We have all been in a surgery where we find something unexpected or we are forced to make a decision quickly that will affect the outcome of the case. Although quick decision making becomes easier with practice, I’ve put together a few ideas that will help you feel more prepared for the elective or emergent surgical case.
This is THE most important part for success. Before each surgery, (especially for one that is new to you) review the approach and pay special attention to major anatomical structures that may be encountered. There are no points lost if you bring a book into the operating room! Then, have a plan A, B, C and D ready to go in your head. Plan A would be the ideal, best case scenario. Plan D is the worst case scenario. For example, my plan A for a fractured leg would be to reduce and stabilize it with my choice of implants. Plan B and C may be alternative fixation methods that are less ideal. Plan D would be that nothing works and the only thing left to do is amputate the leg. This way, when things are not going as planned, you’ve already thought of different outcomes.
If you know the surgery needs to happen fast for patient or anesthetic reasons, have all your materials to close the incision either already open on your table or ready to go nearby.
This usually happens when you encounter things like blood, gastrointestinal contents and urine. With blood (expected or not), it’s all about getting good visualization and then control. Materials that are typically helpful are your fingers (put pressure on it!), gauze/laparotomy pads, Kelly hemostats and suture. Having these ready before you start is beneficial. Ask yourself, “Can I safely ligate this large vessel?”
GETTING VISUALIZATION AND HELP
If you recognize you’re having trouble, help yourself by extending your incision, getting retractors, or asking for help. It’s not worth the struggle to save a few centimeters on the length of your incision. Have someone identified before you go into surgery that would be available to scrub in.
ENCOUNTER SOMETHING UNEXPECTED
Can you remove it? If the answer is no, then can you biopsy it? If the answer is no, then can you perform a fine needle aspirate? Take all the samples (biopsy, fine needle aspirate, culture, etc.) at the time of surgery if you’re unsure because it’s a lot easier to not submit something than to wish you had sampled a lesion. Calling the owners can be helpful because they may have certain wishes on how you proceed.
Abdominal explore for a mass of unknown origin (above).
Ovarian tumor consistent with a teratoma (above).
DEFINITION OF INSANITY
Trying the same thing over and over again expecting different results? Stop, step back, and take a breath. You have time! Sometimes just changing your perspective (going to the other side of the table) or asking someone their opinion is enough to help.