The Work of Human Hands

Excerpt

On the next day, Hendren brings Lucy to his table. She is anesthetized and put up in stirrups. Her body is draped with a sheet, all but the area around her cloaca. Hendren scrubs and gowns and comes into the operating room. Dorothy Enos, his longtime nurse, hands him a stool, and he sits.

His eye is level with Lucy's bottom.

"Scope, please."

A resident hands him an endoscope, an optical instrument that illuminates the interiors of organs while delivering a steady flow of water or saline to ease passage and improve visibility. An endoscope can be configured to perform minor surgical procedures, such as electric cutting of unwanted tissue, which Hendren often encounters. A camera can be attached to the eyepiece for videotaping and group viewing. At a teaching hospital, a setup like Hendren's is indispensable.

As carefully as he might handle a Ming vase, Hendren inserts the scope into Lucy's single hole.

"Dorothy, may I have the camera, please?" he says.

Enos often ribs Hendren about his obsession with filming. And there are times when she would enjoy wrapping the cable around his neck.

The chief wants just about everything on film. Bladders, tumors, vaginas, intestines, penises, anuses, chests, normal parts, deformed parts, and extra parts. Certainly every one of his cloacas. In the old days, it was sixteen-millimeter technology he brought into the OR, and a Nikon thirty-five-millimeter camera, which, held together with tape, he still uses. From the perspective of the support personnel, the Nikon is but a minor annoyance. Hendren sometimes needs new batteries or film, but those are easy problems. That video, on the other hand -- that damn twenty-thousand-dollar video and endoscope setup of his -- is a major pain in the ass. Tapes must be labeled and cued. The VCR must be started and stopped, stopped and started, the instant Hendren wants. Depending on the size of the scope or the region of the anatomy, the brightness must be adjusted. The camera must be focused. Enos is a most proper and mannered woman, a gardener and fancier of theater and ballet, but she can have a sharp bite to her wit. She does not attempt to disguise her feelings toward the video. It was she who helped popularize the term Hendren cooked up: fideo, which combines video and the f word, a word Enos would never use. Hendren finds fideo highly amusing and never misses an opportunity to explain its etymology to a newcomer.

Flooded with saline, her cloaca looks like something that belongs deep undersea, not inside a little girl. It resembles a coral bed, perhaps, the pink and white folds of tissue slowly undulating as the current eddies and flows.

Enos attaches the camera, no bigger than two size-C batteries, to the endoscope's eyepiece. A bright circle appears on the monitor, perched on a shelf of the video cabinet, which is on casters. Much to everyone's dismay, the fideo can follow the chief if he goes to another operating room.

"All right, Dorothy," Hendren says, "shoot it."

Lucy's insides appear on the screen. As nurses and residents gather around the monitor, Hendren travels slowly in.

Flooded with saline, her cloaca looks like something that belongs deep undersea, not inside a little girl. It resembles a coral bed, perhaps, the pink and white folds of tissue slowly undulating as the current eddies and flows. Seeing his first Hendren endoscopy, Lawrence Rangecroft, a pediatric surgeon visiting from Newcastle Upon Tyne, England, thought it resembled a Jacques Cousteau production, and it does.

Hendren travels farther in, straight in, on through a narrow fistula into the rectum, which is the end section of the large intestine. In a normal child, of course, he would not be able to get to the rectum by any path but through the anus, but Lucy has no anus. The rectum is enlarged. The urine that has been escaping her stoma has first been collecting here.

Hendren is please that Richard Harmel, Lucy's first surgeon, did not attempt anything with the rectum. Many children have come to him after surgeons have mucked around with rectums, which to the inexperienced seem the part of the cloacal puzzle that is easiest to solve. In fact, whereas the surgeon may manage to get the rectum pulled through to the bottom, Hendren often has found that damage has been done to surrounding tissues vital for the definitive reconstruction. Even if adjacent structures remain intact, rectal repair is deceptively difficult. The best intentions without experience, as Hendren has often seen, can lead to trouble. "In general," wrote Willis J. Potts, a surgeon influenced by the great Robert Gross, Hendren's mentor, "atresia of the rectum is more poorly handled than any other congenital anomaly of the newborn. A properly functioning rectum is an unappreciated gift of greatest price. The child who is so unfortunate to be born with an imperforate anus may be saved a lifetime of misery and social seclusion by the surgeon who with skill, diligence and judgement performs the first operation on the malformed rectum." Hendren remembers the passage well.

Retracting the scope a bit and then angling up, Hendren finds the bladder neck. It doesn't look too bad, a promising sign, since urinary continence depends on a functioning bladder neck. The bladder itself is abnormally small, but in some measure that's due to Lucy's urine-filled rectum compressing it. Most likely, he will not have to enlarge her bladder with intestine or a wedge of stomach, a situation that would further complicate the already complicated. Hendren finds the point where a ureter, the one that drains her normal kidney, enters into the bladder. He does not find a second ureter. She probably doesn't have one; but in any event, it wouldn't do her much good. It probably would connect only to her multicystic kidney.

No question, Hendren thinks, it's going to be a tough one....
He would have to take Lucy apart in order to put her together again.

Hendren does find four small pits marring the otherwise smooth lining of Lucy's bladder. One by one, he tries getting a catheter into them. No go. Hendren has no idea what they are, not a clue what nature intended when they were made.

Like Harmel, Hendren fails to discover a vagina. Until he opens her up, he will not know for sure whether she has one. Or two. "I just reconstructed such a case from Oklahoma where there were two small vaginas that communicated with the bladder neck that we simply couldn't see," Hendren writes in a letter to Harmel, whom he will periodically update. "Also, I recently operated on a youngster in Cologne, Germany, where the same thing was true, where at the operating room table we found a well-formed vagina on each side, one pointing off to the left and the other pointing off to the right, so that they were really not between the rectal segment and the bladder at all.

"Thus, anything is possible up in there."

No question, Hendren thinks, it's going to be a tough one.

When next he saw Lucy in January 1991, Hendren would have several missions in additional to the fundmental mission of any surgery -- which is getting the patient through alive, uninfected, and headed home in improved condition.

First, he would have to discover, through dissection, exactly what he had to work with. He would have to find or fashion a vagina so that someday Lucy could have sexual relations. He would hope to find an ovary or two, one or more Fallopian tubes, and a uterus. He would hope to find a way to connect them to whatever he came up with for a vagina, so that someday Lucy would have a chance at having a baby of her own.

He would have to make an anus and hook up her rectum so that, in time, she could be continent of stool. He would have to make a urethra and, possibly, tailor the bladder neck so that she could be continent of urine. At some later operation, he would have to get rid of her stomata. I will do whatever I can so she doesn't have to go through life leaking or with a bag.

He would have to make Lucy's genitalia outwardly normal so that when she was old enough to know, about the time she was three or four, she would not consider herself different from other little girls.

He would have to take Lucy apart in order to put her together again.

-- Use of this excerpt from The Work of Human Hands by G. Wayne Miller may be made only for purposes of reviewing or promoting the book, with no changes, editing or additions whatsoever and must be accompanied by the following copyright notice: Copyright © 1993, 1999 and 2000 by G. Wayne Miller.