When You Have to Play with Snakes

by Larry Puls, @larrypulsauthor

Endometrial Cancer; Lymph Node Involvement

The CT scan tells a story. Maybe not the hopeful story we wanted. In the pelvis, there is an enlarged uterus and within its walls sits a cancer—now seeping blood. The biopsy confirms the diagnosis. The cells under the microscope show its cancerous pattern. And though this is not a good thing, it’s not the worst thing here. What is worse is the six-centimeter cancerous lymph node that has found a home on top of the vena cava—the largest vein in the human body. It jumps out from the images on the computer, almost taunting me.

Ruminating over the complexity of the forthcoming surgery, I find myself filled with trepidation. The vena cava is about two inches across and serves as a conduit for so much blood per second that it intimidates most surgeons. And the wall of that vessel is not much thicker or stronger than wet tissue paper. And in this case unfortunately, the devil is sitting on that vein.

The abdomen opens and there are no other signs of the cancer, except what was already known. One for our side. Taking out the uterus is the easy part. A few clamps and a few sutures, and it is in the bucket. But as I look into the upper abdomen and consider the life before me, I realize that the difference between a chance at cure and/or likely death lies now in that one, single, solitary lymph node. With my hand now carefully caressing it, it is about the size of a golf ball—and secured into place by roots, tiny threads laid down onto the surface of the enormous vein.

Inside of me resides a visual image of a day, years ago, when I lost a patient on an operating table from a hole in this large vein--a scenario not unlike this one. How do I divorce myself from that image? I pause and think. I pray that the Lord will guide me through the next hour.

One final look at the vascular surgeon across from me, and then I remind the team, there are to be no sudden moves, no sneezes, no laughs. Everyone’s gaze becomes focused on the six-centimeter fleshy piece of tissue, filled with cancer that will likely take her life—unless—we are fortunate enough to extract it—safely.

The picture reminds of a deadly hornet sitting atop a venomous snake in hibernation, but one that could wake in an instant, and with a vengeance. And either the hornet or the snake have the innate ability to strike in their own way. So, my mind says kill the hornet, and leave the snake alone to sleep, and this can all be over soon. I uncover the hornet's home and begin to tease its roots. Clip then cut, and then clip some more. Gently massage the top of the vein and see if the tenuous roots will give up some ground. Stop, then take a deep breath and steady my hands. Don’t let the snake wake up.

I gain a foothold, and the lymph node begins to lift up from the inferior portion. If only I can do the same from the superior pole. Time will tell. Tease some more. A give. My heart races wondering if the sudden lurch in the node created a hole in the snake. But there is no blood flowing—well maybe just a trickle. I take a moment to search my soul, and my heart slows once again. I look across at the vascular surgeon, who like the fireman, is there just in case. And no one wants the “just in case”. I forge ahead.

Aiming my headlight down once again, I continue the same sequence of events. Clip, then cut, then tease, then clip some more. The fine little sticky fibers that are rooting this lymph node down begin to give up the fight. The final clip of metal is placed and then node is removed, but before we hand it off, I stare at the nodal bed once again, the snake if you will, and make sure that it has not come out of hibernation… It is still sleeping.

Now time will tell us the rest of the story. But we are blessed that day. My soul is at peace.

When You Have to Play with Snakes, Larry Puls, (Click to Tweet)