How often do you get complex cases and what does a complex case look like?
Is there a scientific process that goes with surgery or is it rote?
"The only routine surgery is surgery that is done on someone else......and it's never just 'someone else.' It's always someone's wife, someone's dad, someone's friend." - Don't know who told me this, but it's true. There is no such thing as simple - even if it's something that you've done hundreds of similar cases, every surgery/procedure has risks. "Easy" cases easily become complex in a myriad of ways:
1. Surgical planning/Preoperative
a. Patient comorbidities are always increasing - and it's never the patient's fault and in their minds, it's up to you the surgeon to offer the same surgery to the obese, smoking, anticoagulated 85 year old as to the marathon-running 20 year old.
b. Timing can be challenging. Sure, it's a colon cancer - but wait, is it a newly diagnosed near obstructing left sided colon cancer? So, we going to stent or resect first, or at all? Will the stent be a bridge or palliation? And are you sure it's only near obstructing? Are those mets? Maybe, but too small to biopsy. What do we do now? What about that EF of 20%? Or oh, it's diverticulitis - maybe the scan looks terrible and the patient looks fine - you taking them to the OR or you watching? Or the scan looks ok but man, the heart rate's higher than you want and is that actually rebound or are they really that tender? Watch or call your attending in at 0200 for a negative exploration? You got to do the right operation for the right person at the right time to have the 'right' outcome.
c. Simultaneously too much and too little information. We are inundated with images, reports, labs, consultant opinions, and ever-changing guidelines. At the same time, there is always that chance you'll miss that key lab or report or that some photocopied sheet in some back-of-chart hidey hole. The patient will deny any knowledge of any medical problem or surgery or medication,
2. Intraoperative
a. Anatomy, anatomy, anatomy - That 'straightforward' gallbladder becomes worryingly complex when you have aberrant anatomy. And every sigmoid I start thinking about the ureter from the moment we start...
b. Inflammation - I've done lap appendectomies in sub-15minutes....and in >2 hours. Gallbladders and appendices are often thought of as 'intern' cases - but add in lots of inflammation and days or weeks of neglect or infection and it's enough to make even seasoned attendings grit their teeth
c. System dynamics - it takes lots of moving parts to get a patient safely to and through surgery. One of those parts fail, and you have unexpected complexity on your hands. Can't find the right stapler? Great, hand sewn anastomosis it is. What do you mean you can't find the laparoscopic needle drivers - how am I going to Graham patch this now? No, I need that clip and I need it now, we're bleeding.
3. Post operative
a. Patient motivation/compliance - sometimes the most 'complex' thing about a case is getting the patient to walk/eat/take their meds.
b. Nursing care - Getting labs, I/Os, appropriate notifications at the appropriate times and all of this when nurses can be 'floating' or caring for 8 patients or have never seen this surgery or this line or tube before is always complex.
In terms of 'big whacks' - it depends on the service. Are you talking vascular, gen surg, thoracic?
As a chief, on my most recent service, I operated 3-7 days a week and usually 1 'big whack' (up to 5 'big whacks'....it was a long day) per day. Typically thought of cases like this are whipples, hepatectomies, LARs, etc.
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Don't know what you mean by 'scientific process' or rote. Usually have heard 'scientific process' meaning more make and test a hypothesis, etc. There is, of course, a great deal of 'scientific' research that goes on in surgery. Lots of good (and not so good) journals.
My goal for surgeries is to do it the same way, every time, and have it go perfectly every time. But, as mentioned, anatomy, comorbidities, and many other factors require constant attention and innovation to get the same great results on different patients.
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