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Figure8.1.“Ishegoingtosign?”
Avoidsellingautopsiesunderanesthesia(AUA)
Wecompared youabovetoanastute salesman, interactingwith
thepatient andhisfamily. In this capacity, you, a respected clinician,
caneasilysellanythingtothetrustingclients.Butbehonestwithyourself
and consider as objectively as possible the risk-benefit ratio of the
procedureyouare trying to ‘sell’. It may be easytoconvincea worried
family that a (futile) operation is indeed necessary, and then at the
inevitable M & M (morbidity and mortality) meeting ( Chapter 50) to
explain that the family forced the AUA on you. Easy and ethical don’t
alwayscoexist!
One should advise surgery only if there is a reasonable
chance of success. To operate without having a chance
meanstoprostitutethebeautifulartandscienceofsurgery.
TheodorBillroth
Concludingremarks
Not only is what you say important but also how it is said.
Introduceyourselfandallmembersofyourteamwhoarepresent.Shake
hands with all members of the family. Conductthe ‘session’ in a sitting
position — you sitting at eye level, or lower, with the patient and his
family.Maintainconstanteyecontactwitheachofthem—donotignore
thegrumpy son hidinginthe corner oftheroom — hemay be the one
whobecomesyournemesis.Be‘nice’butnot‘toonice’—thisisnotthe
timetosmileorjokearound.Justplaytheserioussurgeoncommittedto
thewell-beingofthepatient.Thissurgeonisyou,soplayyourself!
Nothingistruerthantheclichéthatshouldbeconstantlyreplayed
in your mind — would you recommend the same treatment to
your father,mother,wife orson? Studies show that surgeons are much less
likely to recommend operations on themselves or their loved ones. Do unto others as you
would have them do unto you — the golden rule. Even if your hands are so keen to
operate…
Iteachmyresidents:“Honestyandsensitivityinhighdosesisallittakes.”Ari
“The patient’s family will never forgive a guarantee of
curethatfailed and the patient will notletthephysician
forget a pronouncement of incurability if he is so
fortunateastosurvive.”
GeorgeT.Pack
1
Formuchmoreabout“Dealingwithpatients,families,lawyersandyourself”pleaseconsult
the so-named Chapter 10 in Schein’s Common Sense Prevention and Management of
SurgicalComplications.Shrewsbury,UK:tfmpublishing,2013.
Chapter9
Beforetheflight:pre-opchecklist
MosheSchein,PaulN.Rogers,AriLeppäniemi,DannyRosinand
JonathanE.Efron
The pilot is by circumstances allowed only one serious
mistake,whilethesurgeonmaycommitmanyandnoteven
recognizehisownerrorsassuch.
JohnS.Lockwood
Aren’t we all fed up of being compared to pilots? RichardC. Karl, a
surgeon and pilot, has pointed out that the two professions are not
exactlythesame:
Pilots don’t fill out a form documenting that they put the
landinggear down. Thisis another fundamentaldifference
in the two professions. We (surgeons) obsess about
documentation; aviation worries about getting the wheels
down.
Idoknowthatitishardertocontrolbleedingfromtheback
sideoftheportalveinthanitistolanda737withanengine
onfire.
Neverthless,likeanymilitaryorcommercialpilot,priortoanyflight,you
have to go over a ‘checklist’ ( Figure 9.1). In fact, the need to check
everythingobsessivelyismorecrucialtoyouthantothepilot.Forwhilea
teamof dedicated and well-trainedmaintenanceprofessionals surround
thepilot—youaresometimessurroundedonlybyjerks.Wedonotwant
to be abusive or rude orpolitically incorrectbut letus be realistic:at 2
a.m. your intern or junior resident is much more interested in his lost
sleep than your prospective operation. And the anesthetist? Your
emergency case is just a pain in his ass. The sooner he or she can
administerthegases, and the sooner they can dump your ‘case’in the
recovery room, or intensivecare unit,the soonerthey can crawl under
thecomfortoftheirwarmduvet.Andthenursingstaff?Forgetthem!Not
in vain today are they called OR technicians. (Lest we be accused of
paintingwithtoowideabrush,therearealwaysthewonderfulexceptions
— some assist us better than any resident... in this scenario, let them
knowtheyareappreciated!).
Figure9.1.“Doctor,showmeyourpilotlicenseandCMEcertificates!”
Sofaceit—youarealone;itisalwaysasoloflightandyoucan
count only on yourself. You are responsible for the success, failure,
morbidity,mortality,andpotentiallawsuit.Hisorherfateisinyourhands.
Thispatient,regardlessofhow manypeoplearebuzzingaroundhim,is
yours.Sowakeupandgooverthechecklist.
The formal ‘OR time out’, dictated by ‘big brother’ — that
mandated final review by the nursing team of the side, site and
natureoftheprocedure—cannot,andshouldnot,comeinsteadof
yourownchecklist.
Thesurgeon’schecklist
•
Does he really need the operation? The cliché that it is more
difficult to decide when not to operate than when to operate is
mentioned elsewhere in this book. Variations of this aphorism are
circulating around the world in many languages. But even more
difficult is to decide against the operation after the operation has
been scheduled. So you decided to book the patient for
appendectomy based on whatthe chief resident toldyou over the
phone—that“theCTiscompatiblewithacuteappendicitis”—and
now, when you arrive in the OR, you find the patient smiling and
sittingin bedwitha softand non-tenderabdomen.Do youwant to
operateon the CTorthe patient? Youdonotneedbigballs(or
ovaries)tobookapatientfortheoperationbutyouneedlarge
ballstocanceltheoperationandorderthepatientback tothe
floor (ward). You needhuge balls to remove the patient from the
operatingtableandmassiveballstotelltheanesthetisttowakehim
up… but if you palpate a large appendiceal mass (see Chapter
23)after the inductionofanesthesia and abdominalwallrelaxation
—whatisthepointofcontinuing?
•
Examinethepatientbeforeheisputtosleep.Neverever—we
repeat—never,never,nevereveroperateonapatientwithout
havingexaminedhimyourself;ifyoudothenyouareafrickin’
butcher!Thattheendoscopistvisualizeda‘bleedingulcer’andthe
patientcontinuestovomitbloodmaybeanindicationforoperation,
but this is your chance to diagnose the large spleen and ascites,
which were hitherto overlooked by the others. You do not want to
operateonaChild’sCportalhypertensionpatient,ordoyou?(See
Chapter25.)
•
Look at theX-rays and imaging studies. Review all X-rays and
imagingstudiesbyyourself.Donotrelyonlyonwhattheradiologist
said or wrote. You may pick up findings, which may move you to
canceltheoperationortodecideonadifferentincision.Finedetails
on the CT may help you to plan the operation. It can show, for
example,thesafestplacetoentertheabdomenandavoidingbowel
loopsadherenttotheanteriorabdominalwall.
•
Positionthepatient.Already before youstartyou have tohavea
generalideawhatyouaregoingtodoorwhatyoumayhavetodo.
Thishasanimpactonyourpatient’sposition.Forexample—does
he need a Lloyd-Davies position, offering access to the anus and
rectum? This may be needed during colorectal procedures — to
insertascope,todecompressthecolonortoinsertastapler.Youdo
notwant tohaveto stopthe operationandplace thepatient inthe
correctposition or tosend the intern crawling undersoggy drapes
playingpeakaboowiththeanus.Inwhateverpositionyourpatient
is to be, check that all limbs are protected and well padded at
potential pressure sites. Poor positioning on the OR table may
result in damage to nerves, skin ulceration and compartment
syndromeoftheextremities—andalawsuit.
•
Warm your patient. See that the patient is well covered and
warmed. Hypothermia increases the likelihood of postoperative
infectionsandcontributestointra-operativecoagulopathy.
•
Thinkaboutpreventingdeepveinthrombosis(DVT).Prevention
ofDVT shouldbeinitiated before thepatientis put tosleep— not
aftertheoperation.Anyabdominalprocedurelastinglongerthan30
minutesisassociatedwithamoderaterisk ofDVT;you canadd to
this specific risk factors such as smoking, the use of oral
contraceptives,aprevioushistoryofDVT,age,obesity,acancerand
soforth.But instead ofponderingtoo much —why don’t you
provideall yourpatientsundergoinganemergencyabdominal
operation with DVT prophylaxis? Whether it is in the form of
subcutaneous heparin or calf compression depends on what your
OR can offer. Bear inmind thatanticoagulation isnot goodfor an
exsanguinating patient! We have seen young patients dropping
deadfrompulmonaryembolismafewdaysafterappendectomyand
young women developing intractable post-phlebitic syndromes
followingappendectomyperformedforpelvicinflammatorydisease.
Alwaysthinkaboutthis.
•
Isthebladderempty?Mostpatientsundergoingmajoremergency
operationsarriveattheORwitha urinary catheterinplace;in the
restyouwillinsertthecatheterontheORtable.Butifcontemplating
a lower abdominal procedure on a non-catheterized patient you
havetocheckthatthebladderisempty.Whenthebladderisfullit
may look to you like the peritoneum — we have seen residents
openingthebladderinsearchoftheappendix .Bladderdistension
may also mimic a surgical abdominal condition, not rare in a
mentally challenged patient. It is your job to see that the nurses
inserttheFoleyproperly.EvenaseniorRNiscapableofinflatingthe
balloonintheurethra,causingmassivehematuria.Wehaveseenit
all.
•
Thinkantibioticprophylaxis(see Chapter7).
•
Documenteverything(see Chapter8).
Now you cango and scrub. While doing so, continue to think and
contemplatewhatyouaregoingtodo.Gothroughtheanticipatedphases
of the operation, refresh the different strategies and options available,
thinkaboutadditional equipmentyoumight beneeding,and finally,look
in the mirror and give yourself an encouraging nod — what a great
professionthisis!Don’tIlookgreatwiththatmaskcoveringmyface?!
Remember:Many lives have been saved by a moment
ofreflectionatthescrubsink.
NealR.Reisman
ButdonotbehavelikeTolstoy’ssurgeoninWarandPeace:“He…
joked… and chatted carelessly,as afamous surgeonconfident that he
knowshis job willoften chat whilehe tucks uphissleeves andputson
hisapron,andthepatientisbeingstrappedtotheoperatingtable.‘Ihave
thewholebusinessatmyfinger-tips,andit’sallclearanddefiniteinmy
head.Whenthetimecomestoset to work I shall do it as no one else
could, but now I can jest, and the more I jest and the coolerI am the
more hopeful andreassured you ought to feel, and the more you may
wonderatmygenius.’”
Youarethecaptainoftheship—behavelikeone;thesightofa
euphoricsurgeondramaticallyenteringtheroomwithhisscrubbed
handsheldhighintheairispitiful.
“Poor judgment is responsible for much bad surgery,
including the withholding of operations that are
necessaryoradvisable,theperformanceofunnecessary
and superfluous operations, and the performance of
inefficient,imperfect,andwronglychosenones.”
CharlesF.M.Saint
“Thesurgeon,likethecaptainoftheshiporapilotofan
aircraft,isresponsibleforeverythingthathappened.His
wordistheonlyonethatcannotbegainsaid.”
FrancisD.Moore
PARTIII
Theoperation
Chapter10
Theincision
MosheSchein,PaulN.Rogers,AriLeppäniemi,DannyRosinand
JonathanE.Efron
1
Incisions heal fromside to side, not from end to end, but
length(asyoumayknow)doesmatter.
When entering the abdomen, your finger is the best and
safestinstrument.
Have you ever heard about the novel concept of
‘macrolaparotomy’—thatitispossibleandsometimesadvisableto
enter the abdominal cavity by cutting into it directly? Yes, with a
knife,withoutinsertingscopesortrocars!Didyouknowthatthiscuttingedgemethod may be useful —particularlyin emergency surgery? This
chapter is dedicated to this bold approach of open abdominal entry—
readaboutlaparoscopicaccessin Chapter12.
The patient now lies on the table, anesthetized and ready for your
knife. Before you scrub, carefully examine the relaxed abdomen. Now
youcanfeelthingswhichwereimpossibletofeelinthetenseandtender
belly.Youmayfeeladistendedgallbladderinapatientdiagnosedasan
acute appendicitis, or an appendiceal mass in a patient booked for a
cholecystectomy.Yes,thiscanstilloccurintheeraofultrasoundandCT,
especiallywhenandwhereimaginghasbeenskirtedorisnotavailable.
Traditionally, abdominal entry in an emergency situation or for
exploratory purposes has been through a generous and easily
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