An easy operation gone wrong
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《英国医生杂志》
1 Swadia Institute of Minimally Invasive Therapy, Police Ground Road, Baroda, India-390 001 swadias@hotmail.com
I was operating on a 4 year old girl with unilateral inguinal hernia. Hernia is rare in girls and the inguinal variety is rarer still. In female inguinal hernia the inguinal canal contains only round ligament, which can be sacrificed, and unlike in males, there are no hassles of dissecting cord structures meticulously.
I made an inguinal incision and deepened till the external oblique aponeurosis, then I opened the inguinal canal, dissected the round ligament, and hooked it up on my little finger. I freed the hernia sac, ligated it, and excised at its highest point. Next, I placed two haemostats slightly apart on the round ligament, intending to excise a segment of the ligament so that the inguinal canal could be completely obliterated. When I cut at one end of the segment, to my utter horror, the "ligament" showed a lumen. I had hooked up the femoral artery instead of the ligament, applied haemostats, and gone ahead and cut it. Disaster.
What had gone wrong? Rather than opening the inguinal canal, I had incised the inguinal ligament: in children the structures are quite close. This had exposed the femoral artery, which I had hooked up onmy little finger, mistaking it for the round ligament. Once it was hooked and hence stretched, the pulsations were either absent or not appreciated. As I had done my residency in the cardiovascular unit, I applied bulldog clamps at the two cut ends, removed the haemostats, andset about suturing the vessel. Unfortunately, the distalbulldog clamp slipped and the vessel retracted into the thigh. Another disaster. With great difficulty, the vessel was found and the anastomosis performed, but the pulsations did not appear in the limb. I panicked and requested help from a cardiovascular surgeon. He made a T incision into the thigh, and we saw that I had inadvertently anastomosed the profunda femoris branch of the femoral artery with the proximal cut end of the femoral artery. I had sectioned the femoral artery at the level of origin of the profunda, and so there were two cut ends distally. Ultimately, all anastomoses were successfully done and the limb was salvaged.
Fifteen years later the girl is a beautiful young lady who stands tall on her own two feet and continues to call me her living god. And that ill-fitting bulldog clamp still adorns my consulting room table to remind me how clay-footed her god is.
What I had I learnt was (to paraphrase Hippocrates) that no surgery is too light to be casual about nor too severe to be despaired of, and it is always beneficial to all to call in a second opinion in times of distress.(Nayan D Swadia, private p)
I was operating on a 4 year old girl with unilateral inguinal hernia. Hernia is rare in girls and the inguinal variety is rarer still. In female inguinal hernia the inguinal canal contains only round ligament, which can be sacrificed, and unlike in males, there are no hassles of dissecting cord structures meticulously.
I made an inguinal incision and deepened till the external oblique aponeurosis, then I opened the inguinal canal, dissected the round ligament, and hooked it up on my little finger. I freed the hernia sac, ligated it, and excised at its highest point. Next, I placed two haemostats slightly apart on the round ligament, intending to excise a segment of the ligament so that the inguinal canal could be completely obliterated. When I cut at one end of the segment, to my utter horror, the "ligament" showed a lumen. I had hooked up the femoral artery instead of the ligament, applied haemostats, and gone ahead and cut it. Disaster.
What had gone wrong? Rather than opening the inguinal canal, I had incised the inguinal ligament: in children the structures are quite close. This had exposed the femoral artery, which I had hooked up onmy little finger, mistaking it for the round ligament. Once it was hooked and hence stretched, the pulsations were either absent or not appreciated. As I had done my residency in the cardiovascular unit, I applied bulldog clamps at the two cut ends, removed the haemostats, andset about suturing the vessel. Unfortunately, the distalbulldog clamp slipped and the vessel retracted into the thigh. Another disaster. With great difficulty, the vessel was found and the anastomosis performed, but the pulsations did not appear in the limb. I panicked and requested help from a cardiovascular surgeon. He made a T incision into the thigh, and we saw that I had inadvertently anastomosed the profunda femoris branch of the femoral artery with the proximal cut end of the femoral artery. I had sectioned the femoral artery at the level of origin of the profunda, and so there were two cut ends distally. Ultimately, all anastomoses were successfully done and the limb was salvaged.
Fifteen years later the girl is a beautiful young lady who stands tall on her own two feet and continues to call me her living god. And that ill-fitting bulldog clamp still adorns my consulting room table to remind me how clay-footed her god is.
What I had I learnt was (to paraphrase Hippocrates) that no surgery is too light to be casual about nor too severe to be despaired of, and it is always beneficial to all to call in a second opinion in times of distress.(Nayan D Swadia, private p)