Cameron soon confirmed with his hands what preparation couldn't. Scar tissue encased Bloom's organs in a substance with the consistency of dried glue. Diagnostic scans could not detect the adhesions, resulting from previous surgery. They would need to be removed, like rind from a tender orange.
"It's going to be a long day," Cameron said.
It was 8:42 a.m.
The only portion of Bloom visible to the surgeons was his abdomen, illuminated by a headlamp that Zemon wore. The rest of his body was draped in thick, blue paper, and his head and arms were curtained off. Anesthesiologist Maria Birzescu, a resident, stood at his head. There, she could see his face, monitor vital signs and inject fluids into his outstretched arms.
Cameron stood in his usual spot on the patient's left. A blue smock covered his lean, 5-foot-9-inch frame. He wore soft-soled dress shoes covered by disposable booties. Only a bit of his thinning gray hair protruded from under his surgeon's cap.
His physician's assistant, Heather Hall, stood on a footstool to his right, holding a vacuum tube to suction blood. Surgical technologist Mary Burns was on a stool to his left, a tray of tools spread within her reach.
Across from them stood Trevor Ellison, a first-year resident awaiting a rite of passage in which he would remove the gallbladder, and the lanky protege, Zemon. Nurse Stephanie Sowinski stood apart, ready to retrieve supplies.
They were going after a tumor. A CT scan had turned up a dense-looking spot on the pancreas, a gland that produces the hormone insulin and enzymes used in digestion.
Bloom, 79, had lost his appetite, and the whites of his eyes had turned yellow, indicating the possibility of pancreatic cancer.
He had come to Cameron because he wanted to continue hearing cases specially assigned to him as a retired judge on the Maryland Court of Special Appeals. He wanted to continue living in Annapolis with his wife, Mary Lou, enjoying the families of his four grown children and taking conversational walks with a friend.
Cameron knew relatively little of this personal information, though Bloom had been a patient before. The surgeon had treated a chronic condition, Crohn's disease, by removing much of Bloom's large intestine in 1994.
His reasons for standing over the same man again stemmed from his own competitiveness. Cameron, who had kept operating after his mandatory retirement at 65 as chairman of surgery, was like an athlete who wanted to put a record out of reach.
This would be Cameron's 1,338th Whipple. His nurse practitioner kept a handwritten tally, taped behind his office door. His goal had grown to 2,000. Each Whipple, for which he charges $8,000, typically lasts five to six hours. He has completed about 120 a year.
Surgeons generally get better at operations the more they do, and Cameron wanted to keep improving. His focus was technical.
He had learned over the decades that every Whipple can be dangerous.
"Good judgment comes from experience," Cameron liked to tell his proteges. "Experience comes from bad judgment. ... I have good judgment."
The surgery begins with a tortuous descent through the front of a patient's torso, virtually to the back. There, the oblong pancreas lies sandwiched amid a confluence of blood vessels under the stomach, just in front of the spine.
The typical circumstance that calls for a Whipple, named after Dr. Allen O. Whipple, a New York surgeon who reported performing it in the 1930s, is a tumor in the head of the pancreas.
The gland's head is a crossroads, where a bile duct from the nearby liver and gallbladder intersects with a pancreatic one before entering the small intestine. A tumor that blocks the duct throws up a signal - jaundice.
To get the tumor, the surgeons disconnect the plumbing that runs through the area, removing the bile-storing gallbladder, part of the bile duct, the diseased part of the pancreas and a portion of small intestine along which the cancer tends to expand. They must also shut down the arteries that feed the tissue they are removing, while taking care not to harm those that serve organs - the liver, heart and spleen - that remain.
Surgeons take out the tissue in one continuously connected piece with the tumor and send it to the lab. Within about half an hour, an analysis shows the location of any cancer and how deadly it is. More suspect tissue may have to come out. Finally, doctors make new intestinal openings and reconstruct the body's plumbing.
At 8:53, the surgeons were just beginning to work their way past a tangled veil of fatty tissue into the interior of Bloom's abdomen. Cameron's role was to act as guide, framing his trainee's moves as together they probed ever so gently for camouflaged vessels and the evidence of spreading cancer. He used the long metal forceps he calls pickups and his fingers.