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Monday conversation - Dr Dev is the man

By Riverine Herald

When CHARMAYNE ALLISON and LACHLAN DURLING were invited into the operating theatre to witness Australian first surgery they were not sure what to expect. But blood and guts aside they watched visiting surgeon Devinder Garewal lead a precision team through groundbreaking reconstructive surgery and it all went like clockwork.

To meet the team, click here. For a gallery of the surgery click here.

THE SUN is barely up and orthopaedic surgeon Devinder Garewal is striding through Echuca Regional Health, prepping the theatre team travelling in his wake.

They are good to go for the first procedure of the day. But this one would be way out of the ordinary – it was the first procedure of its kind in Australian history.

The country’s first navigated short-stem reverse shoulder surgery. A medical mouthful that in English means a 74-year-old suffering chronic pain was about to get his life back.

Best of all, he was going to be able to give his wife (and his grandchildren) a proper hug.

And get back to the outdoor life he loves – fishing, prospecting and gardening – but has not been able to do properly for longer than he cares to think about. Dev, however, had bigger fish to fry.

Previous X-Rays show the patients shoulder has moved up, his humerus is hitting bone and causing pain. The ball and socket shown in this will be reversed, thanks to the new prostheses.

He was about to create his own little piece of Australian medical pioneering in partnership with the brainiacs from Exactech who had made the new ‘short-stem’ prosthesis about to be inserted into the patient’s shoulder.

The cutting-edge prosthesis is just 50mm shorter than the traditional long-stem model but is far less invasive as less bone needs to be removed and gives the patient future options if there is any sort of relapse or damage.

It was a first here but Dev’s done more shoulder surgeries of this type (navigated reverse shoulder) than he can remember.

“I think it’s somewhere between 40 and 50,” he said.

“So today, for me, is not daunting.”

While Dev is tying up loose ends, Exactech’s Andrew Stubbs is around the corner setting up the perioperative plan for the surgery.

Sophisticated 3D models flash onto the screen, showing where bone has been lost to wear and tear and where, according to the CT scan; the ideal spots are to insert the prostheses.

A screenshot from the Exactech software shows the angle where the drill will enter the bone.

“If you look at this view, it shows where the vault is, that’s where the best bone is. We need it to be right in the middle,” Dev said, examining the plan with Andrew.

“We also need to calculate depth so the back of the prosthesis is at the correct angle and low enough so the baseplate doesn’t touch on the undersurface of the socket side.

“That looks like it’s in a good position.”

Once signed off the plan is saved to be used during surgery. For this type of operation the tech is in the theatre actually calling most of the shots.

Like a player in a chess game he must be steps ahead of Dev, ensuring the scrub nurse has all the instruments at the ready while keeping an eagle eye on the technology in case disaster strikes.

Then the rehearsals are over, the team have checked everything off, the patient, now completely under, is swept out of the anaesthetic room with local GP/anaesthetist Sam Kennedy by his side, the surgeon looks everyone in the eye and it’s curtains up.

There are 10 people and so many things that go ping packed into the theatre but like the ultimate conductor (to the soothing jazz soundtrack on the stereo) Dev kept everyone in tune and kept everything going forward.

“Here we go,” Dev said.

“We’re about to perform Australia’s first navigated short-stem shoulder replacement.”

Momentous words for what turned out to be a pretty tame start to the surgery. As tubes, cords and supports are set up and the patient’s arm sterilised, banter ricochets around the room.

The team clearly take the life-or-death nature of their job seriously – but like any high-pressure, high-stakes role, they still need to have a bit of fun.

The set-up complete, Dev makes the first cut boldly and deeply.

The cut is clean, amazingly to the uninitiated, there is no gushing blood, and ERH surgical resident Luke Brennan is there to suck away any stray blood.

Forcing the cut open with a retractor, Dev exposes the striated muscle beneath.

“So we’re going into an interval between two muscles at the front of the shoulder,” he said.

“One is the deltoid and one is the pectoral – that interval is indicated by a vein that comes up the arm.

“So the first job is to try to find that vein.”

A burnt-hair smell hangs in the air as Dev singes away scar tissue beneath the muscle using a diathermy or ‘firestick’ – clearing the site to get at the shoulder joint.

That takes him through a thin, slippery-white biceps tendon which he simply cuts and then sews it to the major pectoral muscle to hold its position.

The shoulder’s sudden appearance is confronting as the bone, usually hidden beneath layers of muscle, tissue and tendons – and wrapped in skin – is gradually exposed.

Dev is handed the short-stem prostheses by scrub nurse Rebecca Gray. The next step is to attach a polyethylene cap.

Removing the front muscle, Dev finally has clear access to the joint and, using clamps, he and Luke gently wedge it out of the body.

“His humerus bone has a very big head and he’s lost all the tendons at the top of it, as we’d seen in the scan,” Dev said, touching the tip of the bone.

“He’s missing a bit of the cartilage on the head as well, plus there are lots of lumps and bumps from arthritis.”

And now the real work – the blood, sweat and tears of the operation – begins.

Handed an oscillating saw with a blade the width of his finger, Dev begins to grind away at the head of the exposed humerus.

Slicing it clean off, he knocks the severed piece, the size of a small plum, with a pair of pliers.

“See, that’s not the normal sound,” he said.

“We’re left with the rest of the humerus. So now we’re going to prepare to put the prosthesis in.”

Grabbing a mallet and broach (a tapered instrument a bit like a chisel), Dev doesn’t just hammer it into the humerus it almost looks like he’s belting it, each blow is so firm, making room for the prosthesis.

“We’re going up in sizes until we get one that fits the bone,” Dev said, swapping the chisel twice.

“And we’re not trying to remove a channel of bone here. We’re actually impacting what bone is there, compacting it so the stem is surrounded by strong bone.”

This is no place for the squeamish, for these surgeons everything from sawing to hammering needs to be as forceful as any handyman’s project.

Only, this is flesh and bone instead of wood.

And every millimetre counts.

So while Dev bangs away, he is expertly navigating that fine line between practicality and precision.

Meanwhile, scrub nurse Bec Gray is using what is surely an apple corer in its spare time to cut tiny columns of bone from the removed head of the humerus which will be used to graft the plate of the prosthesis to the old socket.

“It’s like she’s making a fruit salad; like making melon balls,” a team member jokes.

After drilling a tracker into a bone just above the shoulder, Dev uses it to communicate with the perioperative plan on the monitor in front of him.

His gaze glued to the screen, he lines up an electric screwdriver exactly where the plan has marked out.

Now we are talking real surgery, if it’s not micron exact it’s just not going to work.

The Exactech navigator - the LCD screen in the back - guides Dev's movements with the drill into the shoulder.

The drilling done, Dev scrubs just enough cartilage from the socket (aka glenoid cavity) so a prosthetic joint can be installed.

Then with tweezers he squeezes the tiny columns of bone Bec extracted into the peg which will connect the prosthesis to the socket – and then it’s screwed snugly in to place.

“The screws are much longer and better fixed because of the navigation,” Dev said.

“This gives more stability to the prosthesis until that peg is eventually held by bone.”

The peg intact, Dev screws the ‘ball’ – a hollow half-sphere of metal – on top.

Now, the ball sits where the socket once lived.

While the short-stem prosthesis will provide a socket where the ball used to be – a total reversal.

Meaning the damaged rotator cuff tendons which previously helped the shoulder move are no longer needed – from today the joint will be moved by the deltoid muscle.

Dev taps in a trial prosthesis, 1mm smaller than the permanent one.

Dr Dev aligns the trial prosthesis at 20 degrees - the implement he screws in will align with the forearm as he hammers it to compact the bone.

“This way, before I put it in I know it feels right and the tightness is good,” he said.

At last, it’s time for the real deal.

Andrew presents the prosthesis to Dev with the dramatic flair of an expert salesman.

“Here we have Australia’s first navigated preserve 10mm stem. Congratulations Mr Garewal and Echuca Regional Health,” he said.

Once the prosthesis is hammered in, a polyethylene cap is tapped on and the new joint is popped into place.

The wound still open, Dev moves the arm around to show the smooth movement of the new joint, the ball and socket gliding easily.

“So it’s been reversed and it’s very stable, this patient should be able to lift his arm into the air and to the side without any difficulty.”

And just like that it’s over.

Dev stitches the skin back together, hiding his handiwork; nurses pack up instruments; the patient is wheeled to the ward.

Suddenly what had been the centre of the world is all but abandoned; no evidence remains of the life-changing and historic surgery that just unfolded.

Except somewhere, down the hall, there’s a patient who will soon wake up.

If Dev got it right it will be the patient’s last surgery.

And because he did get it right, Dev has many more to come.