Originally published in the March 2015 issue of Veterinary Practice News
You don’t have time to make every mistake in your career, especially in surgery: A mistake could cause significant harm to a pet, get you in a sticky situation or cost your patient his life.
These suggestions are meant to start a reflection, not to offend anyone. They apply to new grads as well as seasoned surgery lovers.
1) Make it Big
“Big surgeons make big incisions.”
Unless you are performing minimally invasive surgery, don’t make mini-laparotomies. Sure, you can remove a spleen or a gastric foreign body through a short incision.
However, stopping there would be a disservice to your patient; that’s only half of your job. The other half is to perform a thorough laparotomy, from the liver to the bladder.
2) Perfect Your Suture
Pet owners will never appreciate how flawless a surgery you performed on Kiki. The only thing they see, and they may see for the next 10 years, is your skin suture. So work hard at crafting the prettiest skin suture possible.
Learn how to close dead space. Strive to appose skin spots neatly. Strive to get rid of dog ears.
Figure out where you can skip skin sutures, and reach a successful outcome with intradermal sutures only, thereby minimizing the scar.
Dr. Phil Zeltzman
A lateral nylon repair failed in this Malamute.
3) Choose Your Material
All suture materials are not created equal for a reason.
Polydioxanone, poliglecaprone 25 and polyglactin 910 are not interchangeable. It has become hard to justify using gut or suture from a spool in 2015.
The same goes for needles. Use a reverse cutting needle where appropriate (skin) and a tapered needle where necessary (hollow organs).
So use the appropriate suture material. And use the appropriate size. Using No. 1 suture in a kitten’s intestine is no way to decrease the risk of dehiscence.
4) Don’t cut Corners
Not working up your patients at least to the current standard of care is a great way to get bitten in the gluteus maximus.
Don’t neglect the preop work-up, i.e. CBC, chemistry, electrolytes and chest radiographs when appropriate. Of course, a quicker or cheaper work up is perfectly fine in a young healthy patient. Just make sure you at least rule out the possibility of a liver shunt or severe anemia.
Also don’t skip steps with hit-by-car patients. Don’t focus solely on a fracture or an open wound. Look at the whole patient. Always take chest radiographs to rule out a pneumothorax, a diaphragmatic hernia or lung contusions.
And please, always take chest radiographs in your cancer patients before surgery.
Dr. Phil Zeltzman
Pinning this radius failed in this shepherd.
5) Think Ahead
Cutting is the easy part; anybody can do it. But it’s just the beginning. Start with the end in mind. Plan your surgery well before the first skin incision. Here are three important considerations:
- If you are removing a skin mass, plan your incisions so that they are parallel to tension lines.
- Unless you are prepared to perform a skin flap, find a compromise between obtaining clean margins and saving enough skin to close the wound.
- Malignant tumors often require excision of 1 to 2 inches in every direction. This includes the most common dirty margin: the deep one. Remember one of the basic rules of cancer surgery is: the best time to achieve clean margins is the first time.
If you feel that you cannot do that, then be humble and refer your patient to someone who will do it right the first time.
5) Don’t Forget Stuff
Retained sponges are one of the most embarrassing situations you can get yourself into so avoid the risk.
Regular gauze squares have a tendency to stick to intestines so ban their use altogether when you do a laparotomy. Instead, only use laparotomy sponges, a.k.a. lap sponges.
This is not the place to be stingy. The (small) added cost is well worth it.
Be acutely aware of where your sponges are. They always should be on your instrument table or in the trash can, except for the one or two you need to use at any moment. When they are blood soaked or soiled, throw them away immediately.
7) Don’t Neglect the Postop
Which blood work should be performed postop? Should you follow calcemia after thyroid surgery? Should you recheck the PCV after a particular bloody surgery? Should you monitor glycemia in a patient with septic peritonitis?
Will you have coverage overnight? Should your patient be transferred to the local emergency clinic? Will you have access to blood products or a generous blood donor if needed?
A human surgeon once said: “I can teach you how to do a splenectomy in 20 minutes. To teach you all the complications, it will take 20 years.”
Of course it is a joke, but it contains a lot of wisdom. If you are going to perform a procedure, you owe it to your patient to know about the possible complications, how to handle them and how to communicate them to your client – before they happen.
8) Have a Plan B
Start with plan A, but always have a plan B … and possibly a plan C in mind.
What will you do if things don't turn out the way you expect? What if you find something unexpected? Have you discussed this openly with your client?
Before performing a laparotomy, here is the kind of explanation you could provide:
“Ms. Smith, I’ve just told you about the best case scenario. I would like to be upfront with you and also discuss the possibility of the worst case scenario. We may find something different than we expect in Kiki’s belly.
“If things are much different, or if the risk level of the surgery is higher than I’m comfortable handling on my own, I would like to be able to call you during surgery to go over options with you. Will you be easily reachable by phone?”
9) Know Your Limits
It’s really tough to be good at everything our wonderful profession allows us to do, including surgery. Forgetting this basic rule can get you in serious trouble.
Here are three real-life examples:
- You know how to perform an enterotomy to remove a foreign body. Are you prepared to do a resection-anastomosis if needed? Did you tell the client it might be necessary?
- You know how to perform a cystotomy to remove bladder stones. Did you discuss the possibility of a urethrostomy with your client? What would you do if a stone, or several, were lodged in the urethra of a male dog? A female dog? How about a male cat? A female cat?
- Of course you can spay a female dog, even a great Dane. Will you be your patient’s best advocate, and recommend a prophylactic gastropexy? Do you know how to perform one?
10) Know When to Refer
Which surgery you perform should not be based on what you can do, but what is required for that particular patient. It’s all a matter of indications.
Just because you are proficient at lateral sutures for treating ACL tears doesn’t mean that it’s a good idea to do it in a 200-pound mastiff.
Performing a lateral ear resection in a typical cocker spaniel is often a recipe for failure when the horizontal canal is also affected. A total ear canal ablation and a lateral bulla osteotomy are required in 99 percent of cases.
Be humble, and know when to refer patients.