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Surgical
Decision-Making
Evidence and Beyond
RifatLatifi
Editor
SecondEdition
123
Surgical Decision-Making
Rifat Lati
Editor
Surgical
Decision-Making
Evidence andBeyond
Second Edition
Editor
Rifat Lati
Department of Surgery
The University of Arizona
Tucson, AZ, USA
ISBN 978-3-031-67390-0 ISBN 978-3-031-67391-7 (eBook)
https://doi.org/10.1007/978-3-031-67391-7
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2016, 2024
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December 22, 2024
Tucson AZ USA
In loving memory of, and my deep appreciation for,
Dr. Rao Ivatury’s invaluable mentorship and unwavering
support throughout my career, I dedicate this book to his
enduring legacy and profound impact on surgery and trauma
care worldwide.
May his wisdom, compassion, humility, and dedication
continue to inspire future generations of surgeons, and his
memory forever be a guiding light in the eld of trauma and
acute care surgery.
Foreword
For decades, various urban legends have remarked about the ability (or lack
of ability) of surgeons to make rapid decisions based on little data, to then
reect upon these decisions, and to learn from their successes and their mistakes. Surgical decision-making always starts with the ability to make correct
diagnoses regarding a patient’s illness and then to decide if an intervention is
indicated either alone or as part of a continuum of care, including medical
therapies. Medicine is truly a team “sport,” but, fundamentally, each patient
deserves to have an individual (captain model): to provide an overall view, to
bring together consultants from many elds when necessary, and to present
fully the pros and cons of the decided intervention, the risks and potential
complications of such intervention, and the consequences of nonintervention
to the patient for his/her decision as to what they wish done. Underlying this
process of surgeon–patient interaction and decision-making is the requirement for up-to-date clinical knowledge regarding best practices, clinical
knowledge, and judgment.
The evolution of surgical clinical knowledge has not always proceeded in
a stepwise fashion. Historically, surgeons learned from each other by apprenticeship through observing operations and inpatient/outpatient perioperative
care. More experienced surgeons would travel long distances to learn new
techniques that were being introduced by another master surgeon. This
method evolved into the publication of an individual surgeon’s results in
treating a variety of surgical problems in patients, presenting such results in a
professional public forum, and defending his/her various surgical approaches.
Surgical societies and organizations were formed to exchange ideas. This was
an attempt to improve surgical decision-making from the eighteenth through
the twentieth centuries. With time, it became apparent that greater knowledge
could be obtained by understanding how “an institution” handled certain
patients with different diagnoses and how the patients’ outcomes varied based
upon their comorbidities and the surgical decisions made before, during, and
after operations. These retrospective studies taught us “associations” but not
causations.
Later, institutions with large clinical volumes created their own prospective databases from which multiple questions could be answered when the
clinical volumes were large enough to provide some statistical validity.
Interspersed over time have been prospective, randomized, clinical trials in
which surgical therapies were instituted based upon randomization of the
patients, and certain predetermined outcomes were then measured. All of
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these types of studies taken together provide a base of clinical knowledge that
assist the decision-making process.
Yet, each patient is an individual with different genetic and environmental
backgrounds, ages, genders, comorbidities, socioeconomic and cultural circumstances, and goals for their lives. In addition, the disease processes
patients encounter have different durations, severities, prognoses, and potential outcomes. Taken together, the complexities of human diseases in patients
make physician decision-making difcult despite knowledge of basic sciences and current best practice guidelines. This book, written and edited by
Dr. Lati and others, provides an important and timely resource for surgical
decision-making because it denes and recognizes the many internal and
external factors that inuence certain surgical decisions for better or worse.
Several points made in this book deserve emphasis. While each operation
should have a surgeon’s standard approach, many factors that occur during an
operation may alter that approach, requiring surgeon exibility in techniques
used and goals to be obtained. Recognizing that each operation is comprised
of a team, we agree with Dr. Lati that the surgeon’s leadership ability and
his/her ability to communicate effectively the tasks at hand to other members
of the team are critical to a successful operation. As described by Dr. Lati in
Chap. 1, managing resources (including time); directing, training, and supporting others; and coping with pressure are some of the critical components
of the surgeon’s leadership ability. It is that ability that usually determines the
patient’s successful outcome.
This book nicely outlines the generic components of the surgeon’s leadership and decision-making abilities and the factors that inuence them. It also
denes difcult clinical situations—from sepsis and trauma to elective or
urgent operations for a variety of pathologic conditions—and provides guidance based on the best current clinical evidence. An expert surgical leader
combines such guidance with focused training, proper communication for
team members, avoidance of intraoperative distractions, and a proper mental
state. These attributes lead to optimal surgical decision-making, which leads
to optimal patient outcomes.
Foreword
Hamden, NJ, USA MaureenD.Moore
Philadelphia, PA, USA JohnM.Daly (Deceased)
Preface
In the ever-evolving landscape of medicine, the practice of surgery stands as
one of the most challenging and dynamic elds. The stakes are high, as every
surgical decision made can profoundly impact patient outcomes, and these
decisions become increasingly complicated in a rapidly changing world,
where patient demographics are changing like never before. As societal values shift and technological advancements unfold, the practice of surgery is
required to adapt, necessitating a profound understanding of both clinical
nuances and ethical considerations. This book, a compilation of invaluable
insights and experiences from leading voices in the surgical community,
seeks to navigate the intricacies of surgical decision-making that have become
increasingly relevant in today’s healthcare environment.
The journey through this text begins with an examination of the legacy
imbued in surgical decision-making. We began by paying homage to the
foundational philosophies championed by our mentors, including Professor
Rao Ivatury, who dedicated his life to the elds of trauma surgery and surgical education. His renowned commitment to excellence, compassion, and
humility serves as a guiding light for current and future surgeons. It calls
upon us to reect not only on the decisions we make but also on the underlying motives driving those decisions. Professor Ivatury’s insights remind us
that the practice of surgery is not simply a technical endeavor but a profound
moral responsibility that must be approached with care and contemplation.
As you delve deeper into the chapters of this second edition of this book,
you will encounter the stark realities of the contemporary challenges in acute
care surgery. The rapid advancement of technology in the form of articial
intelligence (AI) presents both new opportunities and ethical dilemmas in
surgical planning. While there is excitement and much expectation for AI,
there is still much to be discovered and it is unknown at the present time.
What is well known is the fact that increasingly, surgeons must navigate complex algorithms and data analytics in their decision-making processes, raising
questions about the balance of human intuition and machine-generated recommendations. Equally pressing is the exploration of the critical factors
inuencing the surgeon’s state of mind. The mental and emotional health of
surgeons, which directly impacts their decision-making capabilities and
patient interactions, is addressed with the seriousness it deserves.
The parallels drawn between pilots and surgeons serve to highlight the
high-stakes nature of our profession. Just as pilots must hone their skills to
react in unpredictable environments, surgeons are faced with rapidly chang-
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ing clinical scenarios that demand sharp acuity and preparedness. This comparative analysis effectively emphasizes the layered complexities involved in
ensuring patient safety and optimal recovery outcomes, drawing on established practices in aviation that may offer valuable lessons for surgical
professionals.
This book does not shy away from confronting and discussing difcult
discussions surrounding surgical burnout, an issue that is increasingly recognized as a crisis in the medical community. This chapter explores the emotional toll that the demands of surgical practice can exact on individuals,
providing insights into coping mechanisms and organizational strategies that
can foster support for those on the front lines of patient care. Moreover, it
addresses the pivotal moments when a surgeon must consider whether to continue operating or transition to different roles. The real conversations about
when it is appropriate to step back from the operating room underscore the
importance of self-awareness and the ethical responsibility to prioritize
patient welfare amid personal challenges.
Each chapter showcases contributions from a diverse range of experts,
combining contemporary research ndings, case studies, and heuristic knowledge that reect the myriads of scenarios surgeons encounter daily. From
tackling complex medical issues such as managing polytrauma patients to
navigating ethical dilemmas in challenging oncological cases, this text offers
an expansive and nuanced overview of decision-making processes across a
multitude of intricate surgical contexts. It emphasizes the need for continuing
education and interdisciplinary collaboration to remain informed and adaptable to the multifaceted challenges faced by modern surgeons.
Ultimately, I hope this volume will serve not only as a valuable resource
for surgeons at all levels but also as a call to action for a new paradigm of
surgical decision-making—one that embraces adaptability, compassion, and
ethical foresight in equal measure. The complexities of modern medicine
demand that we don’t simply rely on established protocols; rather, we must
be inspired to think critically, explore alternative approaches, and engage in
dialogue that challenges the status quo. As you turn the pages, you are invited
to reect upon our shared commitment to the art and science of surgery, a
profession that continually demands the best of us and inspires the profound
responsibility of keeping human lives at its core.
While the editor of each book is the driving force behind this compilation,
it is the individual chapter authors who embody the dedication and pioneering spirit that characterizes the surgeon’s journey. Collectively these authors’
visionary leadership and commitment to surgical education shine through in
the rich tapestry of perspectives compiled in this book. May this collection of
wisdom, reection, and inquiry ignite critical discussions and inspire the next
generation of surgeons to navigate the complexities of their craft with courage, wisdom, and integrity.
Preface
Tucson, AZ, USA RifatLati
September 22, 2024
Prologue to First Edition
Complex surgical procedures carry signicant risks and complications.
Despite the most conscientious preoperative preparations, surprising events
may still occur. If the operation takes an unplanned turn, the surgeon has to
make difcult decisions. An absolute must is continuous awareness of the
patient’s physiologic status—including uid status, urine output, use of blood
and blood products, bleeding, current medications (such as vasopressors),
and biochemical endpoints of resuscitation. Even when the operation is going
well, the biochemical prole of the patient may not be optimal or even satisfactory, which may directly affect the outcome. In addition, the surgeon must
recognize his/her own physiologic status; if tired, for example, cutting corners and making major errors are much more likely. In this book, we address
these and other elements that are important for the intraoperative decisionmaking process. How do we as surgeons make intraoperative decisions under
what can be inauspicious conditions? That question has not been answered
appropriately in the literature. When a patient is dying in our hands from
bleeding that we cannot control, when irreversible metabolic shock does not
respond to anything that we do, when new problems emerge out of the blue,
when things go alarmingly wrong: In such dire moments during a carefully
planned operation, how do we decide what to do next and how should we
overcome our own fear? Many of us make decisions that later on we cannot
explain, that we cannot say why we did things a certain way. Usually these
are decisions made on the basis of a “gut feeling,” or “intuition,” or the “gray
hair effect,” among other attributes. Yet, the anatomy of such decisions is of
great importance to all surgeons and to those who work with surgeons. In this
book, we will review theoretical as well as any objective data that we as surgeons use to make intraoperative decisions. The decision we make, often with
very limited amount of information, will decide between someone living or
dying. How do we make decisions in split seconds to take someone to the
operating room now as opposed to a bit later? How do we decide to operate
on a dying patient without a CT scan and no laboratory data, just based on the
fact that he or she is in shock, just to nd liters of blood in the abdomen, a torn
vena cava, liver, spleen, or some major blood vessel?
When the patient is dying in the operation room, everyone panics, but the
surgeon reaches in the open abdomen and compresses the aorta between his/
her ngers, in order to let the team catch up. Is there a molecular explanation
for this? Non-surgeons have created and put forth many theories and hypotheses in the literature. But our collective rsthand experience as surgeons’
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