Most technically difficult surgical procedure?

[el_pistolero]

Did a quick Google search and while there are some threads discussing "the most technically challenging procedure" or "the most difficult surgical specialty" here in SDN, I figure there's no thread yet asking it from a specific point of view. Apologize if it has been asked before...

So, what do you think is the most technically challenging procedure IN YOUR RESPECTIVE FIELD? The most complex? And what's your personal favourite?

As a lowly MS3, i could think of open AAA repair in vascular, whipple in surg onc/HPB, aneurysm clipping in neurosurg, OPCAB in CT.. Would like to hear the opinions from those guys, as well as other surgeons.
Specifically, though, I'm curious about the procedures in breast, endocrine, and colorectal surgeries...

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[DoctwoB]

There is no good answer to this question because it depends on patient circumstances. A whipple may be more "technically challenging" then a thyroid, but what about a re-op thyroid in someone with prior neck radiation? Inguinal hernias can be routine cases that you take the intern through or disasters where identifying any semblance of normal anatomy is extremely difficult. Some surgeries are higher stakes then others (a CABG or aneurysm repair gone wrong is worse then an inguinal hernia that recurs or a dead testicle), but that doesn't make it more technical per se. As with trying to "rank" most things related to surgery, it's a futile effort.

 

[el_pistolero]

There is no good answer to this question because it depends on patient circumstances. A whipple may be more "technically challenging" then a thyroid, but what about a re-op thyroid in someone with prior neck radiation? Inguinal hernias can be routine cases that you take the intern through or disasters where identifying any semblance of normal anatomy is extremely difficult. Some surgeries are higher stakes then others (a CABG or aneurysm repair gone wrong is worse then an inguinal hernia that recurs or a dead testicle), but that doesn't make it more technical per se. As with trying to "rank" most things related to surgery, it's a futile effort.

Thank you very much for your answer, much appreciated!

Ahh, you see there I'm just a clueless med student... 😀
What about the most complex case(s) you've ever done or scrubbed in? Do you have any favourite procedure(s)?

 

[VisionaryTics]

Revision cosmetic rhinoplasty

 

[Mad Jack]

Probably some of the cardiac procedures they do in utero.

 

[Handinhand]

An arterial switch in a neonate with transposition has to be up there. Those damn coronaries are the size of pencil lead!

 

[mimelim]

An arterial switch in a neonate with transposition has to be up there. Those damn coronaries are the size of pencil lead!

I did one of those two years ago on a 6 day old. The heart was the size of a strawberry. Putting the coronaries back together was one of the most taxing things I've seen in an operating room.

 

[Goro]

Ummm...what happened to the rest of the pelvis??? What necessitates this procedure??

Internal hemipelvectomy

 

[mimelim]

Sounds miserable. Need a microscope for your microscope. What size suture?

We were actually using loupes, no microscope 😳. 6-0 for the aorta/pulmonary, 8-0 for the coronaries. My loupes are only 2.5x, I was scared the entire time that I was going to rip the 8-0 because depending on the light, you couldn't really see it.

I think the most technically challenging surgery I've seen is either that or facial reanimation when I was on my PRS month.

 

[Winged Scapula]

We were actually using loupes, no microscope 😳. 6-0 for the aorta/pulmonary, 8-0 for the coronaries. My loupes are only 2.5x, I was scared the entire time that I was going to rip the 8-0 because depending on the light, you couldn't really see it.

I think the most technically challenging surgery I've seen is either that or facial reanimation when I was on my PRS month.

Yeah, I was going to say pediatric CT, facial reanimation or a Kasai I did as a junior resident.

 

[Pir8DeacDoc]

For people with facial paralysis either from infectious etiology or from meeting an ent and having parotidectomy or ear surgery go wrong

 

[mimelim]

So what are you actually doing? Nerve transfers, muscle renervations?

Nerve grafting. Basically creating symmetrical facial expressions by connecting the functional facial nerve to the muscles on the contra lateral side. Works surprisingly well.

 

[Pir8DeacDoc]

Not all facial re-animation is done with nerve grafts. There is some data about using the ansa cervicalis as a cable graft or branch of CN XII for re-innervation. Generally, at least from my residency experience, the results from those procedures are disappointing. We mainly did an upper lid gold weight (to aid in eye closure and protect the cornea) , as well as a brow lift, and a static sling with gortex to the corner of the mouth to aid in oral competence. Overall the best approach is to not have facial paralysis in the first place, but obviously there are a lot of situations where that's just not possible.

 

[Handinhand]

I'll never do Ortho Onc, but some of the stuff they do is just amazing/terrifying. Im not nearly good enough to go in that direction. Later I'll post some pictures of th Van Nes rotationplasty.

Could I ask what turns you off about Onc? I think it's something I would really like to do but there's not a ton of info about the field, given that it's so small/specialized.

 

[hanky1982]

Ortho Onc is its own science. Understanding Ortho Onc is very complex and often turns off residents who would rather slam in a nail or do a total knee in the same time it takes you to eat lunch. In Ortho we tend to be much more turn-and-burn for lack of better words. Usually high volume cases that are fairly straight forward with very good patient outcomes. Ortho Onc is pretty much the exact opposite of that. Huge volume of information to learn through the microscope combined with very complex cases. Hemipelvectomies, distal femoral replacements, total femurs, etc. are VERY long cases (or can be) where the patients are unfortunately behind the eight ball.

Also there is a huge difference in expectations and outcomes. For instance, a 23 year old who needs an ACL reconstruction so they can get back to doing triathlons can do very well. It brings a lot of satisfaction to see them do well and is a constant reminder of why we do what we do. Now imagine a 23 year old who is staring at cancer in the face and undergoes a hemipelvectomy (where you loose half your pelvis and usually your leg). They obviously won't have the same outcome. We like to fix things, and we can't really fix cancer. We can do palliative procedures or others where we cut the cancer out, but we can't fix it. We (generalization) usually like healthy and happy patients who do great from what we do, not those that are very sick, dying or unable to do well from our procedures.

I think (again speaking generally) the amount of knowledge needed to identify common Ortho Onc diagnoses combined with the super complex cases with low functional outcomes turns the vast amount of residents away. It can be depressing, very depressing; but the procedures are downright wicked.

 

[dienekes88]

Thank you very much for your answer, much appreciated!

Ahh, you see there I'm just a clueless med student... 😀
What about the most complex case(s) you've ever done or scrubbed in? Do you have any favourite procedure(s)?

The most technically challenging cases are challenging for different reasons, and you won't even realize the complexity until you get more immersed in the field. Even then, when you are assisting, it is one thing. When you are performing the operation, it is something completely different.

Off pump CABG is incredibly difficult from a technical standpoint, but not every OPCAB is created equal. Revascularizing the anterior wall is actually the easiest, i.e. laying down your LIMA-LAD, but it is the patient's life line (only thing that separates us from the cardiologists), so you really can't mess it up. Doing grafts to the OMs off pump is incredibly difficult, because you can't lift the heart too much to expose it very well, so it is partly hidden by the retractor and the left chest. You are literally sewing in a hole. OPCAB looks real tricky when you are assisting. However, when it's actually you trying to do the toe stitch in the LIMA-LAD, then suddenly sewing on the beating heart feels like you are operating during an earthquake.

Something like a valve sparing aortic root replacement or a complex mitral valve repair require an excellent knowledge of the anatomy and a very keen eye for the geometry of the valve. The difference could be between having a repair last forever and coming back to do a redosternotomy and replacement in a few years. Thoracoabdominal aortic surgery and aortic arch surgery can be very tricky with respect to pump management, neuroprotection, circulatory arrest, unforgiving tissues (Marfan, Loeys-Dietz, Ehlers-Danlos IV...), etc. Other incredibly difficult operations: Redo-sternotomy with live bypass grafts. Redo-sternotomy and heart transplantation in a patient with previously repaired complex congenital heart lesion.

Most of complex congenital heart surgery is not only incredibly challenging from a technical standpoint but also requires intellectual gymnastics.

 

[RJGOP]

I'm not a surgeon, but I'd imagine complex facial reconstructions (due to trauma) are extremely difficult and tedious.

 

[el_pistolero]

Thanks everyone! Lots of great inputs in this thread (in fact, all of the comments here are terrific!) and I really really appreciate it! I think it's pretty clear to me now that the technical difficulty of ANY surgical procedures has LOTS to do with the patient's conditions and the surgeon's experience and expertise.

The most technically challenging cases are challenging for different reasons, and you won't even realize the complexity until you get more immersed in the field. Even then, when you are assisting, it is one thing. When you are performing the operation, it is something completely different.

Off pump CABG is incredibly difficult from a technical standpoint, but not every OPCAB is created equal. Revascularizing the anterior wall is actually the easiest, i.e. laying down your LIMA-LAD, but it is the patient's life line (only thing that separates us from the cardiologists), so you really can't mess it up. Doing grafts to the OMs off pump is incredibly difficult, because you can't lift the heart too much to expose it very well, so it is partly hidden by the retractor and the left chest. You are literally sewing in a hole. OPCAB looks real tricky when you are assisting. However, when it's actually you trying to do the toe stitch in the LIMA-LAD, then suddenly sewing on the beating heart feels like you are operating during an earthquake.

Something like a valve sparing aortic root replacement or a complex mitral valve repair require an excellent knowledge of the anatomy and a very keen eye for the geometry of the valve. The difference could be between having a repair last forever and coming back to do a redosternotomy and replacement in a few years. Thoracoabdominal aortic surgery and aortic arch surgery can be very tricky with respect to pump management, neuroprotection, circulatory arrest, unforgiving tissues (Marfan, Loeys-Dietz, Ehlers-Danlos IV...), etc. Other incredibly difficult operations: Redo-sternotomy with live bypass grafts. Redo-sternotomy and heart transplantation in a patient with previously repaired complex congenital heart lesion.

Most of complex congenital heart surgery is not only incredibly challenging from a technical standpoint but also requires intellectual gymnastics.

Thank you for your excellent answer! Are you in CT? Unrelated with this thread, but I have a couple of questions about OPCAB and open valve repair surgery..
I understand that numerous studies haven't yet proven OPCAB to be superior to on-pump CABG. However, here, in my country (a third-world country), OPCAB is still frequently performed on the basis of cost alone. So, how often is it performed in your institution and in the US in general?
Regarding open valve surgery.. apparently percutaneous valve repair is on the rise. For now it is only performed for high-risk patients, but with rapid technological advancements in interventional devices, I'm actually pretty convinced it could replace open heart surgery as the first-line treatment for valvular heart diseases. Any chance US CT residencies would incorporate transcatheter valve repair training to their programs?

Apologize for my poor English...

- el_pistolero

 

[neusu]

Skull base tumors that wrap around cranial nerves, posterior circulation aneurysms, and vertebral column resections tend to be technically challenging in our field.

 

[dienekes88]

Thanks everyone! Lots of great inputs in this thread (in fact, all of the comments here are terrific!) and I really really appreciate it! I think it's pretty clear to me now that the technical difficulty of ANY surgical procedures has LOTS to do with the patient's conditions and the surgeon's experience and expertise.

Thank you for your excellent answer! Are you in CT? Unrelated with this thread, but I have a couple of questions about OPCAB and open valve repair surgery..
I understand that numerous studies haven't yet proven OPCAB to be superior to on-pump CABG. However, here, in my country (a third-world country), OPCAB is still frequently performed on the basis of cost alone. So, how often is it performed in your institution and in the US in general?

Actually, studies generally favor on pump CABG over OPCAB:
GOPCABE
CORONARY
ROOBY

At most of the institutions where I rotate, it is <10%, and many of those are MIDCAB. There is one hospital where we rotate that is probably 60-70% off pump. Overall in the United States, about 20% of coronaries are done off pump. The peak was in the early 2000's.

Regarding open valve surgery.. apparently percutaneous valve repair is on the rise. For now it is only performed for high-risk patients, but with rapid technological advancements in interventional devices, I'm actually pretty convinced it could replace open heart surgery as the first-line treatment for valvular heart diseases. Any chance US CT residencies would incorporate transcatheter valve repair training to their programs?

Apologize for my poor English...

- el_pistolero

Perc valves aren't just "apparently" on the rise. They are on the rise.

PARTNER IIA and SURTAVI are bringing TAVR to intermediate risk groups. However, TAVRs are restricted in the Medicare Coverage Decision to certain sized practices that involve heart teams, which require involvement of a cardiac surgeon. This is not the case in other parts of the world.

Never bet against technology. Having said that, TAVRs at this point are bioprosthetic. It is well known that bioprosthetic valves have a certain failure rate over time, and patients younger than 65 are recommended to undergo replacement with a mechanical valve (Mayo data suggests that patients up to age 70 should be receiving mechanical valves). Implanting mechanical valves will be a major technical hurdle given access issues given that even the bioprosthetic devices, which can be crimped down considerably, can have somewhat tricky access issues. In those cases, surgeons will have to adapt to new operations to facilitate delivery: transaortic, transapical, and iliac conduits.

Some US residencies incorporate TAVR (transcatheter valve REPLACEMENT not repair) into the training program, though it seems like the main skills are developed during a super-fellowship for now. I don't know the extent to which wire skills are incorporated into cardiac residencies around the country. In any event, part of it is resident dependent. Some folks just aren't interested in the cath lab. I don't know if it will replace open heart surgery as first-line therapy, though it will no doubt take a big bite out of the pie as it were. Just as there are still patients who come to CABG without getting stents, there will be patients coming to AVR having never gotten a TAVR. Cardiac surgeons just can't be left behind as the technology develops. Cardiac surgeons are doing more and more to compete: minimally invasive techniques, valve repair, decreasing transfusion rates, hybrid operations.

 

[rigid]

Skull base tumors that wrap around cranial nerves, posterior circulation aneurysms, and vertebral column resections tend to be technically challenging in our field.

👍

 

[Perrin]

An arterial switch in a neonate with transposition has to be up there. Those damn coronaries are the size of pencil lead!

My son had this done a few months ago at a week old. It went off without a hitch, but I can't fathom the concentration and dexterity it takes to work at that scale. Thank you.

 

[Buzz Me]

Agree with the arterial switch operation in a premature infant weighing < 5 lb. Tiny heart, tiny coronaries, no margin for error.

 

[thedrjojo]

No love for a liver transplant on a cirrhotic with portal Htn, massive collaterals, and an Inr of 4.5 and platelets of 20?

 

[caffeinemia]

Robotic trancranial vaginoplasty

or alternatively, Robotic transvaginal cranioplasty.

(FYI, great joke from UCSD General Surgery - center of robotic surgery excellence)