Clinical Pearls Surgery

OB/GYN News,  March 15, 2000  by Bruce L. Flamm

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One of my mentors used to say, "If you haven't had any complications, you have not done much surgery." The point of this comment is that some complications are unavoidable. On the other hand, the incidence of certain complications can be lowered.

The first two pearls presented in this column deal with staying out of trouble in the operating room. The final tip deals with getting out of trouble after a complication occurs.

* If it's not bleeding, don't make it bleed.

I take credit for this pearl and proudly call it "The first rule." Residents who scrub with me learn it quickly.

Have you ever assisted on a cesarean section and smiled with contentment as the first row of sutures results in a completely hemostatic closure of the uterine incision?

But then your eagle-eyed colleague spies a microscopic spot of blood. Unsatisfied with the situation, he or she asks for another suture and plunges the needle deep into the uterine wall. Your contentment turns to despair as the real bleeding begins. If all goes well, another suture or two will stop the flow.

In other cases you and your colleague will take turns placing sutures in different directions until the situation is finally almost as good as it was just before the first rule was broken.

This "pearl" is a warning to think for a moment before reaching for a suture or the electrocautery when a tiny spot of blood is seen. The two questions to ask yourself are, "Is this amount of bleeding significant?" and "Will what I am about to do likely make the situation better or worse?"

* Always be a little nervous in the operating room.

I learned this tip 20 years ago from gynecologic oncologist Philip J. DiSaia. He seldom mentioned this to interns since it was clear they were nervous all the time. But by the 4th year of residency most of us felt fairly confident in the operating room.

In the middle of a case, Dr. DiSaia would often ask, "Are you nervous?" If you said "yes," he would be pleased, but if you said "no," he'd point out that you should be.

The point he was making is that you should always be on your toes in the operating room. A little bit of fear can be a healthy thing.

* Don't hesitate to call for assistance.

During our training we learn that the uterus and adnexa dwell in close proximity to portions of the gastrointestinal and genitourinary systems. In spite of all the precautions we take, even the most cautious ob.gyn. will occasionally enter bowel, bladder, or ureter.

Most of us are pretty good with our hands and might therefore be tempted to fix these problems ourselves. But with the exception of small bladder lacerations located remote from the trigone it is probably best to avoid this temptation.

True, you might perform a repair that would rival that of any general surgeon or urologist. But if something goes wrong, someone will surely ask, "When was the last time you performed this type of repair?" It would be difficult to explain that you did it once or twice before, during your residency many years ago.

So don't hesitate to call on a surgical colleague who has more experience doing these repairs.

DR. BRUCE L. FLAMM is area research chairman and a practicing ob.gyn. at the Kaiser Permanente Medical Center in Riverside, Calif.

COPYRIGHT 2000 International Medical News Group
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