Hello world,

I began volunteering at the Christiana care hospital in Wilmington Delaware for about a 2 weeks now. My mission is not to just get volunteer hours, but to dive into the ins and outs of the hospital environment. My primary focus is to be an observer, by exposing myself to as much surgical cases as possible. To watch and learn from surgeons, PA’s and nurses. Surgeries are extremely gruesome…. but fascinating! Although I have never been truly [introduced] to the hospital OR, turns out it was pretty much as expected. As a volunteer, the job duties I am responsible to perform are to clean, wipe and synthesize the entire OR after the case is over. While the cases are in their procedures, I take that time to explore and watch surgeries from the outside window of the OR. Sometimes, I get lucky enough to stand right beside the doctor as he performs the surgery.

On June 29, 2018 I was granted the opportunity to watch a leg amputation. The patient had an infection in his lower leg extremity that caused him to dis-articulate his right knee. Preventing the infection from rising and spreading through the higher leg extremity. The orthopedic surgeons that performed this Knee disarticulations (KD) were two Residents fresh out of the womb of medical school. I ceased this chance to ask as many questions as possible. To learn and to partially see if they really knew what they were doing. Anyways, The lower half of the leg had all sorts of bumps, bruises and hematoma in the tissue. The incision took place in the middle of the kneecap-down. 

The doctors began by outlining the middle of the knee joint to cut directly through the joints and cartilages that connected the femur to the tibia. It is essentially a knee dis-articulation done between the surfaces of bones. Rather than cutting through the actual bone. Cutting through tendons, ligaments and muscular systems to reach all the way through to the popliteus tendon, the posterior region of the knee. As cruel as it may sound, I was excited to see the amputation. When it comes to surgeries, you cannot be soft-hearted. This time I was smart enough to bring a small notepad to write down notes, unlike last time where all the information just slapped me in the face and still left me clueless and overwhelmed. Anyhow, here are my notes, thoughts and further explanation about the case to the best of my knowledge.

The Procedure

The incisions are sharply carried down circumferentially to the level of the knee, through the joint, and along the drawn posterior flap. One of the two doctors began cutting with a scapula through the skin into the tibiofemoral joint, that controls the range of motion of the knee, reaching the cartilage. Where they began using a bovie, an instrument used for electrosurgical dissection and hemostasis. Takes awhile to cut through someone’s leg but nonetheless they cut through the tendon and reached the Anterior Cruciate Ligament, famously referred to as the ACL. It was my first time vividly seeing an ACL and now I have that image stuck in my head. Doctor Ben, one of the doctors performing the procedure, mentioned that the main goal is to reach the popilateral vessel to tie it then cut it. The popliteal artery is a deeply placed continuation of the femoral artery.

So just a refresher on the systemic circulation pathways. Oxygenated blood is pumped from the left ventricle of the heart into the Aorta, down the abdomen into the lower extremity, passing through the pelvis to the illiac artery branching into external and internal arteries, in this case through the external artery into the femoral artery to the posterior popliteal artery.

Essentially, the surgeons were cutting to reach the popliteal vessel and with great care not to disturb the insertion of the Adductor Magnus, a large triangular muscle that adducts and medially rotates the hip. Meanwhile, preserving the cruciate ligaments and the posterior capsule. Once they finally reached the popliteal blood vessel, they tied the end of the artery first, to stop blood flow, then tied the vein. After ensuring all is done correctly the distal leg was removed from the operative field with ligation of the popliteal vessel. However, the surgery was not over yet. After the removal of the lower leg, the doctors shaved down the head of the femoral bone, starting distally and ending proximaly using a saggital saw to shape the head into a box. Then persevered the cruciate ligaments and posterior capsule. With the patella advanced to cover the distal surface of the femur as an end-weight bearing surface. When it came to suturing the quadriceps tendon is sewn to the preserved cruciate ligament and posterior joint capsule so that the posterior surface of the patella is in direct contact with the distal end of the femur. Next, the hamstring muscles are myodesed to the quadriceps tendon and posterior capsule using 2.0 polydioxanone to cover the distal femur. Looking something like this…

There we have it! That was a leg amputation!

All in all, this was an extraordinary yet very knowledge and useful experience for me. I am delighted to be volunteering and learning through exposure through real hospital settings rather than just reading about it through books. These blogs are intended for personal growth in my understanding to medicine. As well as, share these stories of my first encounters in the OR and to refer to them in the future!

References

Albino, Frank P, et al. “Through Knee Amputation: Technique Modifications and Surgical Outcomes.” Advances in Pediatrics., U.S. National Library of Medicine, Sept. 2014, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4179362/.

Ibrahim, Mohamed, and Stephen Rouse. “Anatomy Final Project: The Lower Extremity .” Google Slides, Google, May 2018, docs.google.com/presentation/d/1ZxDuDNoC6k_hXHZru4x2UlB7GtED86w_NZq1sPTqfek/edit.

Smith, Douglas. “The Knee Disarticulation.” Amputee Coalition, 2004, http://www.amputee-coalition.org/resources/the-knee-disarticulation/.