‘cold-stick’ surgery

Kathryn: August 2014

IMG_1568 I arrive at the clinic around 11.15 on a sunny August day and go to visit Kathryn on the Delyth ward. She seems very calm and composed as she lies in bed, waiting to be taken down to the theatre for her operation, which is due to begin at noon. She greets me with a smile. We shake hands and I notice how small hers feels in mine.

She has come to Cardiff from Abergavenny, having been diagnosed with endometrial cancer in May. She tells me that the referral to Cardiff concerned her initially, it made her think that there must be something ‘really wrong’. I sympathise and tell her that this is a worry I have heard a lot from patients who bypass their local hospitals and come to Cardiff for treatment, but the reality is that their extra journey is not to do with the severity of their condition. The real reason is that Cardiff, as the regional centre, is far better equipped and staffed to deal with complex oncological surgery than most local hospitals. But Kathryn’s case highlights the obvious need to give patients more information about their referrals if only to avoid adding even more worries to the fear and confusion that many of them already feel.

Kathryn is an enthusiastic participant in the Drawing Women’s Cancer project. She talks about having seen the website, and reading the information we offer patients as they decide whether to consent. Her manner and her smile invite me to feel at ease and I thank her as I move towards the chair next to the bed. This proves to be a complex manoeuvre however, due to the distinct lack of space and the chair being almost covered by the curtains that are pulled around the bed next door. Two nurses are attending to another patient behind the curtains, helping her, it seems, into a wheelchair, and the curtains themselves are creating no barrier at all to their invasion – albeit it unintentional – of Kathryn’s already small area. To add to the problems their patient must be either deaf, or elderly, or both, as the nurses are having to raise their voices almost to a shout. It crosses my mind that as Kathryn is very softly spoken a recording of this meeting would make for an interesting transcription. I am glad I decided simply to chat at this first meeting. Help is at hand, seeing my problem Kathryn shuffles over in the bed and insists I sit on the side. I feel a little awkward but I agree to ‘perch’ there and we begin to talk.

She begins by recalling the anxieties, the frustrations created by medical appointments that came two weeks apart in what felt to her like a painstakingly drawn out process towards the final diagnosis. She acknowledges now a sense of strangeness about what has happened because she says she has had a constant, if underlying fear of cancer all her life, and now she actually has it she, ‘weirdly’, feels better. We speculate on whether this is because her fears have now become ‘real’, even though the particular reality of her present condition is definitely not a positive one, and she goes on to tell me how, since she has been ill herself, she has realised how many people around her either have or have had some type of cancer, and moreover, ‘you would never know!’ Her sense of astonishment as she relates this to me feels grounded in an almost palpable emotion, and indeed there is nothing disingenuous about her whole manner. I feel deeply moved by her generosity as she allows me to witness her experience of something that is confusing, perhaps disempowering, and definitely challenging on so many levels.

She says that she deliberately hasn’t looked at any Internet sites for information about her condition because ‘doesn’t want to know’. Her husband on the other hand logs on regularly and has even signed up to a chat forum about cancer of the womb. She tells me about how he insists on giving her snippets of what his fellow forum members are saying and we laugh about the ‘man-thing’, the way that husbands and partners often want to do something to ‘fix’ the problem, even though the ‘fixing’ is not necessarily the real issue.

We move on then, perhaps in relation to the idea of fixing, to talk about how she feels about her own body. Here there is a noticeable shift from her positively vibrant engagement with the things we have discussed up to now. A strange detachment has come over her. She says that she is ‘leaving all that to them’ (the doctors) and that she is more concerned with what is going on for her emotionally, ‘in my head’, and as she talks about her feelings the detachment starts to make sense. She has managed to separate herself emotionally, defensively perhaps, from the physical reality that she faces. But time ticks on and as she begins to think about the impending operation she says that she is most worried about how she will recover. She says that it is hard – actually ‘hurts’ to acknowledge that although she feels fine right now she fully expects to go home feeling much worse than when she came in. But she has a goal. She walked up Pen y Fan the other day in the glorious sunshine, and this is the challenge she has set herself, that walk, as soon as she feels well enough.

Empathy here is too academic a word, a concept, for what I am feeling. I want so much for her to walk up that damn hill and I want to tell her that she will. But I can’t. Nothing can be so certain. We talk about the project, about the need for communication and about how women need themselves to talk about their experiences, just as she is doing now, but as the idea of the operation becomes increasingly real she begins to feel upset. She says, ‘I have three sons’, as she places both hands gently on her stomach. ‘It’s where they were created.’ There are tears. I reach for her hand and we smile for each other. I say, ‘some things don’t need to be said.’ She nods.

Kathryn’s treatment has to be a full hysterectomy although the surgical procedure will be laparoscopic, otherwise known as ‘keyhole’ or minimally invasive surgery wherein the surgeon operates using hand-held, long-shafted instruments, which are inserted into the patient’s abdomen through small incisions. One of these instruments is the laparoscope itself which constitutes a telescopic rod-lens system connected to a video camera, or, if digital, with a connected charge-coupled device attached to its end. Also attached is a fibre-optic cable system, connected in turn to a ‘cold’ light source (halogen or xenon) that provides illumination inside the patients’ body. The distinct physical advantages of laparoscopic surgery over the more common, open procedure are primarily due to the smaller incisions. These serve to reduce both the amount of potential blood loss and the length of time it takes the body to recover from the surgery itself. The psychological advantages of the procedure are perhaps obvious here and easy to relate to the physical.

In conventional laparoscopy two surgeons work alongside each other. One must position the laparoscope correctly in the ‘target anatomical area’ so that the appropriate images are transferred onto a nearby 2D video monitor for the other to follow. Further instruments are inserted and manipulated through three or four other small incisions in the patient’s abdomen in order to perform the operation. This is ‘cold-stick’ laparoscopy, and is in contrast to robotic surgery where, using the ‘da Vinci System’, the surgeon is able to operate even more remotely from the patient by using four interactive robotic arms while seated at a console away from the operating table. Any movement of the surgeon’s eye or hand at the console will in turn move the surgical instruments or reposition the camera, and where the instruments are designed with a ‘jointed-wrist’ device their range of movement actually exceeds the natural range of the human hand. Motion-scaling and tremor-reduction controls further interpret and refine the surgeon’s hand movements and enable very exacting and delicate work.

There is no robotic equipment here in the Cardiff clinic however and Kathryn’s surgery will be ‘cold-stick’. We do not talk so much about the details of the operation, and I decide not to mention my mixed feelings in anticipation of my first time witnessing this type of procedure. I am surprised at the excitement and expectation I feel, but at the same time concerned as to whether this reaction is somehow inappropriate. I decide then to ignore the dilemma, which really is far less important than how Kathryn herself is feeling, and direct my thoughts towards empathy with her as she lets me know that she is happy at least not to have to undergo abdominal open surgery.

At just after noon I gently knock and enter the ‘green room’ where four surgeons are bent over a patient whose belly is open and bloody. Everybody acknowledges my presence with a smile; I am clearly becoming a familiar figure now in theatre, trying hard to quietly and unobtrusively move around in the background with sketchbook in hand. The patient on the operating table is a large woman, much older than Kathryn. The surgery is open and abdominal. This must be the first patient on the list, still on the table since early this morning. The theatre nurse confirms this and tells me that the procedure turned out to be far more complex than was first anticipated and so is taking much longer than expected. Kathryn’s operation will therefore be considerably delayed and I feel a pang of sympathy for her as I imagine her waiting up on the ward. I am tempted to stay, but I know I cannot, as this patient has not consented to being part of the Drawing Women’s Cancer project. I have to leave, respectfully, and go back to the research office to wait.

IMG_1565Two surgeons will perform Kathryn’s operation and I take advantage of a chance to chat with them as they take a short break between one procedure and the next. One, while eating his salad lunch from a Tupperware carton, tells me that his choice to specialise in Obstetrics and Gynaecology was in major part based on his belief in the benefits of real communication with his patients. He says that his experience in other areas of surgery led him to decide that there is not as much opportunity to take on an empathic and supportive role in talking with patients about their diagnoses and about their treatment as there is in ‘Obs and Gynae’. This sensitive man likes to offer the ‘personal touch’. He wants to ‘talk to his patients’. As he talked to me it was clear how much he understood the significance of maintaining a subjective perspective even in a situation where he would have to, necessarily, give greater credence to a detached objectivity. At the very least, the sheer physicality of what a surgeon must do needs emotional subservience. Who after all would want their surgeon to be anything less than totally focused on getting the job done, and done well? Subservience however is not synonymous with inertia. Emotion, compassion and human understanding are not left at the door of the operating theatre; they rather serve as drivers, strengthening the will and steadying the hand.

It is 2pm and Kathryn is finally wheeled into theatre. She looks small and slight on the bed, and so very vulnerable. I feel strangely at odds with myself because I cannot quite recognise how I feel on seeing her here, unconscious and oblivious to all the activity around her. Maybe it comes from what she said earlier about leaving her body up to the doctors. As they lift her onto the table I am anxious, I feel very protective towards her and I sidestep backwards and forwards to make sure I keep an eye on her while at the same time staying out of the way of the nurses and technicians who are hurriedly setting up the equipment for the operation.

The set up as a whole is complex and unlike anything that I have seen before. As well as the permanent video screen in the corner of the room, two more temporary screens are being positioned around the bed along with their accompanying gadgetry. There are so many people around me, all organising so many things with such a fluid professionalism that I feel, very keenly, the discomfort of my qualitative roots, here transplanted into quantitative soil. My own subjectivity and that of Kathryn, the woman on the table, now has to become almost irrelevant as here, in this room, this theatre full of science and instruments, objectivity steps up to the front of stage to take its accolade, and I can ‘feel’ the fame of it.

I want to understand everything, but I know I never can so I try to focus on the things that will stick in my mind. Powerful lights are set into place and sterile instruments are counted out, noted on the whiteboard and laid in order on the table beside the patient. The surgeons laugh and chat as they scrub their hands before donning gloves and masks in the room at the back. The anaesthetist keeps his vigil at the head of the bed, checking his data as Kathryn breathes softly beside him. Finally everything is set.

The surgeon who likes to talk to his patients now sits between Kathryn’s legs, which are raised on stirrups and spread apart. He needs to position a plastic ‘device’ into the vagina, and carefully suture it there onto the cervix. It will provide a hard surface to cut onto when the operation is under way. It is green, and later it will become luminously so on the screen.

Both surgeons are now either side of the patient and a junior doctor takes over the position between the legs. Kathryn’s entire abdomen has been exposed and anointed with iodine and now it is filled, ‘insufflated’ with carbon dioxide gas to the extent that it poignantly resembles a pregnancy. The expansion elevates the abdominal wall above the internal organs and creates a space within which the surgeons see clearly – via the laparoscopic camera – and work. CO2 gas is used because it is common to the human body. It can be absorbed by tissue and removed by the respiratory system, and, reassuringly, it is non-flammable, an important asset where electrosurgical devices are being used! Working together, the surgeons insert four separate instruments into Kathryn’s body; tiny incisions allow entry for a laparoscopic camera, two ‘grippers’ and a diatherm. The surgeons make minor adjustments to the position of the video screens and begin to work. They are physically detached, their hands on the instruments at a bodies distance and invisible in relation to the actual mechanics of what they are doing. It is as if they are playing a video game, but here with very real consequences. They watch the screens with levels of concentration that is extraordinary to witness, and hand-eye co-ordination is here tested to its limit.

I cannot draw. I too am transfixed by the screens. Cut, cut, seal, cut. A multitude of images flit and dance as one or the other of the surgeons moves the camera around the abdominal cavity to delimit the ‘anatomical target area’. The colours of the organs are translucent and move over each other like the oil glazes that I use when I am painting as the surgeon’s steel instruments invade and dissect the boundaries between tissue and hue. The imagery becomes almost hypnotic as the colours coalesce into a kaleidoscope of tonal value that favours every nuance, and none.

 Colour. I always turn to thoughts of colour in this situation. In terms of the art-science relation, which is indeed a fundamental driving force in the Drawing Women’s Cancer project as a whole, colour itself can be understood as a fundamental linkage between the two, and the power that colour has in bringing art and science together, a power that is almost tangible here in the operating theatre, comes perhaps in part from what Johannes Itten calls its ‘beauty and immanent presence’. The indication of religious fervour in Itten’s protestations lacks subtlety and is made even plainer as he goes on to assure us that you have to love colour before it will unveil its ‘deeper mysteries’, but as a leading figure of the Bauhaus, Itten himself straddled the boundary between the objective and the subjective, demonstrating that artists are not the only ones to be moved by the guile of natures hues. For me however, as an artist, the ‘mystery’ of colour resides not so much in the use I put it to, but rather in the philosophical nature of it. According to John Gage in Colour and Meaning: Art, Science and Symbolism, Stephen Melville only posed the philosophical problem of colour, neglecting to address it. But how to address it without encountering grey areas? Derek Jarman wrote about grey as the ‘sad world into which colours fall’. Kandinsky’s grey is ‘void of resonance, and so, Melville’s colour remains,

Bottomlessly resistant to nomination, attaching itself absolutely to its own             specificity and the surfaces on which it has or finds its visibility, even as it appears subject to endless alteration arising through its juxtaposition with other colours. Subjective and objective, physically fixed and culturally constructed, absolutely proper and endlessy displaced, colour can appear as an unthinkable scandal.

For myself, here in theatre, I am disorientated within the Melville’s scandal. The transition from living body to video screen is confusing and understanding becomes lost in the communicative space in between. I struggle to recognise which way round I am seeing these organs that are highlighted in two dimensional flat form, but suddenly all becomes clear in the ‘champagne layer’, the soft veil of bubbles caused by the gas that float, sparkle and gently explode into tiny fingers of light inside Kathryn’s body. I watch as the fallopian ligaments finally take comprehensible form, just before they are separated and severed. I see the uterus, now discovered, as it hangs forlornly between the ovaries, the broad ligament like the outstretched wings of a weak and dying bird, exposed and vulnerable to predation. So much detail, so much disassociation. In the cavity blood begins to pool in smaller hollows and fissures. It is the deepest and richest of red hues, boldly defying the translucency of the colours of the surrounding tissues. But even as it pools it is withdrawn through a suction tube. It is the ‘excess’ that can only hinder the meticulous procedure being carried out. The ligaments that secure the uterus are now located and severed in turn. The uterus itself succumbs to being cut out by its very root.

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