“First thing is to select the patient properly for the procedure you’re going to be doing. You don’t do a radical cystoprostatectomy with lidocaine infusion on a 65-year-old diabetic patient with coronary artery disease, because he would be more likely to suffer a complication, cardiovascular or otherwise.
You need to make sure you’re doing the right surgery on the right patient so the surgery does not interfere with longevity. That is the most important decision.
The next thing to do, after deciding what procedure you’re going to do, is to go over that procedure in your mind—the steps you’re going to go through. If you’re working with a resident, you need to know the capabilities of that resident, and you need to know if this procedure is appropriate for his level and his skill set.
If you’re a private practitioner, you need to assess honestly whether the procedure is beyond your skill set. People don’t necessarily think about these things.”
Nelson Stone, MD
“Prior to surgery, it’s critically important that the surgeon rethink exactly what’s going on in that individual patient, what their anatomy is, and what’s known from their preoperative studies, so both a picture of what the abnormalities are and how to approach them are clear in the surgeon’s mind.
The other thing that’s very important for avoiding problems and dealing with potential complications as they come along is to develop and have back-ups in place—to consider all of the options for dealing with any problem that might occur. If, for example, you’re going to try to remove a stone from the ureter, make sure you have a backup wire in place up to the kidney, so that if something goes wrong you can always put a stent in and protect that urinary system, usually allowing it to heal on its own.
Then, consider all other approaches once you’ve hit a difficult point in the procedure before stopping the procedure. Be aware of what is both safest and most efficacious. Have back-ups in place, consider all the alternatives before just moving forward in one direction.
Occasionally, we see people who seem to get fixed on a single idea—sort of a target fixation—without considering all of the other alternatives. That can be problematic in the emergency room when doctors get fixed on a single diagnosis, but similarly that issue occurs during surgical procedures when people get fixed on a specific approach—I have to chase down that stone, I have to follow that stent, I have to continue with this operation rather than backing up and looking at other approaches. You need to be flexible.”
Peter N. Schlegel, MD
“Pay attention to detail prior to surgery.
Since I do oncology, I rely a lot on x-rays and imaging studies. Carefully looking at images helps you plan your surgery, lets you know if there is any aberrant anatomy, and gets you ready for potentially unexpected problems.
Look carefully at all the information you have for surgery, from the patient point of view. There are two aspects of informed consent. One is, what are the most common complications that may occur, and then, not as common, what are the most serious complications that can come up? You have to make sure the patients and their families are well prepared.
Then intraoperatively, what I tell my residents all the time is, ‘Same way every time.’ Doing a relatively small number of types of operations, this is a little easier for me. Having a system and a methodical way is good for me. I usually operate with a resident, so it helps to have consistency of approach in the operating room.
After surgery, you have to recognize that complications are inevitably going to happen, so early identification and prompt recognition are important. Identifying and managing complications early can mitigate the severity. If complications do happen, it’s critical to communicate with the patient and his family, and that I think is often the hardest part.”
Maxwell Meng, MD
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