Tuesday, April 6, 2010

Woman vs. Wild

Gynecology is filled with fun and satisfying procedures. Of course, there are those cases that are technically difficult, (i.e. tumor debulkings, vaginal hysterectomies) that make you embrace the title of surgeon. But gynecology is also a land mine of small procedures that are fun in the same way as zit popping. Quick and satisfying.

Today was an OR day of hysteroscopy. This is a procedure in which a patient is put to sleep and a special camera is placed inside her uterus to look for any abnormalities. Simple enough. My second case of the day, however, was no simple hysteroscopy. The patient was a 54 year old female with a history of postmenopausal bleeding. There are many causes for this: atrophic endometrium (aka thin and fragile lining of the uterus), endometrial polyps, pre-cancer and cancer of the uterus. As I placed the hysteroscope into her uterine cavity, I saw it, projected on the OR television screen: the polyp of all polyps, spanning from the top of her uterus to the top of her cervix. It was an endometrial polyp on steroids.

Polypectomies are fun. You see one, you grab it, you pull it, and you’re done. And you have a neat product to show off afterwards. I told you, it’s like zit popping.

polypectomy, however, was not your average procedure. I placed my little graspers through the hysteroscope and lined it up with the big, fat stalk of this polyp. I bit into it. I twisted. I pulled. When I looked again, I saw only the tiniest bite out of the polyp stalk. The polyp held its ground. This happened over and over again, for about 5 full minutes. Meanwhile, my attending and chief in the background are cheering me on. “Come on grab it! You got it! Twist! Pull! Pull! ...(silence)... Did you get it? Ohhh…(sigh)” The polyp remained there proudly, laughing at us.

I took out the hysteroscope. I needed a bigger instrument. I was determined to show this polyp who was boss. I inserted a polyp grasper through the cervix into the uterine cavity. Blindly, I felt around with my tool and tried to grab on to something. The little mofo kept escaping my grasp. My chief resident stepped into try. Finally something. She pulled out a nice 1cm polyp! That was it! We got it!

We replaced the hysteroscope to take a final look. Once inside, lo and behold, what do we see? The mother effing polyp was still there, it all its glory (minus a tiny bit from its end), taunting us. I pulled the hysteroscope out again. I went in again with the graspers even more determined this time. I felt something. I tugged. And tugged. Finally, another 1cm piece came out. “Yay!” we shoutedd! We must have gotten it this time! For good measure, I curettaged the endometrium (I inserted a sharp instrument to scrape out the lining of the uterus). I did this to make sure we got every last bit of polyp. When I finished, I reintroduced the hysteroscope. You can guess what happened. Polly the Persistent Polyp was still waving back and forth at us! “How’s it going suckas???” it seemed to say. I was fuming – and laughing at the same time. We all were. At this point, the entire OR staff (my attending, my chief resident, the scrub tech, the circulating nurse, and the anesthesiologist) was cheering me on to take this pesky polyp down.

Again I remove the hysteroscope. I picked up the granddaddy of graspers – the myoma graspers (meant for fibroids). It barely fit through the cervix. When I fully inserted the instrument, I felt it bite. I twisted. I turned. As I pulled the remainder of the polyp out, I swear I heard it curse at me. “I’ll be baaaaack….”

Whatever. Round 5 and I’m the winner.

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