
'I haven't read anything recently about staples and tumour growth,' Lindsay said uncertainly.
'I've some references in my office,' the professor said quietly, his attention back on the wound. 'I'll give them to you later.' Moving quickly, he extracted Merrin's retractor, passed it to his scrub nurse, tucked the bowel they'd been working on back into the abdomen, uncovered the gauze-covered remainder of the bowel and small intestine and directed it all back into place.
He swiftly inserted a drain through the skin and threaded it down around the surgical field then pulled the abdomen closed.
'Closing, Chris,' he announced—Merrin assumed to the anaesthetist because the man beside her raised a lazy hand in response. 'Vicryl to close, please. Lindsay, swap places. We've been fast. You can finish here.'
'Thanks, Prof.' Beside her, Lindsay moved, walking around the scrub nurse's trolley to the other side
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