The juniors watch the seniors perform
some operations and think it is a piece of cake or something. They
perform the operations following the same steps, and often nothing
gos wrong, more out of luck than good planning. One example of this
is while performing a vaginal hysterectomy. They make a transverse
incision on the anterior vaginal mucosa, not knowing exactly where
they make the incision and why exactly there and not elsewhere. They
keep cutting the fascia underneath, not knowing how close the urinary
bladder is.
“Why do you cut where you are
cutting?” I ask when I feel one of them is particularly dangerous.
“To open the uterovesical fold of
peritoneum.”
“Where do you place your incision?”
I ask.
“Here.”
“But what landmark do you use to
decide where to cut?” I persist.
“About an inch from the external os”
is the most precise answer I have received to date.
“No. You cut at the junction of the
portio vaginalis and the anterior vagina” I say.
“Uh …” is the usual answer or
there is no answer and I rejoice that it is not “Duh…”
“You seem to be cutting rather
boldly” I say. “Do you know where the urinary bladder is?”
“Here” the resident points in the
direction of the anterior vagina.
“Yes. But how close to your
incision?”
“…”
Then I proceed to put a bladder sound
through the urethra into the bladder and show that the limit of the
bladder is just within 5 mm of the incision. That hopefully scares
them.
“Remember you can open the bladder if
you go 5 mm beyond” I warn. I do not make it a routine, because I
do not like to risk introduction of infection into the bladder. The
other day my Assistant Professor told me a story, which added another
reason for not doing so.
“Where I trained, the professor used
to put a bladder sound into the bladder as a routine, to show where
the limit of the bladder was. One day, the Registrar did that to show
the Houseman where the bladder was. Unfortunately he did not know how
much force to use. The bladder sound perforated the bladder and came
out of the anterior vagina. Then they had to call the urologist to
repair it.”
