Originally published in the July 2015 issue of Veterinary Practice News.
Being a quick surgeon shouldn’t be a goal in itself. Being a good surgeon is a much wiser goal.
However, being good and fast might be the ideal combination for the anesthetized patient’s sake. We polled four board-certified surgeons* who shared 10 pearls to become more efficient in the OR. This is a sequel to June’s column titled “How to save time before surgery.” Each suggestion may seemingly only shave off moments. But over the length of a procedure, these moments add up in such a time-sensitive environment.
Thoroughly concentrate on the task at hand. Avoid talking about the weather, your upcoming vacation or the last episode of “Dancing with the Stars.” Avoid distractions and interruptions, such as unnecessary staff, loud music or phones in the OR.
During surgical procedures, appropriate staffing should never be underestimated. A well-trained, experienced technician can focus on anesthesia so that the surgeon can focus on the surgery.
A good technician won’t be shy about notifying you of true concerns about the patient, as opposed to annoying beeping related to a faulty probe or electrode. The technician should be aware of the timing of medication administration, which could have been discussed during your “morning huddle” (see last month’s column), along with the correct surgical site (left versus right), unusual IV fluid rates, proper patient clipping, exact patient positioning, timing of medication administration (e.g. metronidazole, insulin), etc.
A strategically used surgical assistant can save a significant amount of time during a surgical procedure. Whether they are holding an instrument or body part in place, or using suction to remove excess fluid and maximize visualization, a well-trained assistant frees the surgeon’s hands and mind to focus on more delicate tasks.
An experienced surgical assistant can also hand instruments to the surgeon, as is routinely done in human surgery.
Visualization is maximized by proper lighting such as powerful overhead operating lights, an operating head lamp or magnification eyewear. As human microsurgeon Robert Acland wisely said, “If you can’t see it, you can’t do it.”
Additional ways to improve visualization include suction and electrocautery.
Suction is very helpful in many situations, such as joint and abdominal surgery. Cautery is a quick and convenient way to provide hemostasis. Bloodletting is so last century…
The surgical approach should be adequately sized to facilitate gentle tissue manipulation and appropriate visualization. Incisions heal side to side, not end to end. Compensating for a tiny incision may lead to pulling forcefully on organs, which can cause tissue trauma at best and sever vessels at worst.
Strategic use of self-retaining retractors, such as Balfour, Gelpi or Weitlaner, will greatly decrease efforts while maximizing visualization. Proper retraction leaves your hands free. It enables you to see what you are doing and therefore can be a huge time saver.
As far as closing incisions, continuous sutures are much faster than simple interrupted – and they have been proven to be just as strong in virtually any location. In addition, skin staples are much faster than skin sutures.
Every OR should have an easily visible clock. This will allow you to keep track of time. Don’t get lost in the procedure.
The morning huddle (see last month’s column) is a great time to discuss the schedule: when to premedicate, when to place the IV catheter, when to induce, etc.
Think about how long the procedure should take or could end up taking if there are setbacks. The main reason to watch the clock is anesthesia time. If your patient has been under anesthesia for a while and you are still struggling with the procedure, it may be time to call for help. Remember, you are not working on a car. You need to recover the patient. The longer they are under anesthesia, the longer and harder the recovery is likely to be.
Enough is enough. “The enemy of good is better.” Know when to stop cutting and manipulating tissue and finish the procedure. Know your goals or endpoints prior to starting the procedure.
A great way to be more efficient during surgery is to constantly think about the next step so that the flow in surgery never stops. Ask for an instrument or suture well before you need it. Make sure the X-ray room is available for postop rads. When you are closing, review any special needs the patient may have during recovery and go over postop treatments and medications. Your mind should never be idle.
As stated in our last column, make sure you have the proper instruments, equipment and unusual medications available well ahead of the procedure. Make sure you have everything you need before you get in the OR. Properly functioning and maintained equipment is a necessity. A checklist could remind technicians to refill the heating pad reservoir and anesthetic gas, to make sure the suction machine works and to leak test the anesthesia machine.
Only remove instruments from the tray that you know you will need. Similarly, get rid of contaminated instruments that you won’t use anymore in a “no touch zone.” Keeping used instruments separate and unused instruments clean will ultimately save time for your staff during the postop cleaning phase.
Wrapped scalpel blades can be added to surgical trays prior to sterilization so they are ready at hand. Crumpling a used pouch and other paper items is a habit many of us have. Yet, it takes unnecessary time; throw it away — as is.
Keep your instruments organized, instead of piling them up randomly. It will make it easier to find instruments when you need them. Only touch what you need when you need it.
All of these small strategies can be used in an effort to have a purpose for every movement.
Here are a few more tips offered by our colleagues:
- Make sure the room is at a comfortable temperature for you.
- Always double-check how your patient was clipped before scrubbing.
- Always double-check patient positioning before draping the patient.
- Adjusting the surgical table to a proper height. It will, in turn, help you by not having to adjust your own position to accommodate. Surgical tables can be raised, lowered and tilted to fit your exact needs, so use those features to your benefit.
Implementing these time-tested suggestions will help you “get in, get done and get out.”
Phil Zeltzman, DVM, DACVS, CVJ
Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at www.DrPhilZeltzman.com, and follow him at www.facebook.com/DrZeltzman.
Kelly Serfas, a Certified Veterinary Technician in Bethlehem, PA, and Zee Mahmood, a veterinary technician in Reading, PA, contributed to this article.
The authors wish to thank their generous contributors: Drs. Mitch Robbins (Veterinary Specialty Center in Buffalo Grove, IL), Justin Harper (Texas Specialty Veterinary Services in Boerne, TX), Myron Downs (Athens Veterinary Surgery Center in Athens, GA) and Denis Marcellin (North Carolina State University’s College of Veterinary Medicine).