What follows might very well become my most controversial surgical column. This list of 12 surgical mistakes is hardly exhaustive. It is, however, meant to start a reflection, rather than to offend anybody.
The challenge with surgery is that a seemingly straightforward procedure can suddenly become much more complicated. Having the necessary skills set is the whole dilemma.
Examples include the “routine” cystotomy, canine or feline, which in fact required a urethrostomy; the “routine” splenic mass, which in fact was a hepatic mass; the “routine” enterotomy, which in fact turned into a resection and anastomosis of three feet of jejunum. Could you handle any of these situations?
Just because you have a hammer, even if you are a hammer expert, does not mean that every problem is a nail.
Not all fractures can be pinned; some require a plate and screws. Not all cases of otitis externa can be treated by a Zepp procedure; many require a total ear canal ablation. Not all ACL tears can be treated with lateral nylon sutures; some patients require fancier procedures, such as a tibial plateau leveling osteotomy or a tibial tuberosity advancement.
It’s all a matter of indications.
Six pennie were removed, but one was left behind in this 3-year-old terrier.
Because of financial constraints or countless other factors, clients might encourage you to take on risks that may not be in the patient’s best interest. What kind of risks?
A simple mass on a distal limb might require a wide resection in order to obtain clean margins, followed by a skin flap. A small lump on a dog’s dorsum may in fact be a pilonidal cyst that extends all the way to the spine. A “skin mass” on a dog’s thorax may in fact stem from a rib, and may require chest wall reconstruction.
Know when to say no to unreasonable requests.
Many anesthetic problems occur not because the patient is sick, but because of human error. Trouble can occur when the music is so loud that you can’t hear the monitoring equipment. Sometimes, we rely on the monitors too much. It is important for the anesthesia person to keep his eyes, ears and hands on the patient and make sure the monitors are working properly.
Sometimes, we don’t notice that vitals are slowly going in the wrong direction, especially when we do not keep anesthesia records.
Sometimes, we become impatient, or we don’t have time, or we’re starving, and we extubate a patient too early.
Proper surgical care does not end with the last skin suture.
Taking radiographs postoperatively is crucial in certain situations. After removing a bunch of coins from a large, fat Labrador, are you certain that you didn’t leave one coin behind? A simple X-ray would tell you.
After a cystotomy for bladder stones, it is now considered standard of care to take X-rays to ensure that no stone was forgotten. One study (Grant et al., JAVMA 2010) showed that of the dogs who had postop X-rays, 42 percent had stones left behind.
If you perform a splenectomy, are you prepared to treat ventricular premature contractions or disseminated intravascular coagulation?
You don’t have to provide overnight care to practice good medicine. But you should inform your client honestly if no human is present overnight; your state regulations may require you to do so.
Depending on the situation, you could offer to transfer a patient to the local emergency clinic. If the client declines, document your conversation in the record.
Failure of humerus fracture repaired with a pin and wire in a 10-year-old cat.
Lack of visualization is a common pitfall. Suction and retraction are two easy solutions. Suction is critical if you deal with a hemoabdomen or if you need to flush an abdomen.
It is difficult at best to perform a thorough laparotomy without using a Balfour retractor. Every practitioner who performs laparotomies should own a Balfour. Even better, you should ideally have a small one and a large one.
Retraction of skin edges can be achieved by using Gelpi or Weitlaner retractors.
In a world with increasing bacterial resistance, it is more important than ever to respect asepsis.
Anybody walking into an operating room should wear a cap and a mask. Anybody scrubbing a patient should use sterile gloves, a sterile bowl and sterile gauze, using aseptic technique. Anybody performing surgery should wear a sterile gown and sterile gloves.
Despite what you may hear in your clinic, nobody in the history of mankind has ever suffocated wearing a surgical mask.
Manufacturers make so many different types of suture materials and sizes and needles is to give surgeons options. Make sure you are using the correct suture for the right organ.
Taper needles are typically used for hollow organs. Cutting or reverse cutting needles are mostly used in the skin. And by the way, poliglecaprone 25 (Monocryl) is absolutely, positively not equivalent to polydioxanone (e.g. PDS).
Using gentle technique decreases tissue trauma, speeds up healing and avoids complications.
Fragile organs like the bladder and the intestine should not be rough-handled with thumb forceps. Rough or poor technique can lead to incision dehiscence, increased abdominal adhesions and urethral tears (while placing a urinary catheter in a blocked cat).
Even very smart surgeons forget things. In human medicine, retained or forgotten sponges and instruments are not uncommon. Given the financial, medical and legal consequences, human surgeons have developed techniques and protocols to decrease the incidence of such embarrassing complications.
Techniques include constant awareness, counting sponges before and after surgery and using exclusively lap sponges in the abdomen.
Multiple small steps should be taken to ensure smooth communication with the pet owner:
- Did your client sign a consent form? Does it state exactly what will be done? Does it specify the surgical site? Does it mention the side of the problem (left vs. right)?
- Do you have valid phone numbers to reach the owner?
- Will you write written, detailed, tailored discharge instructions?
- Will you provide emergency phone numbers in case the owner needs help after hours?
Fortunately, most practitioners know their limitations. It is important not to get in over your head, possibly encouraged by a client trying to cut corners. There are armies of lawyers out there who would be more than happy to suck your bank account dry and make your life miserable.
Follow these suggestions to avoid becoming an easy target for them.
Chris Longenecker, a certified veterinary technician in Reading, Pa., contributed to this article.