AV Fistula – The Surgery

Procedure we called it. Because it’s small, done under local anaesthesia and can be discharged from the hospital on the same day. Or the real reason – too scared to call it a surgery. Let’s not be scared and call it what it is – a minor surgery.

In the previous post, we learnt what is an AV Fistula and why we need it. Some of the readers of the blog have asked me to write about the surgery with special emphasis on my experience through the surgery. Sorry I don’t have comments on the blog to prove it, but you don’t have a choice – read on.

The buildup

Once the doc saw the numbers on my blood work, he declared let’s get the Fistula done soon. Get admitted on Monday. We’ll hydrate you for a day and see what to do next. We sensed the seriousness in the tone and didn’t ask many questions – or should
I say any questions.

The weekend was spent reading, and the few phone calls and mails to office to let them know I would be off work for the week. I had already read up on what and why Fistula, but there wasn’t much info on how the surgery would go and other patient experience about the whole process. As due, we reached the hospital in time thanks to Raaghu who picked us up late from home but dropped us in time at the hospital for the admission.

The first day

I was put in a room, robes on, hospital tag and IV line attached, and then there was nothing left to do but wait. The doctor came in, no small talk, took a look at my wrists and elbows and said let’s do it at the elbows. He was the nephrologist, he ordered the nurse to put me on fluids for the next 24 hours and monitor the vitals along with my urine output. I had an uneventful night – apart from the 92 year old grandpa who constantly craved for coffee deep into the night. He was in because he was just old and had taken a tumble that had send the sugar racing.

The Prep

An afternoon surgery was planned and since it was a local anaesthetic process, there was no requirement to have an empty abdomen. Hence I had my lunch at around 12:30 and waited for an hour for my ferry to the OT. (called OR is some parts of the world) As I was wheeled into the OT complex I could see a white board that had a list of all the surgeries for the day.  I was a little taken aback on how they could just list them so publicly. It had details of the patients, doctors on duty and even the procedure. Perhaps the OT complex is an small community in itself and everyone’s a professional. But they have guests – the patients, who may not always be so trustable to keep the contents of the board to themselves. 

The surgeon walked in as I was being prepped and wasn’t happy that the staff wasn’t ready for him. Sir, 2 minutes  pleaded who seemed to be the senior most nurse in the OT. They quickly adjusted my position on the operating table, held out my arm and dabbed it in betadine and other disinfectants. As one nurse held my arm up to drain out excess betadine, I could see a tattoo on her arm that red “Irresponsible” for a second I felt like the moment the cop saw Mr. Bean in the hospital – luckily Dr. Timepass was in town, and I could see the funny side soon. 

The surgeon stormed into OT 3 a few minute later and the nurses stiffened up again. He tore the scrub that was draped over my face to reveal the right side view – Don’t cover the face, the patient can get claustrophobic – actually I felt comfortable and warmer while fully covered. 

Just a small prick, after which you wont feel anything. The surgeon said to me

Prick, Sting and a Shock

I wasn’t sure if it was the surgeon or a nurse, but I felt the prick, a sharp sting and a sudden shock run down my arm – maybe that’s why they had padded my palm. Then everything went numb. I could hear the surgeon voice commands like we see in movies – scalpel, forceps, clamps, suction and a few others that I can’t recall. I couldn’t hear cutting or what was happening inside as my left arm was totally numb. 

About 10 or 20 minutes into the operation, the “Irresponsible” nurse came over to my right side and asked sir are you awake? Not so irresponsible I was thinking when we asked again, sir can you open your eyes? I opened my eyes and gave a thumbs up on my right hand. But as I kept my eyes open and turned my gaze upward, I could see my reflection in the clear glass and shiny rim of the huge operating lights. The incistion itself was hardly 2 inches long – so nothing much could be made out – but it felt funny that all their efforts to shield the patient from seeing the blood and gore was undone. 

Soon after I felt my arm tightening. Like when you feel the arm under pressure while they check your BP.  I hadn’t realised what had happened. The surgeon continued voice commands for more tools, and he said get the Heparin ready – the anti clot. The nurses were fiddling or getting it rather slowly and the surgeon made sure he didn’t waste time and gave them some constructive negative feedback – on which I laughed a little. He must’ve notices my shaking belly as he acknowledged the laugh and addressed me to say the main operation is done, we’ll just close it up.

Surgeon's tools

I could hear some hard pulling and yanking in between shouts of wet your hands, wet my hands, don’t touch him without wetting your hands. Is this how all operations go? maybe just mine because it was a minor surgery. He was the only doctor in the OT, the 4 others were either nurses or far too junior than the main Surgeon

Its done, it went well. He said more like a declaration and went out to meet my parents. The nurses got me out to a room just outside called the Recovery where I spent the next 2 hours before being moved to my room. 

My arm felt tight. The pressure at the elbow was still there and I couldn’t flex and stretch – I felt I wasn’t supposed to move my arm because of the stitches and tried to keep still. It wasn’t until late that evening – around 7:30 that my Nephrologist walked in and told me to feel the Fistula. I put a finger on it and could feel it – like a jet of water running in pipe. Just that it was my blood and was flowing in full force just a few millimeters below the skin. I little freaky, but I managed to stay sane. I had an uneasy night – the stiffness, the pressure and the uncertainty of whether I should move my arm or not kept me up most of the night. 

The Next morning

My Nephrologist’s assistant came in early morning as I was having my breakfast.  He saw that my arm was half flexed – and seemed really regid. He said no you need to move it constantly. That’s when it became clear.

  1. The pain was not of the stitches.
  2. The stiffness would only get worse if I didn’t move the hand.
  3. The stitches were secure enough and there’s no need to worry about them ripping.
  4. It is essential to exercise – the flex and stretch movements as well as the wrist pumping action. 

As I tried to stretch – my arm would ache – exactly at the point of the surgery and hence I asked the doctor again if it was normal. He then explained beautifully. 

The veins are superficially located, but arteries are located deeper. So in the surgery, they first made an incision of about an inch and a half on the outer skin, then they dug deeper, seperated your muscles a little, found the artery and linked a portion of it with a suitable nearby vein to create the AV Fistula. Since they went beneath the muscles and fiddled with all that’s inside, the muscles would be disturbed and stiff. By exercising – making the flex and stretch exercise you will get the muscle to perform their intended action and hence restore their original shape and condition. The wrist pumping action will increase blood flow into your arm, and there are many reasons why more blood is better than less – faster blood, more nutrients, more flow and fluidity and hence faster healing.

Hospital Tag

Exercising became easier and made more sense after knowing this. The arm slowly gets better, the veins in your arm slowly start popping and the jet of high pressure blood flowing in a pulsating motion just under the skin becomes an everyday thing that you’ll learn to live with. It’s not easy, but where’s the fun in easy?


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