Pediatric surgery is shaping up to be an excellent two weeks of variety and choice. Sure, we have to get in around 5:30 each morning to collect vitals on our 35+ patients, but after that, we’re free to see whatever procedures we want. The lounges are chock full of coffee, chips, bagels, nuts, beverages, and other things which make me feel like I’m at a high class desk job rather than learning as a medical student. I’m also lucky there’s a visiting MS4 from Puerto Rico who was kind enough to show me the ropes — it’s so much less intimidating to learn from a fellow medical student when it comes down to orienting oneself to a new clinical environment.
So how’d the first day go? Pretty awesome!! For example, a colleague and I observed a laparoscopic cholecystectomy prior to our scrub orientation this afternoon. The attending walked over to the monitor we were watching the procedure from and asked us to identify the cystic duct and cystic artery, identify the anatomic reference point in question (Calot’s triangle), asked where the common bile duct drains (2nd stage of the duodenum), and asked about the “critical view of safety” in the context of cholecystectomies.
I had never heard the term “critical view” before, but come to find out, it makes a lot of sense. The cystic duct (coming from the gallbladder) joins the common hepatic duct (coming from the liver) to form the common bile duct (CBD). As part of isolating the gallbladder for resection, we want to avoid injury to the CBD while clipping off the cystic duct; therefore, proper identification of structures is “critical.”
In the image to the right, the gallbladder is visualized superiorly (the glistening white thing), with the liver behind (the big pink bulge which takes up most of the image posteriorly). There’s a triangular “window” which is dissected in the fascia to visualize the liver — the right boundary is the cystic artery and the bottom-left border is the cystic duct. How do we know it’s the cystic duct? Because it clearly attaches directly to the gallbladder.
So now my alarm is set for 3am, bags are packed, and I’m looking forward to a full day of scrubbing in on procedures. 🙂