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A CT scan of a Anita Froggatt's lung shows a mass
With a video image of the procedure visible in the background, Dr. Tim Sherwood removes the upper lobe
Dr. Tim Sherwood looks at a video monitor during a recent operation |
BY JIM HALL
Dr. Timothy Sherwood had sliced and stapled his way through three pulmonary arteries, one pulmonary vein and an airway in Anita Froggatt's chest.
He had separated the upper lobe from the middle lobe of her right lung, and now he was ready to remove the upper lobe.
Sherwood operated on Froggatt on Tuesday at Mary Washington Hospital to help determine why she had been short of breath and coughing.
X-rays and CT scans taken months earlier revealed a white spot in the upper lung. Biopsies and blood tests that followed were inconclusive.
Medications didn't help, and Froggatt's doctors had no answers. The Spotsylvania County resident is 59. She smoked for 20 years but stopped in the 1980s.
Was the spot lung cancer? Or was it something else, perhaps damage done by fungi or bacteria?
Sherwood will eventually have the answers, but first he had to remove the suspect lobe.
A thoracic surgeon, Sherwood arrived at the Fredericksburg hospital this spring. He brought with him from Johns Hopkins Hospital in Baltimore knowledge of small-incision lung surgery.
In the past, surgeons at Mary Washington did lung surgery through 7-inch incisions in the side of the chest. Patients' ribs had to be moved, causing pain and long hospital stays.
Sherwood offered Froggatt something different. He told her he would make three small incisions in her side, insert specially designed tools between the ribs, and remove the lobe.
Sometimes, he said, he had to change his plan in the middle of surgery and open the chest. But usually, the small incisions offered enough room.
Sherwood also promised reduced pain and a shorter hospital stay with this keyhole approach. Froggatt agreed to it. She arrived at the hospital early Tuesday for her surgery.
Preparing to operateOperating room No. 12 was bright and chilly when the team wheeled Froggatt in. Mark Ivory, a nurse anesthetist, had already started an epidural in her upper back.
Soon he gave her other drugs to paralyze her and block memory and pain. Then he inserted a tube in her throat and took over her breathing.
For the next three hours, the regular beep of the pulse oximeter, combined with the music of Fergie and Bon Jovi, served as backdrop to the surgery.
While Ivory worked, the others--Connie Ramirez, Judy Bowmar, Rebecca Coons and Maureen Brennan--prepared Froggatt.
They positioned her on her left side on a bean bag and stuffed pillows around her to hold her in place. They wrapped her in a warming blanket and sterile drapes.
On her side, where Sherwood would make his incisions, they applied a plastic wrap, soaked in iodine, to fight infection.
Sherwood made the first incision at 8:30 a.m., just beneath her right armpit. One cut was an inch long. The others were smaller, so small that when he placed the tip of his finger in one, it fit snugly.
The journey withinThe holes were portals to Froggatt's inner chest. Into them Sherwood slid cutters, clamps, prods and grabbers. At one point, Froggatt had five tools sticking from her chest.
A thin silver rod that glowed at the end was the most important. This was the camera.
"A little more to the right, please," Sherwood said to Ramirez, his assistant, who stood across the table, directing the camera.
Sometimes Sherwood leaned over Froggatt and peered into the largest of the holes. More often he watched a monitor in front of him.
The monitor displayed a landscape of pinks and reds, folded tissues with ribbons of blood and air.
Sherwood pushed deeper through this maze to a point 7 inches below the surface of the skin. He poked, prodded and peeled, dissecting into the fissures between the lobes.
"Turn the Bovie down to 20-20, please," he said.
"20-20," Brennan replied.
The Bovie was Sherwood's "scalpel," an electric wand that burned and sealed whatever it touched. When he used it, a veil of smoke temporarily obscured the camera.
When Sherwood reached the upper lobe, the color changed from healthy pink to something more ominous.
"There it is," he said.
Isolate the vesselsThe spot that looked white on Froggatt's CT scan was actually a mix of brown and black. When Sherwood touched it with a probe, it was dense and firm.
The lobe would have to come out, but before Sherwood could remove it he had to isolate it from the rest of the lung and the adjacent heart.
First he found the pulmonary vein, purple and blue, and inserted it into the mouth of his stapler.
"A moment of trepidation," he said.
The stapler looks like a caulking gun, with a long snout and an angry set of teeth. When Sherwood placed a vessel in its mouth and pulled the trigger, it cut the vessel and sealed the ends with six lines of staples.
A misfire, he said, would be an emergency, with blood spilling into the chest.
But the stapler worked perfectly. Sherwood cut and sealed the vein, and with it out of the way, he could see two of the pulmonary arteries, like white threads, beneath it.
He sealed those arteries, then the windpipe and a third artery.
Cut to close"Fifteen millimeters," he said to Bowmar, the scrub tech at the table.
He had separated the lobe and was ready to remove it. He wanted the larger of the two retrieval bags that Bowmar had.
The bag had a long handle and looked like the net used to catch a fish in an aquarium.
Sherwood folded it, then pushed it into the chest. With his other hand, he used a grasper to coax the lobe into the bag.
Soon the lobe and 20 nodes that he had plucked from the chest were sealed in paper cups for shipment to the lab. If the mass is cancer, the nodes will show how far it had traveled.
To finish, Sherwood removed his tools and sewed shut the incisions. He left a drainage tube inside Froggatt and two thin catheters to deliver pain medication. They would come out later. It was 11 a.m.
From "cut to close" was 21/2 hours, he said.
Outside, Sherwood found Warren Froggatt, Anita's husband, to tell him that the operation had gone so well that he was sending Anita to the recovery room, rather than to intensive care.
"Everything came out without difficulty," Sherwood said. "There was clearly a mass there we could see in the lobe of the lung. I don't know what it is yet. We sent a little piece of it off for culture."
Froggatt spent one night in the hospital and left the next afternoon. On Friday at her home, she said she was tired and sore.
She wondered if she had been too active Thursday, when she took her first shower and walked to the mailbox with her husband.
"I don't feel too bad," she said.
She still had not heard from the lab. She's betting that the mass was from a fungus she picked up while living in Arizona.
Jim Hall: 540/374-5433| The Fredericksburg area's medical community has grown in recent months with the addition of Dr. Timothy Sherwood, a thoracic surgeon, and a host of other specialists and sub-specialists. Among them are:
Drs. Maha Alattar, Sandra Crouse and Amandeep Sangha arrived this summer to serve as inpatient and outpatient neurologists at Mary Washington Hospital. Alattar is also a sleep specialist. She completed a fellowship in sleep disorders at The Cleveland Clinic. Drs. Brian Mirza and Victor Stelmack arrived this summer to do bariatric, or weight-loss, surgery. Mirza also completed fellowship training at The Cleveland Clinic in minimally invasive surgical procedures. Drs. Reshma Parab, Leslie Taguba and Francisco Cruz arrived in March Dr. Kay Blanchard arrives this week from Houston to work as the area's first female general surgeon and the first female surgeon to specialize in breast cancer. Also new are Dr. Rod Flynn, a surgical oncologist; Dr. Avnit Ahuta, a rheumatologist; and Dr. Lawrence Roberts, a trauma surgeon and medical director of the hospital's new trauma service. --Jim Hall
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