Sukanya Sam, MBBS, DGO, DNB

Chennai, India

It is near-most bliss, a somber quietitude, from the moment the surgeon scrubs, which takes about ten minutes, soaping up past his elbows, calmly lathering up, fingers interlocking and then not, covering every inch and then rinsing with saline—holding up his hands methodically, allowing the liquid to fall sequentially from his hands up till the elbows. All this he does in complete silence, almost meditatively.

Then he walks up to the table, where the nurse holds up the scrub gown and he slips into it. He waits. A pair of number seven gloves is offered to him.

The patient is under spinal and her pregnant tumescent belly is exposed. He holds the sponge forceps and paints the abdomen with Betadine, a yellow brown thick antiseptic, right from the xiphisternum to mid thighs. He does this three times. Then the nurse places the drapes and they are set.

He holds out his palm open wordlessly and she places a scalpel in his hand. He looks up at the anesthesiologist at the head of the table, who gives an imperceptible nod.

The surgeon is ready.

In a deft stroke, he makes a curving transverse 12-15 cm incision suprapubically and the skin is incised neatly. Sometimes God is kind and there is no blood. Sometimes blue purple vessels run across the subcutaneous fat and the surgeon stops: he pays attention and is rewarded justly. Two clamps across, and cautery: the vessels shrivel and die. He picks up the scalpel again.

The yellow fat in little round alveolar pockets pouts out and he probes deeper until the white sheath of rectus is before him. He pauses. Gently, he makes a nick. The reddish muscle beneath shudders and comes into view. He picks up the sheath, uses a curving scissors and cuts neatly towards the end of his curving incision until he reaches the incised skin edge. This he does on both sides. He places two Allis forceps superiorly onto the edges of the sheath and separates the muscles off the sheath. Inferiorly, he does the same.

Now the rectus muscles lie in the midline and if he is skilful enough he can part them with his hands and shear it off his field of view—without cutting, bloodlessly.  He sees the papery thin, slippery parietal peritoneum, knows he must be careful, for the bowel lies close. He uses a curved artery to pick up the peritoneum and the nurse places another pickup near his. He cuts in between almost transversely and the pregnant uterus is before him now, glistening, rising up like a little hillock.

A retractor is put in, he revises the same pick ups, only this time with the visceral peritoneum—the bladder slips off the lower end of the uterus where he must incise. Any error, and the bladder would open up in front of him. The bladder is held down by the retractor and it is now that he makes a small 3 cm incision, not too large, not too small. Strands of black hair gratifyingly emerge through the incision—the baby's scalp. Too deep, and he can cut through the scalp—control, precision come into play throughout.

He stretches the incision with both hands, thumbs touching each other side by side and then as far away as possible. Retractor out, he cradles the baby's head in his hand, and delivers it out and the rest of the body follows.

This whole thing takes about ten minutes, perhaps less.

And then there is the process of reconstruction. What he destructs, he re-creates. Layer after layer, putting it all back together.

The uterus: a long row of stitches where the incision was made, when done, in its pathology of perfection makes one think—pretty maids all in a row. A rising peak of mound with its curling fallopian tubes embracing a pair of pearly white grey ovaries on either side.

In a moment of closer inspection, he sees the ovaries, nestled against the reddish fronds, small and oval about 3 x 2 cms, variegated, thick in some places and thin here and there, from where an egg would push against the surface from within, rupture the covering layer of cells and emerge each month.

A woman is born with all the eggs she would make during her reproductive years–this amounts to an average of about 400-500 eggs.

Such is the masterful mechanism in place: only one egg in each cycle would grow to completion to be picked by the pouting fimbria by its side, while other eggs never meant for fruition simply die. They were not meant to be (quaint is the description of menstruation–the weeping of a disappointed uterus in mourning for a failed conception).

One egg from millions of preprogrammed ones meets one meant-to-be sperm among the hundred thousand sperms somewhere in the ampulla of the tube where they would unite to fuse and break down and grow a new human being. For membrane fusion between the egg and spermatozoan, a complex interplay of attraction, binding, decimation and fusion has to occur. In about six days after the rendezvous, the resultant flux of cells is ready to make its connection with the endometrial lining and prepares to set house.

The surgeon knows he is blessed—every time he plucks a baby from the womb, he is witness to the miracle of life—that "same life that shoots in joy through the dust of the earth in numberless blades of grass and breaks into tumultuous waves of leaves and flowers."

He sees all this in a sweeping glance. Tubes, ovaries: check, normal.

If all goes well, he must now commence with closure. There are many pitfalls that might arise to test his competence—uncontrolled bleeding, adhesions, an adherent bladder—in such times, he needs to summon calm from chaos.

Closure is painstaking work. The surgeon approximates each layer with a different suture material, enjoining the tissues in the hope that he exits the field as it were.

He respects the material he works with, avoiding slipshod rough handling, and he is paid justly in return. Too quick, too terse, too reckless and he digs deeper and deeper into a hole that takes him a long time to clamber out. Patience is the key.

The placement of sutures, the knots—reef knots, granny knots, square ones, left handed, right handed, no matter the type, they must be perfect. The way they must fall in, their pliantivity, the motion of the hands as they are placed, the pressure. Too aggressive and they will snap. Too gentle and they will slip.

And finally, in the perfection of a subcuticular, the elegance is complete. Fallible and yet so prevailing. On healing, a barely indiscernible scar merges along Langer’s lines. Almost good as new.

Surgery is a beautiful experience. Going into oneself. One has to prepare one's mind and lull it into an inner zone. Be painstakingly patient. One has to slowly tease the tissues and ease into anatomical planes, to achieve a bloodless field that would boast of an intimate knowledge only an accomplished connoisseur can soar with. Beautifully so.

The surgeon knows all this. He has taught himself all he needs to know, from books, from his mentors and most of all from what he has learned himself.

Locard’s principle states that when two bodies or objects come into contact, there is always an exchange of material and so it is with the surgeon and his patients. With time, the surgeon has perfected his skills, learned.

And then, one day, he is the master of it all.


Sukanya Sam, MBBS, DGO, DNB is a specialist in Obstetrics Gynecology with a keen interest in human nature and literature. She lives in Chennai, India.