Saturday, September 28, 2019

The Surgical Abdomen

While fresh, young  surgeons pour over detailed cross-sectional CT scans or overpriced, extravagant ultrasounds, old surgeons relied on the wisdom gained from a physical exam and meticulous history taking to delineate abdominal pathology. "Hot Bellys," in the vernacular of the day could be a real hornets nest to deal appropriately with, and the wily veterans had there own brand of diagnostic techniques which were crude, but effective.

Decisive clinical diagnosis was elusive, but a strange hodge-podge of clinical maneuvers (if you could call them that) were enlightening to the battle tested old surgeon. Observations were also key element  of the work up.  A "sweated brow" or "a hypovigilant countenance" suggested a septic process. Jaundice suggested some sort of hepatic dysfunction and a strange blue periumbilicular coloration signaled an internal bleed.

The exam of the acute abdomen consisted of, euphemistically, what would be termed palpitation, percussion, and auscultation, but was really poking, pushing, lifting, listening, and twisting limbs around with gusto, much like a pretzel.

The psoas test was performed by forcefully flexing the thigh while rotating the foot outward. The test was contraindicated with concaminant orthopedic injuries. A positive response elicited a vociferous verbal response from the hapless victim  patient and suggested a lower abdominal process.

A shake test was of great value when the patient had difficulty identifying the area of maximal belly pain. While in a supine position the patient's hips were slightly elevated off the bed while a vigorous to and fro shake was delivered. Dr. Slambo, my favorite general surgeon, had an interesting method of augmenting the shake delivery that only applied to ambulatory patients weighing less than 75 kg.

With the physician and patient standing back to back with arms interlocked together at the elbows a gentle elevation is initiated by the good doctor leaning forward. The optimal height was with the patient's feet about 6 inches off the floor. The abdomen is bowed such that the viscera are near  the surface while a side to side shimmy/shake elucidates the problematic quadrant. The technical name of this procedure (according to Dr. Slambow)  was the elevated, gyrating, gambol gambit and it was far better than one of those new fangled CT scans when it came to elucidating the exact focus of abdominal distress..

Dr. Slambow also knew how to augment just about any type of palpation technique with a miraculous gooey, slippery substance known as ordinary Surgilube. He began with a full tube, superior to the umbilical concavity and began squeezing until there was a generous pool of  goop.  He then began exploring the aching quadrant with his hand gliding across the abdomen like a shoe that stepped on a banana peal. The quantity of Surgilube used during the procedure also provided valuable insights when planning the surgical intervention. More than 1/2 a tube of the gelatinous goo signaled problematic obesity that called  for extra long instruments and a platform for Dr. Slambow to stand on while he looked down into the wound.

Fist percussion commonly known as a blow to the upper bread basket was performed along the anterior thoracic wall by placing one hand on the skin and beating it with a fist. Exquisite pain evidenced by vociferous howls indicated cholecystitis or hepatic issues.

Murphy's inspiratory sign can be demonstrated in acute cholecystitis  by asking the patient to take a deep breath while pressure is judiciously applied below the right rib cage. As the liver descends, the inflamed gall bladder is brought into contact with the abdominal wall causing immediate cessation of the inspiration.

I really liked scrubbing on acute abdomens because the offending problem was identifiable and fixable. There was no better feeling than seeing a seriously ill person stroll out of the hospital with a new appreciation of life. Viewing that so vulnerable  prepped abdomen supine on the table awaiting the surgeon's ministrations always put me in a contemplative mood with the realization that despite all our political and religious differences  we are all just meatsacks enjoying an undeserved period of wellness so no matter what or who, With this thought lurking in the back of my foolish mind, I tried to be nice to everyone and treat patients as though they were my mother, father, or child.


  1. Good to see you're back OFRN! Dr Slambow sounds like quite a character.
    Cheers from Sue

  2. Thanks, Sue, I can always count on your loyal readership.

  3. The first thing I thought of was, "Hooray, a new post from Bob!" Dr. Slambow's elevated, gyrating, gambol gambit must have been quite the sight to behold if someone was just walking by. My husband is recovering from a Crohn's flare today, I'm glad that technique has fallen by the wayside! Have a great day, looking forward to more stories :) -Rosemary

  4. Thanks, Rosemary. I hope your husband recovers quickly and has a long, uninterrupted remission. TPN was the only thing that worked when my Crohn's got nasty. I think that I was actually addicted to TPN and the assorted pumps and paraphernalia that accompanied the infusions. Hmm.. that might be a story for another post.

  5. A story about TPN would be most interesting! Thank you for the well wishes, I hope you are in remission yourself. All the best! -Rosemary

    1. One of the benefits associated with aging is that the intestinal torture of Crohn's has faded. I have extraintestinal joint polyarthropathy problems now but they are a walk in the park compared to the problems when I was a youngster.

  6. May not be all for the best that palpating, observation, and percussion have fallen by the wayside. Advanced imaging techniques still rely on skillful human interpretation. To the inexperienced and ignorant , it might be better to think that these archaic physical exam techniques had fallen by the wayside. In any case, all the bright lights and loud sounds are reassuring to the Rosemarys, er, general public, until the balanced billing statement comes in the snail mail.

  7. It's good to hear from you Kathy, I've been trying to post on a more regular basis on Fridays in a vain attempt to get folks to peruse some of my newer posts. The old ones get lots of views, but not the newer ones. I must be losing my touch.

    Charity hospitals like the one I trained at did not have many patients that could pay a big bill so most everything was done on the cheap. It's amazing patients recovered as well as they did. There was lots of caring, but not much money.