I've written before about the hazards of the colostomy takedown. When they go well, the patient is eternally grateful. Nobody wants stool collecting in a belly bag the rest of their life. But we always tell patients that only about 70% of colostomies are reversible after a Hartman's procedure. Sometimes you get back inside a patient who has recovered from perforated diverticulitis and it's just an unholy mess, bowels matted together, anatomy distorted, the pelvis scarred and inaccessible.
Recently I took back one of my nicest patients for a colostomy reversal several months after emergency surgery for a complicated colovesical fistula. It took almost an hour just to get inside his abdomen as I chipped away cell layer by cell layer with the sharp scalpel, separating fascia from bowel. Finally I freed things up and was able to inspect the pelvis. Usually the rectal stump can be easily identified and isolated from the other pelvic structures. In this case, I saw a uniform sheet of peritonealized scar tissue running from the bladder to the sacrum. When the assistant introduced a probe through the anus, I could see a bulge somewhat posterior to the bladder but it wasn't clear to me that there was a distinct tissue plane between the two structures. The rectum was down there somewhere but I wasn't certain exactly where. And for a case like this I think you need 100% certainty. You're taking a patient who was living independently at home, healthy and symptom free, and you subject him to an elective procedure that, if it goes wrong, could potentially adversely alter his existence irreparably. First do no harm. Generally, we surgeons perform operations on ill patients to relieve pain and suffering. This was different. My patient suffered from the psychological pain of having a colostomy, but there was nothing physical or mechanical that reversing his colostomy would make better. So certainty was paramount. It had to be perfect. I dicked around a little while but ultimately I could not pull the trigger. I bailed. I closed him back up and kept his colostomy in place.
Failure in surgery can be defined in a lot of different ways, I've learned over the past three years as an Attending. Errors of omission (laziness, not following up on tests, ignoring a patient's complaints/symptoms) are inexcusable in my mind and I hope that the way I was trained and my own ethic will stave off any future such errors. Conversely, errors of commission are sometimes difficult to identify until one reviews a case in retrospect. Maybe I shouldn't have done that case laparoscopically. Maybe I should have kept those antibiotics on board a few days longer. Maybe I shouldn't have left a drain in that patient. These errors are the ones that keep us up nights and distract us from enjoying a quiet Sunday afternoon at home. The painful deliberation and doubt that creeps in after a completed act. By nature surgeons are aggressive and tend toward the supremacy of action over contemplation. It isn't natural to "do nothing" when a patient comes to us. It's especially hard for a young surgeon to recognize his own limitations, to understand when "action" is actually the wrong course of action.
After my patient awoke from the anesthetic, I went to discuss the operation with him. I wasn't looking forward to it. Even though I know I probably did the right thing, I couldn't evade this feeling of shame, that I had failed him, that I couldn't safely assuage his specific form of pain. I sat down in a chair next to him and spoke quietly, like a penitent schoolboy in the principal's office. I couldn't safely do it, I told him. I apologized. It's OK Doctor, he said. He appreciated my honesty. He's a terrific guy. He recovered uneventfully and went home in a couple days. I've referred him downtown to the Empire to see a colorectal specialist. (Perhaps he can be reversed with some sort of coloanal pull-through procedure which I'm not particularly comfortable doing.)
So no harm was done. My patient will get a second opinion from a specialist who can hopefully give him another shot at getting rid of his colostomy. But I can't seem to shake this hollow feeling that I failed him. Call it youthful hubris, inexperience, whatever. I wanted to be the guy who made him better. It's selfish, I know. It's not supposed to be about me. But maybe I could have done things differently at the original operation that would have made the take down procedure easier. I run things over and over through my mind and I'm consumed with self-doubt and uncertainty. But I think that's ok. It's allright to feel the sting of failure every once in a while. Nobody said this surgery business was going to be an easy gig. You can't get too comfortable. You have to be constantly vigilant for ways to change and improve. I don't want get complacent. I want to get better....