Something that is said a lot by surgeons is that unless you do something then you will never understand just what it takes. I realised today that this feeling depends on what you are doing. For routine stuff such as castrations where the goal is to remove some organs through a small tidy incision with no impact on function I am confident. I know what I am doing, how to do it, and that everything is going fit back together afterwards.
Today however I was put into a new situation, I assisted on an amputation after a car accident, and was left with a big hole on the side of the chest to cover with skin. I was basically doing reconstructive plastic surgery for the first time – and I started to feel the pressure. I had to make sure that the skin came together without tension without any dead space and with good opposition. I started walking the top flap down across the open space suturing it to the underlying muscles as I went. Once I had reduced the space here I realised that the edges did not line up – it was my responsibility now to cut the skin so that it fit together. For the wound to be straight with no dead space as if I left space underneath the skin it would form a seroma and fill with fluid. This has always looked so easy when someone else is doing it, however now it was me and it was not so easy. This was the easy wound as there was not going be much movement here yet I was still not sure just how much I could or should take.
I did the only thing I could that made sense and did it in stages as I brought the skin back together and it worked. Nothing like the results in the textbooks – however tonight I am going sleep fine with confidence that it was a good job and will heal.
The next part of the surgery was to repair a wound on the back leg as well – the skin had been peeled back either side of the thigh from the front with dirt inside with really dirty edges. This time it was more difficult to judge – this wound was going have movement across it with every single step. Every step was going change the tension on this wound, and it was big from the top of the thigh all the way until just above the top of the knee. Normally the length is not a consideration (wounds heal side to side not front to back!) – however the closeness to the knee meant that different tension patterns were going apply to different parts of the wound.
I made my plan; I picked up the scalpel, placed it against the skin roughly 3mm from the torn edge and started my cut. My cut was long and went around the entire wound taking in a random hole at the lower end as well. It was slow, and I was petrified that I was going take too much, or worse go too deep and cut something I shouldn’t. As I cut there was bleeding – I’m lucky I know more about bleeding now than most – and seeing this blood I was concerned but not alarmed as it was only a little. I clamped it off whilst I finished my cut – clamping it applied pressure and gave it time to clot so that by the time I was going suture the wound it would have stopped bleeding.
I then set about cleaning the surface of the open wound that had been contaminated with a curette (like sharp edged spoon) so that I had a clean wound bed that would stick to the skin I was going place over it. I took my now relatively cleaner wound and then flushed it with sterile saline to hopefully remove as many germs as possible that I may have missed and started suturing it back together. Firstly bringing the edges of the skin close to each other, and then suturing the edges of the skin together.
Finally it was time to head to recovery – which went extremely smoothly with the dog up on its 3 good legs within 30 minutes of the end of surgery. I just hope now the dog finds an amazing home.