Tips for Surgeons

1. Be humble and pray: I remember in training an attending saying there is no praying in the operating room. While his intentions were good in that he was meaning to make sure you do a good job and don't rely on God to patch up bad surgical technique, I wholeheartedly believe, yes of course do a proper and thorough job, but do be humble and invite God's favor and blessing upon your work!

2. Be careful with non-emergency big or complicated cases: Take your time to think through if the patient really needs the operation and if you are the best person in the area to do the operation. Be careful when patients are over 70 years of age as this seems to be a significant point of divergence as to how many people age. Some go downhill quite rapidly after reaching 70, others are physiologically strong and look great for another decade or two (think "protoplasm"). Also think when the BMI is above 35 as it can make everything more difficult and risky. If it's a tough or low volume case, review, get good equipment and a good team, and consider using a headlight and Bookwalter.

3. Do not operate on a recent extensive lysis of adhesions within 6 weeks: Avoid potential disasters when surgery is not emergently needed. 

4. Make sure you are in good mental and physical shape: Cancel if you need to, ignore the pushback you will receive by inconveniencing everyone. Patient safety and good outcomes are always of utmost importance.

5. Be careful who your assistant is, and settle the assistant who is too active: Do so gently and patiently.

6. Be mindful of disruptive or grumpy staff -- keep the atmosphere professional and collegial: Don't let them get you upset, and create a safe space for people to speak up.

7. Don't settle for second rate instruments or suture: Go back if necessary to make it right.

8. Be time efficient: Do not waste time -- as much as can be done prior to induction should be done prior to induction. If struggling laparoscopically, consider HALS at 15 minutes, or open at 30 minutes. An efficient and well-done open operation is generally better than a mariginally done "minimally-invasive" operation. Keeping cases under 2 hours is ideal. Over 4 hours not so much.

9. Balance meticulousness with efficiency: Do not be overly compulsive, but take time to see well and suction -- it is better to be in the right plane and be a bit slow and safe than to be hasty and cause bleeding and stress. This applies to elective controlled cases. In unstable and exsanguinating cases, damage-control and speed are or paramount importance.

10. Be careful operating with another attending: If you are not familiar with them and/or they cannot function as an excellent assistant, it is often better to have a good career assistant so there are not too many cooks in the kitchen.

11. When doing an exploration, open if you need to: Biopsy lesions and some specimens may need to be sent fresh for flow cytometry.

12. Never leave the OR with oozing: An infection from hemsotatic gauze is better than a hemorrhagic code! Or you can also pack and leave the abdomen open (but not too tight) or hold pressure.

13. Make yourself and your assistant(s) comfortable: You will do a better job.

14. Make the patient comfortable: Position before going to sleep. Pad and position well. Level the patient from time to time if doing extended dissection when in Trendelenburg.

1. Open repairs:
   - Clearly identify the three named nerves (iliohypogastric, ilioinguinal, and the genital branch of the genitofemoral nerves) and avoid them with any sutures.
   - Do not skeletonize the ilioinguinal nerve.
   - Any small branches from the ilioinguinal and genital banch nerves that must be divided can be divided deliberately (and sparingly).
   - Do not skeletonize the cord, simply reduce/ligate the sac and any cord lipoma.
   - Repair the floor by double breasting the transversalis fascia rather than performing a Bassini.
   - The superior sutures to the conjoint tendon should not be too tight to prevent long-term cutting through the muscle like a seton.
   - Use liposomal marcaine.
   - For the Lockwood repair: if using a small plug, remove the inner petals, and use the anatomy such that the plug is effectively a flat mesh with small overlap -- place the knots inside the plug, and get the Cooper's ligament stitches low down on the plug, and the inguinal ligament stitches "higher up" on the plug.

2. TEP/rTAPP:
   - Use cautery sparingly but do try to keep the field dry for visualization.
   - Do not skeletonize the vas and the gonadal vessels.
   - Keep a layer of fascia and fat on the sidewall laterally to protect the nerves from the mesh.

This is a little tongue-in-cheek. But what I mean is to keep the big picture in view. Years ago when general practitioners did surgery, and general surgeons did a good deal of general medicine, it was more commonplace to keep a patient's overall physiology in mind. Now as I see some surgical residents less involved in the management of their patients due to hospitalist services and work-hour restrictions, it appears that successive generations of surgeons are at risk of becoming like other specialists who have a weaker grasp of a patient's physiology. This clearly applies to pre-op and post-op management, but also applies to intra-op methodology. 

Sometimes as surgeons we have a tendency to think like anatomists and our meticulousness and compulsion can lead to diminishing returns working against physiology. Remember that time in the OR and dissection of tissues all contribute to cytokine release and inflammation. So we want to strike the perfect balance of just enough dissection to get a quality repair, whilst not doing unnecessary maneuvers that may make things "look" better while providing no meaningful benefit and costing us extra cytokine burden and time under anesthesia.

A surgical intern was making rounds with a very experienced faculty surgeon at a university hospital. They were examining a patient who was recovering from a small bowel resection for a Crohn's stricture. In the hallway, the attending asked the intern how one performs a small bowel anastamosis. Not being fully familiar with all the different surgical techniques, the intern, a few steps away from being a medical student sitting through histology lectures, replied that he would do an end-to-end anastamosis with a running long-absorbable monofilament suture. The attending scoffed and replied that he had been performing two-layer repairs for decades with excellent results and couldn't imagine why anyone would trust the repair to one layer, and a running layer at that! The intern nodded respectfully and the two continued on rounds. 

Later that evening, the intern looked up the surgical literature and found a plethora of studies showing no difference in leak rates between the two techniques, and many advocating for a single-layer as it is faster. The intern internally confirmed his suspicions that a technically adequate approximation of the tissues is all that the body needs for its physiologic healing process to join the two pieces of intestine. But the intern wisely did not discount the experience of the senior faculty surgeon and tucked away in his mind that indeed there may be times and situations where a second layer could avoid a leak.

The point of the above story, which has, along many other controversial topics, occured time and again in teaching hospitals, is that, while we do not disregard the paramount importance of various surgical technical maneuvers, we always temper elaborate dissections with the reality of physiology and biochemistry at play in the human body.