Palamaner: Surgery (May 11)

Today we got to observe Dr. Jacob perform surgery to repair the claw-like hands and the foot drop that people with leprosy get. For the non-squeamish, I randomly found a photo album of another doctor performing a similar surgery that you might like to look at. The following is my understanding of the surgeries we saw today, and is as correct as my limited understanding of anatomy and leprosy allows. The nerves that innervate the muscle that straightens the fingers of the hand is attacked by the leprosy bacilli, and so the muscle dies, and the person cannot straighten out their fingers. The surgery to repair this is quite interesting, though it also seems to have its drawbacks. The patient is put under local anesthesia on the entire arm and hand for the side that is being operated on. Then, incisions are made on the first segment (closest to the palm) of each finger (not the thumb though), and on the middle segment of the middle finger. The muscles and tendon that operate the middle segment of the middle finger still work, so this tendon is cut. Then an incision is made in the palm of the hand, and the tendon from the middle segment of the middle finger (that was just cut) is then pulled all the way through the finger and out of the palm. Dr. Jacob then splits this tendon into four equal pieces (still attached to the arm muscle). He then inserts a tool through the incisions he made in each finger and out the hole int he hand, grabs one of the newly cut tendons, and pulls it back through to each finger. This looks pretty cool/weird. Then he stitches this tendon to the intact tendon of the first segment of the finger. In this way, the tendon that was used to straighten the middle segment of the middle finger is now split into four and is used to straighten the lowest segment of each of the four fingers, and as such the patient can now straighten their four fingers.

After watching two claw surgeries, Ajay and I skipped the beginning of the third one to set up the wireless for our laptops before we returned for the foot drop surgery. When we returned, Dr. Jacob was just finishing up the claw surgery on a young girl I had remembered from the previous day. Her surgery was more complex, as she was also getting her thumb repaired. For the thumb, they cut out a tendon that goes to your ring finger middle section. To get the opposable movement, they first pull this tendon out near the wrist, then they feed it around the lower corner of the palm (the pinky side), split the ligament, and attach one piece to a tendon at the front of the thumb and one to the back of the thumb. When we arrived I was surprised because the first two surgeries were relatively bloodless due to their arm being tied off, while there was a fair bit more blood in this one. This was because of the increased complexity due to the thumb surgery. Dr. Jacob said they had to untie the arm after 20 minutes otherwise there is unbearable pain in the arm. I was also surprised because this girl who seemed pretty happy the day before was in some pain, due to the length and complexity of the surgery. It’s weird, seeing her in pain was the only thing that made me feel sick in the OR that day. Finally though Dr. Jacob finished the stitches and bandaging and that surgery was over.

Finally, the foot drop surgery. In this condition, the nerves innervating the muscle that allows you to lift your foot towards your shin is dead, and so for these people their foot is permanently pointed and slightly turned outwards. If this is not corrected, they get used to walking on the outside/top of the foot, and their bone structure changes. To correct this, Dr. Jacob first makes a large incision on the inside side of the foot (for the football/soccer fans are, the place where you are supposed to receive the ball). The tendon here is cut (the person will no longer be able to swivel their feet as well anymore because of this I think). An incision is made above the ankle, and the tendon from the inside of the foot is pulled out to here and split in two. Then two incisions are made on the top of the foot, one more to the inside and one more to the outside. Similar to the hand surgery, Dr. Jacob pulls the tendon from the ankle through to these new incisions, and stitches them to tendons at this site. In this way, the person is now able to use their functional muscle to pull their feet up, and have a more natural stride. For both the claw and the hand surgery, there is extensive pre-operative and post-operative therapy required. Now that I have seen the surgery I am even more interested to see the differences in mobility and function between pre-op and post-op patients.

It got a bit surreal when they put on the music, and the first song was Livin’ La Vida Loca, followed by some Backstreet Boys, Venga Boys, Barbie Girl, and got even weirder when the Can-con started: Avril Lavigne’s Complicated and Summer of ’69 (which I think is probably one of the more popular Canadian songs worldwide).

Another thing that re-struck me during the surgery was the toughness and resiliency of the human body. During surgery what I thought were some pretty harsh things were done to human tissue. Though I have very little experience with taking apart a chicken or raw meat, so that might be why I am so surprised at the toughness of flesh. Still, I remember when I saw my first surgery, a quintuple bypass 7 years ago, I was amazed that you could just punch holes in an artery on the heart around a blockage, and then attach a bypass vessel with a sharp needle and thread, and yet the heart could be restarted and would keep on pumping, and not even care about the apparent torture it had been through. Similarly, I was impressed with the integrity of human tendons and skin. Dr. Jacob would just pull out the finger tendons through the palm, they would be clamped and then he would cut that one tendon into four and then sew it onto another tendon, and the tendon’s integrity remained. Similarly, when he was using his tools to go in and pull tendons where he wanted them, the body was surprisingly yielding and it all worked out. The human body is quite remarkable.

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