We were all waiting. The patient, already anaesthetised, was lying on the operating table. The anaesthetist, sitting at the head of the table, presiding like father at Sunday lunch, kept one eye on the machine by his side and the other on the patient. Two junior nurses were standing quietly behind the theatre sister. They’d tidied up the corner of the theatre where the sister and I had scrubbed and gowned.
The sister stood on one side of the operating table and I, the junior house surgeon, stood on the other side. We were waiting for the surgeon who was going to perform the operation. The patient had already been swabbed with antiseptic and, except for a small square of naked flesh, his whole body was covered with green, sterile towels.
Suddenly, the door to the theatre opened and the surgeon poked his head round it. ‘Sorry I’m late,’ he called. ‘I’ve got to see a patient in casualty.’ He nodded to me. ‘Would you mind starting without me? I’ll be along when I can.’
The noise I made as I gulped must have sounded deafening. I’m sure it must nearly have woken the patient despite the fact that he was deeply anaesthetised.
‘OK,’ I whispered. I turned back to the patient.
The small square of naked flesh had grown, stretched suddenly into a daunting field-sized area of pink skin.
‘It’s easy,’ said the anaesthetist. `An appendectomy is just like taking a tooth out.’ He knew I’d never done an operation by myself. He perhaps didn’t know I’d never even taken a tooth out.
The theatre sister offered me a scalpel.
‘Thank you,’ I managed to murmur. I gazed down again at that field of pink skin. It looked big enough to land an aeroplane on.
Suddenly I didn’t have the faintest idea where to start cutting. Yes, I’d seen nearly a dozen similar operations performed when I’d assisted the surgeon. And it seemed so very, very easy then.
‘I’m sorry,’ said the sister, suddenly, unexpectedly. She moved two of the green towels back a little, so that an even larger area of skin was exposed. She held one of the towels still for a moment, an inch or so to one side of the umbilicus. Hinting.
It came back to me then. I had to make the incision at a point a third of the way along an imaginary line drawn between the superior iliac spine and the umbilicus.
The incision needed to be perpendicular to that line, and, if I made it in the right spot, I should be able to make do with an incision about two and a half inches long. Not quite keyhole surgery, perhaps, but pretty good. And likely to leave my patient with a small, neat scar.
I’d seen the surgeon I was working for take an appendix out through a hole which didn’t seem to be more than an inch long.
But I wasn’t feeling that ambitious.
I lifted the scalpel and dug it deep into the patient’s skin. Terrified that I might have cut too far I lifted the scalpel out again quickly.
A small drop of blood oozed out of the tiny hole I had made. I wiped it away and put the scalpel back in position. This time I pressed down as hard as I dared and drew the scalpel along the skin for a couple of inches.
For a moment I could see no sign that I had even punctured the skin, and then blood slowly began to ooze out of the thin wound I had made.
The sister offered me a sterile swab. I dabbed half-heartedly at the wound. Blood continued to flow out, forming a small puddle on the skin. I gazed at it horrified.
The sister gently took the swab from my hand and pressed it down firmly on the wound. When she lifted it up a few seconds later, the bleeding had temporarily stopped.
Slowly blood began to ooze again from two small, cut vessels. The sister put the diathermy coagulating forceps in front of me. I picked up the diathermy, which burns and seals broken blood vessels, pressed the pedal to switch on the electricity and touched one of the bleeding vessels with the tip of the forceps. There was a small puff of smoke, a sizzling noise and the bleeding stopped. I then burnt the second vessel and closed that off too.
The sister took the diathermy forceps from me and handed me the knife again.
I looked down into the wound. It was less than a quarter of an inch deep, but the thin layer of fat which I had cut was beginning to fall outwards. I made another cut along the bottom of the wound I’d made. And so we went on. Each time I hesitated the sister would hand me whatever I needed, before I knew I needed it. I never questioned her.
By the time the surgeon came into the theatre, apologising profusely for being so late, I’d divided the tissues right down to the peritoneum, the thin layer of tissue which lines the abdominal cavity.
While the surgeon scrubbed and gowned, I tidied up the wound, made sure I’d missed no bleeding points, and, finally, cut through the peritoneum.
I moved back from the table as the surgeon approached, making room for him. He shook his head and waved a hand at me.
‘Get back where you were,’ he said. ‘What are you stopping for?’ He moved into the position usually occupied by the surgeon’s assistant.
I stared back at the wound. All the confidence I’d built up drained away. How could I operate knowing that the surgeon who’d taught me all I knew was assisting me?
The surgeon looked up across the table and called to the two junior nurses, standing ready to fetch things for the theatre sister.
‘Come here,’ he said.
They edged closer to the table, terrified of touching and desterilising any of the towels and drapes covering the patient and the instrument trolley.
‘What do you know about this operation?’ the surgeon asked one of the nurses.
The nurse paused for a moment. ‘It’s an appendectomy,’ she said in a whisper.
The surgeon nodded. ‘And what’s this?’ he asked her, pointing to the peritoneum I’d just cut. ‘The peritoneum,’ stuttered the nurse, after a moment or two.
Again he nodded. ‘Now that the surgeon has got through the peritoneum,’ the surgeon waved a pair of forceps in my direction, making it clear that I was the surgeon to whom he was referring, ‘he picks up a pair of bowel forceps and brings some bowel out of the abdomen. He’s looking for the large bowel and, in particular, he’s looking for the caecum.’
And so he went on.
As he talked, I did precisely what he said I was doing. As far as everyone else in the theatre was concerned, he was just taking the opportunity to teach a couple of junior nurses about an appendectomy. As far as I was concerned, however, he was providing me with precise and thorough directions. Not necessary. But nice to know he was there. Just in case.
I found the appendix, removed it, tied off its blood supply, closed the peritoneum and then proceeded to close all the layers I’d opened.
The surgeon never interfered.
When I’d put the last stitch in and taken the skin towels off the patient, I walked proudly out of the theatre and into the surgeon’s changing room.
There I usually completed my task as assistant to the surgeon by writing up the operation notes, details of what had been done in the course of the operation. But this time the surgeon was already sitting down writing the notes for me.
‘Do you want me to do those?’ I asked.
The surgeon shook his head. ‘This is the assistant’s job,’ he said. He wrote a few more sentences and then tossed the notes onto the table in the middle of the room and walked out. ‘Thank you,’ he said as he left.
Automatically I picked the notes up to see what he’d written. At the bottom of the page there was a space for the surgeon’s name.
In this space he’d written my name and underneath it, in precisely the same way that I usually wrote my initials under his name when I’d assisted and written up the notes, he’d put his initials. I felt curiously proud. I’d performed my first operation as the senior surgeon.
There was a knock on the door and the theatre porter appeared. ‘Excuse me, doctor,’ he said, ‘but the next patient’s on the table and the surgeon wonders if you’d be kind enough to come and assist him.
There isn’t much time for reflection in surgery.
First published in The Weekly News, 24th June 1972. Taken from Stories with a Twist in the Tale by Vernon Coleman, available as an eBook and a paperback on Amazon.