Rifat Latifi

Surgical
Decision Making
Beyond the Evidence
Based Surgery

123
Surgical Decision Making
Rifat Latifi

Surgical Decision
Making
Beyond the Evidence Based Surgery
Rifat Latifi
Department of Surgery
Westchester Medical Center,
New York Medical College
Valhalla, NY, USA
Department of Surgery
University of Arizona
Tucson, AZ, USA

ISBN 978-3-319-29822-1 ISBN 978-3-319-29824-5 (eBook)

DOI 10.1007/978-3-319-29824-5

Library of Congress Control Number: 2016936679

© Springer International Publishing Switzerland 2016

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To Ronald C. Merrell, MD, FACS a mentor, collaborator, and a
friend, whose uncompromising vision to make the world better
and dedication to care for sick and injured patients have
inspired and guided me over the years to make some
of the best decisions I have made.
Rifat Latifi, MD, FACS
Foreword

For decades, various urban legends have remarked about the ability (or lack
of ability) of surgeons to make rapid decisions based on little data, to then
reflect upon these decisions, and to learn from their successes and their mis-
takes. Surgical decision-making always starts with the ability to make correct
diagnoses regarding a patient’s illness and then to decide if an intervention is
indicated either alone or as part of a continuum of care, including medical
therapies. Medicine is truly a team “sport,” but, fundamentally, each patient
deserves to have an individual (captain model): to provide an overall view, to
bring together consultants from many fields when necessary, and to present
fully the pros and cons of the decided intervention, the risks and potential
complications of such intervention, and the consequences of nonintervention
to the patient for his/her decision as to what they wish done. Underlying this
process of surgeon-patient interaction and decision-making is the require-
ment for up-to-date clinical knowledge regarding best practices, clinical
knowledge, and judgment.
The evolution of surgical clinical knowledge has not always proceeded in
a stepwise fashion. Historically, surgeons learned from each other by appren-
ticeship through observing operations and inpatient/outpatient perioperative
care. More experienced surgeons would travel long distances to learn new
techniques that were being introduced by another master surgeon. This
method evolved into the publication of an individual surgeon’s results in
treating a variety of surgical problems in patients, presenting such results in
a professional public forum, and defending his/her various surgical
approaches. Surgical societies and organizations were formed to exchange
ideas. This was an attempt to improve surgical decision-making from the
eighteenth through the twentieth centuries. With time, it became apparent
that greater knowledge could be obtained by understanding how “an institu-
tion” handled certain patients with different diagnoses and how the patients’
outcomes varied based upon their comorbidities and the surgical decisions
made before, during, and after operations. These retrospective studies taught
us “associations” but not causations.
Later, institutions with large clinical volumes created their own prospec-
tive databases from which multiple questions could be answered when the
clinical volumes were large enough to provide some statistical validity.
Interspersed over time have been prospective, randomized, clinical trials in
which surgical therapies were instituted based upon randomization of the
patients, and certain predetermined outcomes were then measured. All of

vii
viii Foreword

these types of studies taken together provide a base of clinical knowledge that
assist the decision-making process.
Yet, each patient is an individual with different genetic and environmental
backgrounds, ages, genders, comorbidities, socioeconomic and cultural cir-
cumstances, and goals for their lives. In addition, the disease processes
patients encounter have different durations, severities, prognoses, and poten-
tial outcomes. Taken together, the complexities of human diseases in patients
make physician decision-making difficult despite knowledge of basic sci-
ences and current best practice guidelines. This book, written and edited by
Dr. Latifi and others, provides an important and timely resource for surgical
decision-making because it defines and recognizes the many internal and
external factors that influence certain surgical decisions for better or worse.
Several points made in this book deserve emphasis. While each operation
should have a surgeon’s standard approach, many factors that occur during
an operation may alter that approach, requiring surgeon flexibility in tech-
niques used and goals to be obtained. Recognizing that each operation is
comprised of a team, we agree with Dr. Latifi that the surgeon’s leadership
ability and his/her ability to communicate effectively the tasks at hand to
other members of the team are critical to a successful operation. As described
by Dr. Latifi in Chap. 1, managing resources (including time); directing,
training, and supporting others; and coping with pressure are some of the
critical components of the surgeon’s leadership ability. It is that ability that
usually determines the patient’s successful outcome.
This book nicely outlines the generic components of the surgeon’s leader-
ship and decision-making abilities and the factors that influence them. It also
defines difficult clinical situations—from sepsis and trauma to elective or
urgent operations for a variety of pathologic conditions—and provides guid-
ance based on the best current clinical evidence. An expert surgical leader
combines such guidance with focused training, proper communication for
team members, avoidance of intraoperative distractions, and a proper mental
state. These attributes lead to optimal surgical decision-making, which leads
to optimal patient outcomes.

Maureen D. Moore, M.D.

John M. Daly, M.D., F.A.C.S., F.R.C.S.I.
Prologue

Complex surgical procedures carry significant risks and complications.

Despite the most conscientious preoperative preparations, surprising events
may still occur. If the operation takes an unplanned turn, the surgeon has to
make difficult decisions. An absolute must is continuous awareness of the
patient’s physiologic status—including fluid status, urine output, use of blood
and blood products, bleeding, current medications (such as vasopressors),
and biochemical endpoints of resuscitation. Even when the operation is going
well, the biochemical profile of the patient may not be optimal or even satis-
factory, which may directly affect the outcome. In addition, the surgeon must
recognize his/her own physiologic status; if tired, for example, cutting cor-
ners and making major errors are much more likely. In this book, we address
these and other elements that are important for the intraoperative decision-
making process. How do we as surgeons make intraoperative decisions under
what can be inauspicious conditions? That question has not been answered
appropriately in the literature. When a patient is dying in our hands from
bleeding that we cannot control, when irreversible metabolic shock does not
respond to anything that we do, when new problems emerge out of the blue,
when things go alarmingly wrong: In such dire moments during a carefully
planned operation, how do we decide what to do next and how should we
overcome our own fear? Many of us make decisions that later on we cannot
explain, that we cannot say why we did things a certain way. Usually these
are decisions made on the basis of a “gut feeling” or “intuition” or the “gray
hair effect,” among other attributes. Yet, the anatomy of such decisions is of
great importance to all surgeons and to those who work with surgeons. In this
book, we will review theoretical as well as any objective data that we as sur-
geons use to make intraoperative decisions. The decision we make, often
with very limited amount of information, will decide between someone living
or dying. How do we make decisions in split seconds to take someone to the
operating room now as opposed to a bit later? How do we decide to operate
on a dying patient without a CT scan and no laboratory data, just based on the
fact that he or she is in shock, just to find liters of blood in the abdomen, a torn
vena cava, liver, spleen, or some major blood vessel?
When the patient is dying in the operation room, everyone panics, but the
surgeon reaches in the open abdomen and compresses the aorta between his/
her fingers, in order to let the team catch up. Is there a molecular explanation
for this? Non-surgeons have created and put forth many theories and hypoth-
eses in the literature. But our collective firsthand experience as surgeons

ix
x Prologue

points to a combination of factors contributing to our intraoperative decision-

making process. These factors include education, clinical know-how, men-
toring, and the creativity and excellence that come with long practice and
with strict discipline.
The aim of this book is to evaluate the current literature on the subject and
to explore what is known and, more importantly, what is not known about
this process. Frankly, while the surgeon may be considered the “captain of
the ship,” there are many aspects of the surgical process that have recently
received major public interest, and these aspects are not in the hands of sur-
geons at all. Involvement of these other disciplines—mainly administration,
regulations, insurance, and government—has become a priority in many
cases. Often, we forget that surgery is both a science and an art, and surgeons
are the conductors of a symphony that truly needs to run perfectly. There are
other differences between surgeons and the physicians in many other clinical
disciplines. While I was a medical student at the University of Prishtina,
Kosova, Professor of Surgery Dr. Gazmend Shaqiri would tell me and others:
“When a patient dies in a medical ward, he or she dies from the disease; how-
ever, when the patient dies in surgical ward, the patient dies from the surgery,
or more importantly, from the decisions made by the surgeon.” This may be
a decision by the surgeon to operate or not to operate. While surgical proce-
dures are far more complex than one individual’s decisions during surgery,
there are elements to this small surgical microcosm that add additional pres-
sure on the surgeon and how he or she copes with this decision. Over the
years, I have been reminded often of the consequences of making a decision,
both wrong and right.
When I started this book, I thought it would be a single-author book,
somewhat of a real rarity these days. However, as the months were passing
by and the project was not being completed, I saw the real reason why: I
really wanted to have other opinions on the matter.
I am hoping this book will serve as a good reference or even inspiration for
others to explore the subject further. I did not and do not envision this as a
book of algorithms and strict protocols, although in a few chapters such sug-
gestions have been made. I wanted myself and the other chapter authors to go
a bit “beyond” the surgical decision-making process and inside the surgeon
as being. I wanted to see if we can explore what makes the surgeon’s brain
and heart “buzz” and continue to work nonstop for many hours.
While at Yale University, before the regulation of working hours for resi-
dents, one of my vascular attendings and I operated basically nonstop from
Friday morning until Sunday afternoon, with a few “power naps” between
cases. I thought I was doing “fine” until I went to start my car. Now that the
adrenaline was gone, I could not even drive myself home. I was completely
exhausted and could not keep my eyes open. I had to call my wife Drita to
come pick me up and take me home. How was I able to go on for so long
while we were operating and yet I could not drive myself the ten miles home?
The anatomy and the physiology of the surgeon are addressed in Chapters 1
and 2. We cannot forget that we are not super creatures, despite what every-
one may think of us; we are all just human.
Prologue xi

Have you ever seen a surgeon emotionally “naked,” burnt out, exhausted,
disillusioned, and simply tired of everything? Even worse, most of us do not
talk about the matter until it becomes a real problem. Not a pretty picture by
any means. At this point, you may be thinking of friends and colleagues who
committed suicide or were on the brink of doing so. Drug and alcohol abuse,
difficulties with personal relationships, multiple divorces, or simply becoming
obese and not caring for oneself are not uncommon among surgeons. We are
just human, and yet, like many other professions, we still have to get up and go
to work and make some incredible decisions that will affect our patients and
their families and, of course, us, and we have to live with those decisions.
I hope this book will explain some of those decisions and how we make
them, but, most importantly, how we live with the decisions we make and
how we improve constantly.

Valhalla, NY, USA Rifat Latifi, M.D., F.A.C.S.

Spring 2016
Contents

Part I The Complexity of Surgical Decisions: Setting the Stage

1 Intraoperative Surgical Decision-Making: Is It Art

or Is It Science or Is It Both? ...................................................... 3
Rifat Latifi
2 The Anatomy of the Surgeon’s Decision-Making ..................... 9
Rifat Latifi
3 The Role of Physiology and the Surgeon’s State of Mind
in the Surgical Decision-Making Process ................................... 17
Rifat Latifi
4 Surgeons and Pilots: What Do We Have in Common?............. 25
Rifat Latifi
5 A Surgeon’s Decisions as the Leader of an Interdisciplinary
Action Team .................................................................................. 31
Rifat Latifi, John A. Stroster, and Katherine E. Center
6 Planning and Preparing for the Operation: Guidelines
and the Evidence-Based Decision Tree....................................... 41
Wilson Dario Rodríguez Velandia, Patrizio Petrone,
Hans Fred García Araque, Soraya SMolero Perez,
and Corrado Paolo Marini
7 The Decision-Making Process in Sepsis and Septic Shock ....... 59
Michelle H. Scerbo and Laura J. Moore
8 Intraoperative Endpoints of Resuscitation ................................ 81
Hans Fred García Araque, Patrizio Petrone,
Wilson Dario Rodríguez Velandia, and Corrado Paolo Marini

Part II Difficult Clinical-Based Surgical Decisions

9 Surgical Decision-Making Process and Damage Control:

Current Principles and Practice ................................................. 95
Ruben Peralta, Gaby Jabbour, and Rifat Latifi
10 Reoperative Surgery in Acute Setting: When To Go Back? .... 103
Elizabeth M. Windell and Rifat Latifi

xiii
xiv Contents

11 Surgical Decision-Making Process and Definitive

Abdominal Wall Reconstruction ................................................ 111
Rifat Latifi, Ruben Peralta, and John A. Stroster
12 Dealing with the Most Difficult Situations
in Abdominal Surgery ................................................................. 119
Rifat Latifi and John A. Stroster
13 Trauma Surgeon Decision-Making: Surviving
Outside the Realm of the Evidence Based ................................. 133
Samir M. Fakhry
14 Management of the Most Difficult Perioperative
and Technical Challenges in Abdominal Transplantation ....... 141
Chirag S. Desai, Yong Kyong Kwon, Mark R. Laftavi,
Vaughn Whittaker, and Rainer W.G. Gruessner
15 Dealing with the Most Difficult Situations:
A Point of View from a Surgical Oncologist .............................. 157
Alberto R. Ferreres
16 Difficult Decisions in Cardiothoracic Surgery:
Acute Cardiogenic Shock ............................................................ 165
Zachary P. Baker, Jack B. Keenan, and Zain Khalpey
17 Dealing with the Most Difficult Situations
in Pediatric Surgery ..................................................................... 177
Oliver S. Soldes
18 A Surgeon’s Thought Process in the Management
of Burn Patients............................................................................ 183
Gary A. Vercruysse and Walter L. Ingram
19 Decision-Making in Reconstructive Surgery ............................. 197
Ethan E. Larson, Tolga Tűrker, and Samuel Skovgaard
20 Decision-Making in Reconstructions for Traumatic Defects
in Extremity Surgery ................................................................... 213
Tolga Tűrker and Ethan E. Larson

Part III Special Issues in Surgical Decision Making

21 The Surgeon’s Burnout: How to Deal with It ............................ 227

Bellal Joseph and Tahereh Orouji Jokar
22 The Surgeon’s Response to a Patient’s Death ........................... 233
Terence O’Keeffe
23 When Should Surgeons Quit Operating? .................................. 239
Stanley J. Dudrick
Contents xv

Part IV The Final Word

24 Final Thoughts on Surgical Decision-Making ........................... 253

Rifat Latifi and Fortesa Latifi

Index ...................................................................................................... 257

Contributors

Hans Fred Garcia Araque, M.D. Hospital Militar Central, Bogotá,

Colombia
Westchester Medical Center University Hospital, Valhalla, NY, USA
Department of Surgery, New York Medical College, Valhalla, NY, USA
Zachary P. Baker, M.D. Department of Surgery, Banner University Medical
Center, Tucson, AZ, USA
Katherine E. Center, Ph.D. Department of Obstetrics and Gynecology,
University of Arizona College of Medicine, Tucson, AZ, USA
Chirag S. Desai, M.D. Medstar Georgetown University Hospital, Medstar
Georgetown Transplant Institute, Washington, DC, USA
Stanley J. Dudrick, M.D., F.A.C.S. The Commonwealth Medical College,
Scranton, PA, USA
Misericordia University, Dallas, PA, USA
Yale University Medical School, New Haven, CT, USA
Naugatuck, CT, USA
Samir M. Fakhry, M.D., F.A.C.S. Department of Surgery, Medical
University of South Carolina, Charleston, SC, USA
Alberto R. Ferreres, M.D., Ph.D., J.D., M.P.H., F.A.C.S. (Hon) Department
of Surgery, University of Buenos Aires, Buenos Aires, Argentina
Rainer W.G. Gruessner, M.D. Transplant Center and Department of
Surgery, Upstate Medical University, Syracuse, NY, USA
Walter L. Ingram, M.D. Department of Surgery, Emory University School
of Medicine, Atlanta, GA, USA
Emory/Grady Burn Unit, Grady Memorial Hospital, Atlanta, GA, USA
Gaby Jabbour, M.D. Division of Trauma Surgery, Department of Surgery,
Hamad Medical Corporation, Doha, Qatar
Tahereh Orouji Jokar, M.D. Department of Surgery, University of Arizona
Medical Center, Tucson, AX, USA
Bellal Joseph, M.D. Department of Surgery, University of Arizona Medical
Center, Tucson, AZ, USA

xvii
xviii Contributors

Jack B. Keenan, B.S., B.S.H.S. College of Medicine, University of Arizona,

Phoenix, AZ, USA
Zain Khalpey, M.D., Ph.D., F.E.T.C.S. Department of Surgery, Banner
University Medical Center, Tucson, AZ, USA
Yong Kyong Kwon, M.D. Medstar Georgetown University Hospital,
Medstar Georgetown Transplant Institute, Washington, DC, USA
Mark R. Laftavi, M.D. Transplant Center and Department of Surgery,
Upstate Medical University, Syracuse, NY, USA
Ethan E. Larson, M.D. Department of Surgery, University of Arizona,
Tucson, AZ, USA
Fortesa Latifi, B.S. Department of Surgery, University of Arizona, Tucson,
AZ, USA
Rifat Latifi, M.D., F.A.C.S. Department of Surgery, Westchester Medical
Center, New York Medical College, Valhalla, NY, USA
Department of Surgery, University of Arizona, Tucson, AZ, USA
Corrado Paolo Marini, M.D., F.A.C.S. Department of Surgery, Westchester
Medical Center University Hospital, New York Medical College, Valhalla,
NY, USA
Laura J. Moore, M.D. Department of General Surgery, The University of
Texas Health Science Center at Houston, Houston, TX, USA
Texas Trauma Institute, Memorial Hermann Hospital, Houston, TX, USA
Terence O’Keeffe, M.B., Ch.B., B.Sc., F.R.C.S., M.S.P.H.,
F.A.C.S. Department of Surgery, Banner University Medical Center, Tucson,
MZ, USA
Ruben Peralta, M.D., F.A.C.S. Department of Surgery, Division of Trauma
Surgery, Hamad General Hospital and Hamad Medical Corporation, Doha,
Qatar
Soraya SMolero Perez, M.D. Department of Surgery, Westchester Medical
Center University Hospital, New York Medical Center, Valhalla, NY, USA
Patrizio Petrone, M.D., M.P.H., M.H.A., F.A.C.S. Department of Surgery,
Westchester Medical Center University Hospital, New York Medical College,
Valhalla, NY, USA
Michelle H. Scerbo, M.D. Department of General Surgery, The University
of Texas Health Science Center at Houston, Houston, TX, USA
Samuel Skovgaard, B.A. University of Colorado, Denver School of
Medicine, CO, USA
Department of Plastic and Reconstructive Surgery, University of Colorado
School of Medicine, Aurora, CO, USA
Contributors xix

Oliver S. Soldes, M.D., F.A.C.S., F.A.A.P. Division of Pediatric Surgery,

Akron Children’s Hospital, Akron, OH, USA
John A. Stroster, Ph.D. Department of Surgery, Banner University Medical
Center, Tucson, AZ, USA
Tolga Tűrker, M.D. Department of Orthopaedics, Banner University
Medical Center, Tucson, AZ, USA
Wilson Dario Rodriguez Velandia, M.D. Department of Surgery,
Westchester Medical Center University Hospital, New York Medical College,
Valhalla, NY, USA
Complejo Hospitalario Universitario de Ferrol, A Coruña, Spain
Gary A. Vercruysse, M.D. Department of Surgery, Banner University
Medical Center, University of Arizona, Tucson, AZ, USA
Vaughn Whittaker, M.D., F.A.C.S. Transplant Center and Department of
Surgery, Upstate Medical University, Syracuse, NY, USA
Elizabeth M. Windell, D.O. Department of Trauma, Surgical Critical Care,
and General Surgery, Legacy Emanuel Medical Center, Portland, OR, USA
 Part I
The Complexity of Surgical Decisions:
Setting the Stage
 Intraoperative Surgical Decision-
Making: Is It Art or Is It Science 1
or Is It Both?

Rifat Latifi

sophisticated machines ever created by humans,

Introduction and yet the pilots are supported by powerful com-
puters and, frequently, have full support from air
The surgical decision-making process is complex, traffic control on the ground. Although surgeons
and optimal outcomes require an integration of have a team with them in every operation, they
evidence, inference and a wealth of experience [1]. themselves make the most important decisions;
As noted elsewhere, naturalistic and complex they are in charge of carrying out the procedures.
problem-solving theories attempt to explain how Once in perfect condition, the human machine on
high-risk professionals make decisions, but such the operating table might be in grave condition,
theories lump surgeons in with other high-risk pro- and may not respond to any intervention.
fessionals whose decisions demand superb accu-
racy, such as pilots and nuclear plant scientists [2].
Later in this book (Chap. 4), I will compare The Checklist
surgeons and pilots, and how these two highly-
intense professions share a few common ele- The checklist is a stepwise model that has been
ments in their daily routine, such as the use of successfully applied for the years on aircraft, as
checklists before the commencement of their well as most sophisticated machines. When
respective procedures. Both the commercial pilot removing a diseased organ, dividing or bypassing
and the surgeon continuously monitor their cur- the stomach for bariatric surgery, or restoring the
rent situations, preventing and resolving crises, blood supply to the tissue at risk, surgeons have
but the key difference is that pilots utilize stan- much looser models for intraoperative steps.
dardized checklists to guide them through an There are only few operations where we strictly
emergency, while the surgeon is instead more adhere to the consistent execution of each step of
heavily reliant on their experience, training, and the procedure every time. An example of an oper-
intuition. Pilots have in their hands the most ation that has been standardized for the most part
is an open coronary artery bypass. For the major-
ity of other procedures, the surgical steps for each
R. Latifi, M.D., F.A.C.S. (*) operation are instead created, modified, and exe-
Department of Surgery, Westchester Medical Center,
cuted by the individual surgeon, often being mod-
New York Medical College, 100 Woods Road,
Valhalla, NY 10595, USA ified based on the patient physiology and/or
anatomy. Even for operations such as the chole-
Department of Surgery, University of Arizona,
Tucson, AZ, USA cystectomy, one of the most routine operations
e-mail: rifat.latifi@gmail.com performed by general surgeon, there are variations

© Springer International Publishing Switzerland 2016 3

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_1
4 R. Latifi

on the instruments that are used, and subsequently differences in surgical approaches, including
the technique that is applied. To this end, each institutional, geographical, and cultural. A sur-
individual surgeon has their own “card” in the geon operating for the same disease, having in
hospitals that they practice. This makes it diffi- mind the same end result, may choose to follow a
cult, or almost impossible to create a reliable, different pathway of execution for the operation
reproducible, easy-to-follow scientific evaluation because two individual patients, despite the same
of a stepwise surgical model that can be taught to diagnosis, age, and gender are never actually
new residents, and it is certainly very difficult to identical.
standardize the details of the surgical steps. In Let’s take one of the most common operations
general, it is difficult to call something “standard,” performed and analyze it: intestinal anastomosis.
because there is so much individualized surgery, It can be performed either with a stapler or hand-
even when faced with evidence of preferred sewn anastomosis instead [4–8]. First, there are a
practice [3]. For the most basic surgeries per- number of variations on stapler techniques, and
formed around the world, when experts are asked certainly a number of variations on the hand-
to describe them, there are differences in their sewn technique: single layer, double layer, silk,
accounts. vicryl, and other suturing materials are all used.
In contrast, there are no differences in the Even when we narrow the discussion to one type
description of steps that each pilot has to follow of suture, for example silk suture, one surgeon
for the given model of the plane. Those steps are may use only 2.0 silk, while another surgeon
well standardized by the industry, and they are never uses 2.0, but instead uses 3.0 silk; the dif-
applicable across the world; deviations made ferences are so minute, but either individual
from these standards are recorded and scruti- would have a strong opinion on why he or she
nized. For surgeons, there are accepted general uses their preferred type of sutures. So it comes
safety standards, but there are no subtle rules that back to surgeons’ education and training, tech-
define each move performed, leaving the deci- nology available to the surgeon, institutional tra-
sions of the surgeon during both complex and dition, region, and finally, the culture of the
simple cases much to their own discretion. surgeon and the patient that is being operated on.
Korenkov et al. [3] have proposed a four-grade In the next pages, I will review these models as it
classification of intraoperative difficulties, from pertains to the above elements, but before I do
easy to very difficult. This classification system that let me address few more other issues.
has not yet been adopted by all surgeons, although
we all have experienced these grades of difficulty
in one form or another. As these authors state, the Standardization of the Surgical
distribution of these difficulties is unknown. Decision-Making Process: Is It
Possible?

Different Approaches to Similar If we concede that we will not be able to stan-

Problems dardize every thought of the surgeon, or every
move in the operating room, is there a way that
There is no recording of the surgeons’ thoughts, we can “protect” the process of surgical decision-
and much of the review process, even when things making from all external factors and make it
go wrong, is extremely difficult. Moreover, the dynamic but with no major fluctuations? If so,
differences and the reasons for individualization trainees anywhere in the world can have access to
of even common surgical procedures are multi- a consistent model every time he or she does the
factorial. Training and education of an individual given procedure. What will constitute “no major
surgeon is the main factor, but one has to remem- changes” is another matter to be discussed and
ber that surgery is a dynamic and highly variable defined, altogether. Will all of the surgeons
process, and there are many other reasons for around the world act like robots and behave as
1 Intraoperative Surgical Decision-Making: Is It Art or Is It Science or Is It Both? 5

creatures with “super brain” but no emotional monitored using EEC while opening the wound,
input”? Obviously the practicality of such attempt during the operation proper, closing the skin, and
will certainly be an impossible mission. Yet, such immediately after the operation. From the ECG
models are being examined and created, prac- recordings, indices reflecting cardiac arrhythmia
ticed, and reported. The fact is that we surgeons and emotional level were calculated. The authors
have simply not written enough to explain how concluded that the process of decision-making
we have arrived at a particular decision intraop- during the vital stages of operations causes a fall
eratively. The reasons for this are multifactorial in the coefficient of heart rate variability, the vari-
as well, but the current ways of reporting data on ance of R-R intervals, and the variability range of
our outcomes including very sophisticated statis- R-R intervals. During all the stages of surgery
tical analyses do not permit such reporting, and studied, and immediately after the operation, an
thus there is a huge void of literature describing increase in tonus of the sympathetic nervous sys-
surgical decision-making processes. Just try to tem occurs in surgeons indicating a rise in emo-
write a paper where you describe your thoughts, tional level [13].
and see if it will be published in any peer- Other critical factors influencing the intraop-
reviewed journal. erative surgical decision-making have been
So while surgeons may have a lot of data to described [14, 15]. The findings reveal that three
consider, eventually he or she has to rely on their factors are of major importance: task visualiza-
own experience and knowledge, their grasp of the tion, communication, and mental model. In addi-
patient’s clinical information, and occasionally tion to the surgeon’s leadership ability and mental
on their assistants’ help. A dynamic stepwise state, creativity might be the most important ele-
model of surgeons’ intraoperative decision- ment of all. Historically, surgeons have shown
making process involves monitoring and assess- solid creativity. It often has changed the way we
ing the situation, taking appropriate actions, and practice medicine and surgery, defying the anat-
reevaluating the patients’ response [9, 10]. That omy and physiology of the body and sometimes
model encompasses components such as intuition buying some critical time. The ideal virtues of
(also known as “recognition-primed decision- any surgeon should include open-mindedness
making” analytical ability) and creativity [11]. and flexibility. While respecting sound surgical
Nowhere is that model more applicable than in principles, the surgeon must be ready to adapt to
complex reoperative surgical procedures, which any new intraoperative challenge at any time.
are often associated with an array of unantici- Creativity in the service of excellence does not
pated problems. In the author’s opinion, an come easily, however. It takes dedication. It takes
important non-technical component that has not a lifetime of continuously studying the art and
received sufficient attention is the surgeon’s lead- science of surgery.
ership ability. Adroitly taking charge of a calami-
tous, often hopeless situation—applying proper
technical skills, assigning different team mem- Surgical Decision and Technological
bers to different tasks, and communicating in a Advances
timely, clear, and calm manner—can make a sig-
nificant difference. In fraught intraoperative situ- Many of the decisions influencing what surgeons
ations, few surgeons have reported that they make do intraoperatively have been influenced by the
decisions through analytical, rational heuristics, availability of the technology. While the histori-
or through trial and error [12]. Rather, one study cal development of all technological advances in
among surgeons has shown that the basis of sur- surgery are beyond the scope of this chapter, our
gical decision-making process is primarily task decision-making process is becoming more and
visualization, communication, and the mental more dependent on technological advances that
state of the surgeon, specifically what is called a we have at hand. We decide which available
mental model [13]. In this study, surgeons were technological tools to use, and then we modify
6 R. Latifi

our decisions around them. But let us assume for ing strategy itself. This is based on intuitive
one moment a world without any surgeons at all, recognition-primed, rule-based, analytical, and
and the decisions to treat whatever is wrong with creative processes [17]. Furthermore, it has been
people will be directed instead by computers or suggested that there is a need for developing an
perhaps something even more advanced in the empirically derived taxonomy to identify and
future. While this notion perhaps seems fantas- classify surgeons' intraoperative leadership
tic, the rapid progress of technological advances behaviors [18]. In an attempt to create the tax-
makes such developments entirely possible and onomy of surgeon’s leadership inventory, eight
probably far more likely than we can imagine or elements of surgeons' leadership were identified:
would care to imagine. In fact, the advances in (1) maintaining standards; (2) managing
brain surgery with directed nanotechnologies, resources; (3) making decisions; (4) directing;
and other technological advances [16] make (5) training; (6) supporting others; (7) communi-
such a scenario very likely and in a very short cating; and (8) coping with pressure [19].
period of time. Why should we have all kinds of Flexibility and an open-minded approach, along
surgeons and the various medical doctors for with a respect for sound surgical principles, are
specific organs, and each system, when the com- important. Accommodating the physiology of
puter will recognize the disease or disorders, and both the patient and the surgeon is also impera-
deliver the perfect required solution in one set- tive. Still, most intraoperative decisions are
ting, be it surgical, medical, or pharmacological? made “on the fly” and are hard to theorize, quan-
One can go a bit further and challenge the notion tify, or categorize. Additional work, especially
if we should even get sick in the first place, and from and on surgeons themselves, is needed to
then perhaps we can intervene at the genetic or delineate further how we make life-changing
proteomic level and change things to suit the intraoperative decisions.
way we, or perhaps the computer, desires. Why
should we have to split someone’s abdomen and/
or chest open to stop the bleeding in a small tiny Summary
vessel or tissue, when this can be done using
some form of an energy-based intervention? Will a book like this, in fact, become obsolete soon
This already happens, but still at the very rudi- after it gets published? Chances are very good it
mentary level. Currently, a surgeon may reach will. If a spacecraft can “fly itself” to other planets
for the scalpel and open the patient’s chest to millions of kilometers away with exceptional pre-
clamp the bleeding aorta, or they will reach for cision, why wouldn’t we expect that we surgeons
the aortic balloon followed by the stent and stop will in fact become obsolete one day? Given that
the bleeding; it depends entirely on where they the human mind is still exponentially superior to
practice. any supercomputer that exists, it is likely that the
decision-making by surgeons is what will become
most valued by the future medical community.
Intraoperative Surgical Decision The simultaneous processing of a multitude of
variables related to the patient’s condition in order
The intraoperative decision-making process can to stay ahead of potential crises are features that
be difficult. It draws on the surgeon’s education, the mind of a surgeon already possesses, and per-
clinical experience, leadership ability, mental haps eventually we will be able to design machines
state, physiology, and creativity, as well as objec- that can reproduce their subtle complexities.
tive data from the patient’s physiology and anat-
omy. A two-step model has been proposed, Acknowledgements Special thanks to Elizabeth H.
which includes situation assessment (with risk Tilley, PhD for her contribution to this to this and other
chapters in the early stage of this book.
and time available to act), and the decision-mak-
1 Intraoperative Surgical Decision-Making: Is It Art or Is It Science or Is It Both? 7

References 10. Pauley K, Flin R, Yule S, Youngson G. Surgeons’

intraoperative decision making and risk management.
Am J Surg. 2011;202:375–81.
1. Marshall JC. Surgical decision-making: integrating
11. Klein G. A recognition-primed decision making
evidence, inference, and experience. Surg Clin North
(RPD) model of rapid decision making. In: Klein
Am. 2006;86(1):201–15.
G, Orasanu J, Calderwood R, Zsambock C, editors.
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12. Velanovich V. Operative decisions. Theor Surg.
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3. Korenkov M, Troidl H, Sauerland S. Individualized
13. Czyzeweska E, Kicka K, Czarnecki A, et al. The sur-
surgery in the time of evidence-based medicine. Ann
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Surg. 2014;259(5):e76–7.
stages of operations. Eur J Appl Physiol Occup
4. Wu Z, Vakalopoulos KA, Kroese LF, Boersema GS,
Physiol. 1983;51:441–6.
Kleinrensink GJ, Jeekel J, Lange JF. Reducing anas-
14. Jalote-Parmar A, Badke-Schaub P. Critical factors
tomotic leakage by reinforcement of colorectal
influencing intra-operative surgical decision-making.
anastomosis with cyanoacrylate glue. Eur Surg Res.
International conference on systems, man and cyber-
2013;50(3–4):255–61.
netics. SMC. 2008;1091–6.
5. Lustosa SA, Matos D, Atallah AN, Castro AA. Stapled
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versus handsewn methods for colorectal anastomosis
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surgery. Cochrane Database Syst Rev. 2001;(3):
of surgical information systems. Des Stud.
CD003144. Review. Update in: Cochrane Database
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Syst Rev. 2012;2:CD003144.
16. Latifi R, Rhee P, Gruessner WR, editors. Technological
6. Beitler AL, Urschel JD. Comparison of stapled and
advances in surgery, trauma and critical care.
hand-sewn esophagogastric anastomoses. Am J Surg.
New York: Springer; 2015.
1998;175(4):337–40.
17. Orasanu J, Fischer U. Finding decisions in natural
7. Law WL, Bailey HR, Max E, Butts DR, Smith KW,
environments: the view from the cockpit. In: Zsambok
Thompson DA, Skakun GB, Graves E. Single-layer
C, Klein G, editors. Naturalistic decision making.
continuous colon and rectal anastomosis using mono-
Mahwah: Lawrence Erlbaum; 1997.
filament absorbable suture (Maxon): study of 500
18. Parker SH, Yule S, Flin R, McKinley A. Surgeons’
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leadership in the operating room: an observational
8. Shogan BD, Carlisle EM, Alverdy JC, Umanskiy K.
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Do we really know why colorectal anastomoses leak?
19. Parker SH, Flin R, McKinley A, Yule S. The Surgeons’
J Gastrointest Surg. 2013;17(9):1698–707.
Leadership Inventory (SLI): a taxonomy and rating
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2007;16(3):235–9.
 The Anatomy of the Surgeon’s
Decision-Making 2
Rifat Latifi

Patient Case decision to cancel the operation and wake up the

patient. This was an error on our collective side. It
As I was completing one case, I was told that the was a Friday, and on Monday we operated on the
next patient was ready in the adjacent room. We patient and repaired the bilateral hernia, laparo-
were just finishing up, so I left the resident with the scopically. The team and I learned a very valuable
first patient and walked to the next room and saw lesson. I did not oversee the resident’s note, and
the next patient was being intubated. I looked at did not ensure that everyone knows exactly what I
the paperwork which stated “abdominal hernia.” I planned to do. There were many stages when this
examined the patient, who was now a sleep. She error could have been caught, but it was continu-
had no abdominal wall hernia. My handwritten ously missed. The human wall to prevent an error,
clinic note read “Bilateral inguinal hernia.” The coupled with the multiple failsafe processes did
informed consent, however, stated “abdominal not work. Neither the patient, nor her family were
hernia.” Because the patient was asleep, I could upset, and they were very glad that we did not do
not examine her. I decided to contact her husband, the surgery on Friday.
a taxi driver, but he did not return the repeated
phone calls that I made. She was a woman in her
mid-thirties, who had a bilateral inguinal hernia Introduction
based on my note. However, my note did not
match the resident’s note, or the consent, which While we the surgeons claim to be and act as
had been reviewed and approved by nurses, preop- leaders in the operating room, this surgical sym-
erative anesthesia, and finally the anesthesiologist phony [1, 2] is created by so many people, orga-
of record. There was a huge discrepancy, and nized in so many layers that one would think that
examining the patient under anesthesia for ingui- we can build a true wall that mistakes cannot pass
nal hernia would not provide definitive answers. through. Yet they still happen, and there is so
(This was back before the mandatory “surgical much that goes on between the perfection
pause” or “time-out.”) In that moment, I made the expected from us, and what often, unfortunately,
occurs. In 2009, Atul Gawande published his
R. Latifi, M.D., F.A.C.S. (*) best-selling book, “The Checklist Manifesto.”
Department of Surgery, Westchester Medical Center, This book documented the decrease in error rates
New York Medical College, 100 Woods Road,
Valhalla, NY 10595, USA of surgeons with the use of checklists prior to sur-
gery [3]. While the use of checklists provides sur-
Department of Surgery, University of Arizona,
Tucson, AZ, USA geons with one tool that battles the overwhelming
e-mail: rifat.latifi@gmail.com complexity of modern surgery, the mechanistic

© Springer International Publishing Switzerland 2016 9

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_2
10 R. Latifi

and cognitive processes that surgeons grapple diagrams can also help surgeons for reference
with are less understood, and frankly greatly purposes with later cases; however, while tools
underestimated. The layers that have been placed such as decision-tree diagrams or checklists may
as way of reducing the fatal errors such as help surgeons organize their work, they do not
performing the wrong surgery on the wrong capture the complexity of intuitive decision-making.
patients still may become permeable and let an Yet, these rudimentary tools, are useful, and will
error get through. keep the work in order.
Experts, such as master surgeons, are not
infallible, yet often they are able to make deci-
sions or question others without any seemingly Physical Factors, Personality
apparent evidence to do so. Such was the case Factors, and Situational Factors
with the patient who had the bilateral inguinal
hernia, illustrated in my case presentation. How A limited number of studies have assessed the
did I decide to cancel the case? I could write a surgical decision-making process by asking sur-
note in the chart stating the facts and any reason- geons to recall decisions made during complex
able person would have seen this as an error that surgery, watch videos of other surgeons during
did not harm the patient. Instead, I saw this as a surgery, or instructing surgeons to view them-
major system issue, and thus decided to cancel selves and to determine why they made specific
the case. I had seen many patients in the past decisions [5, 6] (Table 2.1). For example, Mitchell
couple of weeks previous to this event and had examined the decision-making process in trainee
been very busy, but I had enough recollection to surgeons compared to the decision-making pro-
realize that this was the same patient I had seen cess in consultants. She and her colleagues spe-
quite some time before seeing her again. The cifically compared their abilities to assess risk
most important mistake was that I had not seen during two different time points while watching
the patient before surgery. There were no mark- short videos of other surgeons. While she found
ing of surgical sites. No double or triple check- no statistically significant differences in risk rat-
ing. Faced with this, I decided that proceeding ings, she did gather important data on what sur-
with surgery at this time was not alright. But geons believe to contribute to decision-making [5]
what made me do that? My intuition? while in the operating room, specifically regard-
Groundbreaking literature on the subject of ing how surgeons critique and evaluate surgeries.
surgical decision-making was written by The real question is can we statistically define the
Abernathy and Hamm [2] in the 1990s. In one of surgeon’s decisions? Can we have a p-value when
their many novels on the subject of surgical intu- in a single case the surgeon decides to perform
ition, these authors describe and defend the role this versus the other procedure in the “heat of the
of intuition in the surgical decision-making pro- moment”? I do not believe so.
cess. They define intuition as the act of knowing Moulton and colleagues conducted a study that
without the use of rational process, or “immedi- interviewed 28 surgeons using a semi-structured
ate cognition.” It is a part of thinking that cannot interview design to ask questions about decision-
be explained. Surgeons who appear to use intu- making during operating procedures [6]. They
ition typically have many years of experience. analyzed these interviews using a grounded
While experience is an important component to theory design and produced a conceptual frame-
gaining this skill, these authors state that it is not work that they describe as the “slowing down
always necessary. phenomenon.” The slowing down phenomenon
The word intuition is not readily received consists of evaluating a situation and switching
among the scientific community. There has been from automatic mindset to effortful mindset.
an argument for the use of clear, analytic Every experienced surgeon has had the “slow
decision-making [2, 4] in order to reduce error down moment” and can recall it, and moreover
rates. Specifically, some surgeons argue for the can recognize when there is a need for such
use of decision-tree diagrams. Decision-tree moment during a complex surgery. I call it the
 2

Table 2.1 Studies that have assessed surgical decision-making

Author and year Title Methods Results
Chatterjee et al. (2009) [30] Assessing the surgical decision- Surgical decision-making Surgical decision-making tool is a useful assessment to see
making abilities of novice and assessment tool on 25 medical strengths and weaknesses of surgeons. Rating scale distinguished
proficient urologists students, urology residents, and staff training level across domains
viewed 8 videos of minimally
complex to complex urological
procedures
Dekker and Hugh (2008) [8] Laparoscopic bile duct injury: Reviewed literature for errors Psychological characteristics related to misidentification:
understanding the psychology between 1997 and 2007; found 49 underestimation of risk, cue ambiguity, and “believing what you
and heuristics of the error errors, 42 of 49 were see”; training should include how to be alert for cues of wrong
The Anatomy of the Surgeon’s Decision-Making

misidentification of bile duct, not duct, learning how to stop yourself once you’ve made a decision
recognized during operation
Massarweh et al. (2009) [7] Risk tolerance and bile duct Risk-taking assessment survey; Found that those who had highest level of risk-taking preferences
injury: surgeon characteristics, demographics, questionnaire on also had highest risk for CBDI injuries
risk-taking preference, and injuries
common bile duct injuries
Mitchell et al. (2013) [5] Intraoperative surgical decision- 27 surgeons (trainee vs. consultant) No difference for risk-taking preferences between trainees and
making: a video study interviewed while watching 3 videos consultants
Moulton et al. (2010) [6] Slowing down when you should: 28 surgeons interviewed; using Found specific characteristics associated with surgical errors:
Initiators and transitions from the grounded theory design, explored physical, personality, and situational
routine to the effortful emergent themes
Yule et al. (2006, 2008) Development of a rating system Cognitive task analyses (critical Five categories of non-technical skills were discovered: situation
[19, 29] for surgeons’ non-technical skills incident surveys) were given to 27 awareness, decision-making, task management, leadership and
surgeons communication, and teamwork; later reliability tested and found
NOTES that with minimal training, surgeons can rate each other’s
non-technical skills
11
12 R. Latifi

ability to “slow down your heart rate.” In other injury were more likely to have trained at a LC
words, when a situation has the tendency to fall course. Surgeons who scored very high on the
out of our own control, such as in major trauma risk-taking assessment had a relative risk for
or unexpected injuries, there is a moment when CBDI that was 17 % greater than the surgeons
you truly have to “slow down your heart rate” and who were trained in LC. The authors concluded
put that final suture that you know will save the that the impact of extremes of risk-taking prefer-
patient’s life. In my practice, I lower my voice, and ence on surgical decision-making can be an
“slow down the heart rate.” I become extremely important part of decreasing risk for injury during
focused on the task at hand. surgery. These authors felt that risk-taking pro-
Through the iterative process used to create pensity should be one characteristic that is
the surgical decision-making framework, evaluated among surgeons.
Moulton and colleagues discovered certain per- Dekker and Hugh [8] reviewed literature on
sonality characteristics that may influence the bile duct misidentification between 1997 and
surgical decision-making process and the ability 2007. They found that of the 49 surgical errors that
to “slow down” during surgery. These character- were reported during this time period, 42 errors
istics include adaptability, willingness to learn, were related to misidentifying the bile duct.
and confidence. No known studies that research Dekker and Hugh attribute these errors to certain
these characteristics have been conducted. psychological phenomena that include inability to
There are several factors that affect the ability read cues, inability to slow oneself during surgical
to “slow down.” These factors include physiolog- procedures, and a belief that the risk is low during
ical, personality, and situational factors. operation. Dekker and Hugh also emphasize the
Physiological factors include fatigue, illness, and need to train surgeons to apply “stopping rules”
endurance. Personality factors include ego, when necessary during an operation and to train
adaptability, willingness to learn, and confidence. surgeons to accept the need for plan modification,
Situational factors include time pressure, avail- which reminds us that Moulton’s personality char-
ability of resources, and social pressures [6]. acteristics may be an important consideration.
This phenomenon has been described as cognitive
fixation and plan continuation by these authors.
Personality Characteristics For example, if a surgeon makes a decision to go
in one direction, but it is not the correct decision, it
Does the personality of the surgeon matter, or is more difficult to modify the plan of action once
rather how does the personality of the surgeon the decision is made. In essence, the surgeon
affect the outcome of surgery? One of the most becomes biased in the direction of his/her first
commonly studied injuries caused by surgeons decision. I call this, as most experienced surgeons
has been laparoscopic common bile duct injury. do, the first mistake leading to the next mistake. In
Massarweh et al. conducted a simple survey of other words, it is important that we as surgeons
members of the American College of Surgeons evaluate the cognitive fixation plan and reevaluate
and asked them to review which factors contrib- by “slowing down our own heart rate” and adapt
uted to bile duct injuries during routine laparo- intraoperatively to new conditions and situations.
scopic cholecystectomy (LC) [7]. The survey
included an assessment of demographics, injuries
reported during surgical procedure, and a short Decision-Making and Situational
risk-taking questionnaire. Out of the 1412 Awareness
respondents, 12.9 % reported having contributed
to more than one injury. These surgeons, on aver- An important concept that may effectively
age, were slightly older than the general sample describe the surgeon’s decision-making ability
and had been in practice longer. Additionally, and how he/she makes decisions in the operating
surgeons who did not report a common bile duct room is that of situational awareness, which
2 The Anatomy of the Surgeon’s Decision-Making 13

has not been studied adequately among sur- situation be considered intuitive or creative?
geons. Military strategists have applied this con- Specifically, creative decision-making requires
cept to operating aircraft, ships, and in emergency more time and less urgency. It appears that there
military situations much more than surgeons is a blend of intuitive recognition decision-
[9–12]. Situational Awareness can briefly be making and creative decision-making during
described as “the perception of elements within surgery.
a volume of time and space, the comprehension Herein lies a key component to the construct
of their meaning, and the projection of their sta- of surgical intuition. Because an expert surgeon
tus in the near future [9].” Numerous studies has many levels of knowledge, he or she is able
looking at the effects of situational awareness in to step away from analytical decision-making,
virtual and real environments among military otherwise known as “taking steps through a deci-
personnel have been conducted [10–13]. Few sion,” and take shortcuts or cut corners.
studies have been conducted that look at how Abernathy and Hamm state that memories are
situational awareness can be applied in the medi- formed in “chunks.” Experts are able to use rep-
cal field, however. Considering studies that have resentations of situations whereas non-experts
investigated situational awareness in the medical remember processes in steps. While everyone
field, communication among surgical team only has the capacity to remember in five to
members, or the usefulness of the concept of seven “chunks,” experts do not need to remember
situational awareness have gained the most the steps of these chunks, thus allowing them to
attention among anesthesiologists and emer- make creative and flexible decisions when under
gency practitioners within the realm of surgical pressure. Specifically, if a surgeon is presented
non-technical skills [13–15]. There are addi- with a familiar pattern, they have more flexibility
tional concepts that have been studied related to to think around the steps needed to perform a task
the decision-making process. because they do not have to “remember” all of
Flin et al. made the case for applying decision- the steps. This allows them to make decisions
making analysis concepts (i.e., naturalistic that seem intuitive or creative [2].
decision-making) in a two-step process that Studies looking at the mechanics underlying
included: assessing and diagnosing the situation, these dynamic decision-making processes have
then using one of four strategies to make a deci- not been conducted due to the difficulty of obtain-
sion [16]. These strategies included intuitive rec- ing the “real-time” data from surgeons while in
ognition, rule-based, analytical, and creative the operating room. It would be unethical to pos-
decision-making. According to Yule and col- sibly jeopardize a patient’s safety and the surgi-
leagues, these strategies are selected based on a cal procedure for the sake of understanding how
continuum of urgency. When the need to make a surgeons make decisions. However, some
decision is urgent, intuitive recognition decision- enlightening studies have been conducted that
making is used, whereas when the need to make examine visual tracking of cancerous masses on
a decision is not urgent, creative decision-making mammograms as well as abnormalities on elec-
is used [16]. However, in real practice, the intui- trocardiograms (ECG) [17, 18]. For example,
tive vs. creative decision-making process is dif- Kundel et al., found that radiologists detect can-
ficult to separate. For example, while the patient cers on medical images well before eye move-
is dying in the operating room from hypotension, ment to the abnormal region occurs [18]. These
the surgeon reaches for the aorta and presses with authors propose that an expertise in medical
two fingers until the blood pressure comes up image analysis results in a “look–detect–scan”
again. The most common response for hypoten- fashion rather than a “scan–look–detect,” indi-
sive and dying trauma patient in the operating cating that expertise brings in an almost “gut-
room is to open the chest and clamp the aorta. level” form of analysis [17]. Additionally, Wood
Would a response made by the surgeon that dif- et al. found that experts in reading ECGs had a
fers from standard training procedures in this different visual scanning behavior than ten-year
14 R. Latifi

medical students [18]. These studies are useful in viewed 27 surgeons asked them to document why
that they provide a foundation for investigating they made decisions during the surgical proce-
the mechanistic underpinnings of surgical dure, but only after the fact. These surgeons were,
decision-making. Of course, the major difference in effect, retrospectively describing what they
between detecting abnormalities in an image and had done with a rubric that was based upon what
in surgical decision-making is the timing; hence, they had been taught; however, psychologists
the concept of situational awareness is relevant. propose that many actions are in response to
Surgical decision-making occurs within an stimuli that the individual is not aware. The feed-
almost unmeasurable, difficult-to-quantify period forward sweep (FFS) is a term used to describe
of time. There is no time to change one’s opinion how visual stimuli are incorporated into the brain
while in the operating room. through the retina and into cortical regions. Every
Complex surgical procedures carry significant time the information reaches a successive stage,
risks and complications, whether performed higher-level areas send information back to lower
alone or in combination. Despite the most consci- level areas for a process known as recurrent
entious preoperative preparations, surprising processing (RP). van Gaal and Lamme [20, 24]
events may still occur. If the operation takes an have proposed that the RP is required for con-
unplanned turn, the surgeon has to make difficult sciousness and FFS remains unconscious. These
decisions. It is essential to be continuously aware authors suggest that this is the proposed route for
of the patient’s physiologic status—including allowing seemingly unconscious monitoring of
fluid status, urine output, use of blood and blood environmental stimuli occurrences. Abernathy
products, bleeding, current medications (such as and Hamm made a similar argument for intuition
vasopressors), and biochemical endpoints of [2]. Intuition is essentially the awareness of
resuscitation. Even when the operation is going subtle cues; this awareness may not be effectively
well, the biochemical profile of the patient may verbalized as it is sensory in nature.
not be optimal, or even satisfactory, and this may One specific area that has been shown to be
directly affect the outcome of surgery. In addi- activated during complex decision-making is
tion, the surgeon must recognize his or her own that of the anterior cingulate cortex, ACC [27].
physiologic status; if tired, for example, cutting This area is activated during error detection and
corners and making major errors are much more competitive complex tasks. The ACC has also
likely [1]. been demonstrated to be involved in conscious-
Yule et al. interviewed 27 surgeons using a cog- ness, such as emotional awareness [28].
nitive task survey [19]. Results revealed that many The formation of memories and how knowl-
errors made by surgeons were not technical errors, edge is stored and accessed is crucial to under-
but in fact, behavioral errors. For example, many standing seemingly gut-level processes. Latent
errors were due to communication problems among knowledge is knowledge that we’ve acquired
team members. Yule et al. documented five areas of through learning and experience, but we are not
non-technical skills that impacted the effectiveness always consciously aware of this knowledge [2].
of surgeon’s performance in the operating room. The ability to access it depends on several factors.
These non-technical skills included situation This type of knowledge, in conjunction with
awareness, decision-making, communication, attention to situational cues, is crucial to intuitive
teamwork, and task management [19]. decision-making. How do we access it?
Numerous studies involving patients with Reliability of the memory of this knowledge is
brain damage have shown that considerable dependent upon the frequency of the use of par-
unconscious processing of visual stimuli, such as ticular knowledge and how recently this particu-
emotional, facial, semantics, and visual illusions, lar knowledge was acquired. Surgeons rely on
occurs [20–24]. Additionally, studies on patients knowledge gained over long periods of time and
without brain damage have shown unconscious from varied experiences. Long-term memory is
processing of stimuli presented to masked healthy knowledge that is stored for long periods of time.
subjects [25–27]. Yule’s study [19] that inter- It can be considered almost a concrete aspect of
2 The Anatomy of the Surgeon’s Decision-Making 15

thought processes or even identity. For example, 4. Weinstein MC, Fineberg HV, Elstein AS, et al.
Clinical decision analysis. Philadelphia: WB
“What street did you grow up on?” is a question
Saunders; 1980.
that most people can answer very quickly with- 5. Mitchell L, Flin R, Youngson G, Malik M, Ahmed
out much thought. This is a memory that has been I. Intraoperative surgical decision-making: a video
built over a long period of time and used repeti- study. International conference on naturalistic deci-
sion making. Marseille, France; 2013.
tively. Short-term memory has a smaller capacity
6. Moulton C, Regehr G, Lingard L, Merritt C, Macrae
and holds ideas for a short period of time, unless H. Slowing down when you should: initiators and
they are used for long periods, then they become influences of the transition from the routine to the
part of the long-term memory pool. Short-term effortful. J Gastrointest Surg. 2010;14:1019–26.
7. Massarweh N, Devlin A, Gaston SR, Broeckel EJ,
memory is responsible for what we are thinking
Flum D. Risk tolerance and bile duct injury: surgeon
of at a given moment and what we are paying characteristics, risk taking preference, and common
attention to. Long-term memory is accessed bile duct injuries. Am J Surg. 2009;209:17–24.
through short-term memory because short-term 8. Dekker S, Hugh TB. Laparoscopic bile duct injury:
understanding the psychology and heuristics of the
is what an individual is currently thinking of and
error. ANZ J Surg. 2008;78:1109–14.
is connected to the activities that the individual is 9. Endsley MR. Towards a theory of situation awareness in
engaging in. Short-term memory acts almost as a dynamic environments. Hum Factors. 1995;37:32–64.
gatekeeper to long-term memory [2]. 10. Endsley MR. A survey of situation awareness require-
ments in air-to-air combat fighters. Int J Aviat
Psychol. 1993;3:157–68.
11. Endsley MR. Measurement of situation awareness in
Conclusion dynamic systems. Hum Factors. 1995;37:65–84.
12. Endsley MR. The application of human factors to the
development of expert systems for advanced cockpits.
The anatomy of such decisions is of great impor-
In Proceedings of the 7th international symposium on
tance to all surgeons, including those who work aviation psychology. Columbus: Ohio State
with surgeons, and patients. The construct of situ- University; 1987. p. 167–71.
ational awareness can be applied to these “gut feel- 13. Gaba DM, Howard SK, Small SD. Situation aware-
ness in anesthesiology. Hum Factors J Hum Factors
ing” evaluations. How situational awareness and
Ergon Soc. 1995;37:20–33.
decision-making are affected by factors such as 14. Durso FT, Sethumadhavan A. Situation awareness:
sleep deprivation and alcohol consumption are also understanding dynamic environments. Hum Factors
important in understanding the decision-making J Hum Factors Ergon Soc. 2008;50:442–50.
15. Shah H, Hamid ABD, Waterson P, Hignett S. Situation
process. Additionally, the mechanics behind this
awareness to support decision-making among emer-
complex decision-making process should be tested. gency care practitioners. In Proceedings of NDM9,
Other elements of surgical decision-making pro- the 9th international conference on naturalistic
cess should be kept in mind as well [29, 30]. decision-making, London, UK; June 2009.
16. Flin R, Youngson G, Yule S. How do surgeons make
intraoperative decisions? Qual Saf Health Care.
Acknowledgements There are no identifiable conflicts 2007;16:235–9.
of interests to report. 17. Wood G, Batt J, Appelboam A, Harris A, Wilson
The authors have no financial or proprietary interest in MR. Exploring the impact of expertise, clinical his-
the subject matter or materials discussed in the manuscript. tory, and visual search on electrocardiogram interpre-
The author would like to thank Elizabeth Teilly, PhD for tation. Med Decis Mak. 2014;34:75–85.
her contributions to this chapter. 18. Kundel HL, Nodine CF, Krupinski EA, Mello-Thoms C.
Using gaze-tracking data and mixture distribution analy-
sis to support a holistic model for the detection of can-
cers on mammograms. Acad Radiol. 2008;15(7):881–6.
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1. Latifi R. Surgical decision-making process: more ques- technical skills. Med Educ. 2006;40:1098–104.
tions than answers. Scand J Surg. 2013;102(3):139–40. 20. van Gaal S, Lamme VAF. Unconscious high-level
2. Abernathy C, Hamm R. Surgical intuition. What it is information processing: implication for neurobiological
and how to get it. Philadelphia: Hanley & Belfus; 1995. theories of consciousness. Neuroscientist. 2012;
3. Gawande A. The checklist manifesto: how to get 18:287–303.
things right. New York: Metropolitan Books, Henry 21. Cowey A. The blindsight saga. Exp Brain Res.
Holt and Company, LLC; 2009. 2010;200:3–24.
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22. Tamietto M, Castelli L, Vighetti S, Perozzo P, 27. Bush G, Luu P, Posner MI. Cognitive and emotional
Geminiani G, Weiskrantz L, et al. Unseen facial and influences in anterior cingulate cortex. Trends Cogn
bodily expressions trigger fast emotional reactions. Sci. 2000;4(6):215–22.
Proc Natl Acad Sci U S A. 2009;106:17661–6. 28. Lane RD, Reiman EM, Axelrod B, Yun LS, Holmes
23. Tamietto M, de Gelder B. Neural bases of the noncon- A, Schwartz GE. Neural correlates of levels of emo-
scious perception of emotional signals. Nat Rev tional awareness. Evidence of an interaction between
Neurosci. 2010;11:697–709. emotion and attention in the anterior cingulate cortex.
24. Lamme VAF, Roelfsema PR. The distinct modes of J Cogn Neurosci. 1998;10(4):525–35.
vision offered by feedforward and recurrent process- 29. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley
ing. Trends Neurosci. 2000;23:571–9. D, Youngson G. Surgeons’ non-technical skills in the
25. Breitmeyer BG, Ogmen H, editors. Visual masking: operating room: reliability testing of the NOTSS
time slices through conscious and unconscious vision. behaviour rating system. World J Surg. 2008;32:
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 The Role of Physiology
and the Surgeon’s State of Mind 3
in the Surgical Decision-Making
Process

Rifat Latifi

Introduction nated symphony. After all, this is a hospital with

highly-trained professionals. In reality, how the
No small surgery exists, or is ever performed. surgery goes will depend on several factors, as
Even the minutest surgical procedure can poten- we will see in many of the subsequent chapters of
tially end with catastrophic consequences. In this this book, but nothing will affect the outcome of
instance, we are not considering such tragedies as a surgical procedure more than the decisions of
performing the wrong surgery on the wrong site, the surgeon, and the patient’s condition and phys-
or even on the wrong patient; also omited will be iologic state. In this chapter, we will examine the
discussion of a sponge or other foreign body left state of mind of the surgeon as a major factor. On
in the abdomen or chest. Even with these situa- many occasions during my elective surgical
tions eliminated, it is highly doubtful that any of cases, patients or their families have said: “Doc,
us would consider a surgical procedure per- please get a good night’s rest” or “Doc, have you
formed on ourselves or a loved one to be “small had a good night’s sleep?” These will be some of
or minor,” and therefore we should appreciate the factors that will be examined in more detail.
that all of our cases can become very personal.
What the crew of this ship, named “The
Operating Theater,” does and does not do may First, Do No Harm
have profound consequences. A team of sur-
geons, nurses, an anesthesiologist, scrub techni- Performing surgery is intense, even when it goes
cians, a radiologist, and scheduling personnel, “smoothly.” As mentioned in the commencement
are all led by the surgeon to execute a surgical of this chapter, there are no such things as “minor
procedure affecting the patient’s life, and the or small surgeries.” Each patient, “case,” or proce-
lives of their family, friends, and their commu- dure needs to be treated with the utmost care. If
nity. Everyone expects that this orchestrated set things can go wrong, they probably will go wrong,
of tasks will be executed like a perfectly coordi- but that does not diminish our commitment to our
patients and their families. Our primary role as
surgeons is to not hurt the patient, hence our
R. Latifi, M.D., F.A.C.S. (*) maxim of do no harm. Additionally, we should try
Department of Surgery, Westchester Medical Center,
to help people live longer, better quality lives, and
New York Medical College, 100 Woods Road,
Valhalla, NY 10595, USA free of pain whenever possible.
Sometimes not all that we do goes as smoothly
Department of Surgery, University of Arizona,
Tucson, AZ, USA as planned, and not every operation is successful.
e-mail: rifat.latifi@gmail.com In the past, surgeons have been known to use the

© Springer International Publishing Switzerland 2016 17

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_3
18 R. Latifi

saying: “The surgery was successful, but the There are a number of factors that may cause
patient died.” While this is not uttered as often disruption of the surgical procedures that com-
today, sometimes everything during the opera- prise the “symphony” of standard perioperative
tion did go as we had wished, but the patient does care. Recently, researchers from Mayo Clinic
not recuperate, develops a major complication, or prospectively analyzed flow disruptions by a
worse dies. Even when things do go well, the trained observer in 31 cardiac surgeries, and
patient may still need to undergo a subsequent described teamwork/communication failures,
procedure, another exposure to anesthesia, equipment and technology problems, extraneous
endure a longer hospital stay, and experience a interruptions, training-related distractions, and
number of unforeseen issues. In 2013 alone, there issues in resource accessibility. Surgical errors
were 5440 in-patient deaths related to one or increased significantly with increases in flow dis-
more of the 238 complications of surgical proce- ruptions; teamwork/communication failures
dures or medical care among non-neonatal/non- were the strongest predictor of surgical errors [2].
maternal discharges (n = 465,110), resulting in In order to ensure a perfectly conducted surgical
aggregate charges exceeding $22.7 billion symphony, the goal of every surgeon should be
(±$515 M) across the United States [1]. One only pursuing a high-quality safety program.
needs to consider the impact of potential compli-
cations to appreciate that no surgery should be
dismissed as minor or merely routine. The Never Event

In order to continue to improve the quality of our

The Consequences of the Disrupted services we in the medical/surgical community
Surgical Symphony have coined new terminology: the never event,
and we have gone to great lengths (rightly so,
Understanding how surgeons make decisions and perhaps) to establish “never event” notion.
how this decision-making contributes to the out- Surgical never events are defined as errors such
comes of the operation or overall treatment is as wrong-procedure, wrong-site surgery, retained
of critical importance. When we discuss the out- foreign body, and wrong-patient events. Such
comes of surgical patients in our quality improve- errors are evaluated continually, and have
ment (Morbidity and Mortality) conferences, we received great public interest. While the consen-
classify some of the complications as “potentially sus among surgeons, administrators, patients,
preventable” or what we say nowadays “room for and their attorneys is that these events are com-
improvement”; whatever we call them, technically pletely avoidable, they occur quite often.
these are errors. Occasionally, there are some seri- According to data from the National Practitioner
ous errors that become the subject of intense study Bank (NPDB) of the United States reviewed by
both by surgeons and non-surgeons alike. Mehtsun et al., between 1990 and 2010, over
These “errors” have been classified by a num- $1.3 billion was spent on malpractice lawsuits
ber of organizations. Yet, not everything that associated with surgical never events. A total of
goes wrong occurs due to an error; such instances 9744 malpractice cases related to never events
have been called “adverse events,” “a near miss,” occurred, with an estimated 4082 surgical never
and “a mistake.” Other classifications of the events occurring each year in the United States
errors include technical (i.e., one should have alone. The most common type of event was
done a different move, or used a different retained foreign body (n = 4857; 49.8 %), fol-
approach), error in judgment (i.e., one did not lowed by wrong-procedure (n = 2447; 25.1 %);
realize how sick the patient was, or totally missed wrong-site (n = 2413; 24.8 %); and wrong-patient
the diagnosis), or pure negligence (we need not surgery (n = 27, 0.3 %). Approximately 7 % of
dwell on this one, but suffice it to say it occurs far these cases ended in death, 32 % had permanent
less than attorneys would have the world believe). injuries, and 59 % had temporary injuries.
3 The Role of Physiology and the Surgeon’s State of Mind in the Surgical Decision-Making Process 19

Perhaps most disturbing about this report is the human mind, and preventing disruptions that
fact that of physicians named in a surgical never may occur. Only then will the surgical symphony
event claim, 62 % were named previously in a sound perfect.
malpractice claim, and 12.4 % were later named
in at least one future surgical never event claim
[3]. This is a truly disturbing trend. Even worse, Stress: The Positives
we do not know the extent of this major problem and the Negatives
worldwide, particularly in the developing world.
Factors related to the individual physician seem The term stress is often associated with negative
to be the most important items to consider in outcomes [6]. This chapter reviews the physio-
never events. The physician’s age (40–49), years logical effects of stress, including sleep depriva-
since graduation (<20), additional malpractice tion, on cognitive function and how these factors
reports, state licensure disciplinary reports and can affect the abilities of a surgeon. Driskell and
clinical privileges reports were all statistically Salas (2006) define stress as a process by which
significant (p = 0.001) for physicians involved certain environmental demands (i.e., perfor-
with surgical never events in this study. mance in front of others, or taking an exam)
The Institute of Medicine (IOM) provided evoke an appraisal process in which perceived
even more startling statistics that exemplify the demand exceeds resources and results in undesir-
gravity of the situation. On an annual basis in able physiological, psychological, or behavioral
the United States, more people die from medi- outcomes [7]. However, certain amounts of stress
cal errors than from motor vehicle accidents, can increase performance responses [8]. While
breast cancer, or AIDS [4]. According to a stress can increase effectiveness for certain tasks,
report published by IOM, between 44,000 and specific forms and amounts of stress have been
98,000 people may die in hospitals each year shown to impair decision-making as well [7].
due to errors. The report was written to evalu- Walter Cannon was one of the first scientists
ate, quantify, and provide suggestions for what to begin analyzing how the adrenal gland was
can be done to increase safety and quality in the responsive to emotional stimuli. He observed the
health care system. The IOM suggested the similar physiological reactions between emo-
development of checklists and protocols to tional stress and sympathetic nervous system
combat common errors [4]. (SNS) arousal [8–12]. Cannon coined the phrase
As suggested by Atul Gawande, checklists “fight or flight,” which has now been used exten-
provide a powerful tool for combating the occur- sively. The SNS aids in the control of most of the
rence of never events and other forms of surgical body's internal organs, particularly during prepa-
errors [5]. While the use of checklists provides ration for the fight or flight response. The SNS is
surgeons with one tool that battles the over- thought to counteract the parasympathetic sys-
whelming complexity of modern surgery, the tem, which generally works to promote mainte-
mechanistic and cognitive processes that sur- nance of the body at rest. He also proposed the
geons grapple with are less understood. Even emergency function theory of adrenal-medulla
more significantly, the factors, such as stress and function that offered a purposeful explanation of
physiological responses to stress that affect these the stress response in that the release of adrena-
processes and contribute to error rates need to be line made an animal more efficient in its struggle
more fully understood. with fear, rage, or pain [8]. Cannon was one of
Let me repeat it again: as surgeons, we are in the first to explain that stress and the physiologi-
command, not only within the operating theater, cal stress response could be positive inducers of
but throughout journey across the entire contin- peak performance in individuals. However, this
uum of care. And as surgeons, we should pay peak performance can be adversely affected by
special attention to every detail of the surgical other stressors, such as lack of sleep, negative
symphony, recognizing the limitations of the emotions, diet, and alcohol intake.
20 R. Latifi

Surgeons experience a specific form of stress errors, due to tasks that require more concentration
that includes time pressure, task pressure, and tend to be more stressful, it has been shown that
coordination among team members to complete a deliberate practice and minimization of intermit-
task. Often in the operating theater, surgeons are tent auditory distractions can help a surgeon be
under immense, time-dependent pressure known able to better multitask during a procedure [15,
as acute stress [7]. How does stress affect a sur- 16]. Since there is no single tool to assess stress
geon and his decisions? For surgeons, stress in the directly, an individual may choose to either mea-
right amount is useful, and prepares them for the sure their subjective perceptions of stress, and/or
pressures associated with surgery. As proposed by objectively assess their physiologic state during
Cannon and observed by many others, the stress moments of stress [14]. The Imperial Stress
response coordinated through the hypothalamic– Assessment Tool (ISAT) is a nonintrusive
pituitary–adrenal (HPA) axis actively prepares the approach to assessing stress during surgery that
individual for specific activities. Glucocorticoids measures both objective (i.e., salivary cortisol
and catecholamines are the primary hormones and continuous heart rate) and subjective (self-
that are released when the stress response system reported levels) components of stress. Validation
is stimulated [6]. Glucocorticoids have the func- studies have determined that the subjective indi-
tion of increasing the availability of energy sub- cators of stress were associated with cortisol lev-
strates and allowing for optimal adaptations to els 70 % of the time, and continuous heart rate
changing demands of the environment. 84 % of the time [17].
Specifically, it has been found that low levels of Another important element of surgical
circulating glucocorticoids and catecholamines decision-making involves learning and memory.
enhance memory function and high levels of these How much can one recall from past training or
hormones disrupt memory function [13]. when one reads an article or book and later has to
Furthermore, according to Mendl, an inverted apply it to their clinical practice? Data are par-
U-shaped relationship exists between an individu- ticularly lacking when it comes to the field of sur-
al’s state of stress or arousal and its ability to per- gery. However, what is known already is that
form a cognitive task effectively, the so-called learning and memory retention can be enhanced
Yerkes–Dodson law, is commonly encountered under certain forms of stress. For example, Joels
[13]. Empirical research on attention and memory et al. proposed that stress facilitates learning and
processes reveals more specific findings. Stressors memory processes when the stress is experienced
appear to cause shifts, lapses, and narrowing of in the context and around the time of the event
attention, and can also influence decision speed. that needs to be remembered, and when the hor-
There is conflicting evidence as to whether hor- mones and neurotransmitters released in response
mones involved in the hypothalamic–pituitary– to stress exert their actions on the same circuits as
adrenal stress response play a part in these those activated by the situation [18]. Specifically,
processes. These hormones, and those involved in physical and psychological challenges, such as
the sympathetic-adrenomedullary stress response, those presented during surgery, will enhance the
do appear to play an important role in memory information-gathering type of behavior that is
formation. Low or moderate concentrations of useful in assessment of the stressor [18]. For resi-
circulating glucocorticoids and catecholamines dents and surgeons, extensive medical training
can enhance memory formation, while exces- prepares them to form a cognitive representation
sively high or prolonged elevations of these hor- for comparison that stimulates arousal, alertness,
mones can lead to memory disruption [13]. and focused attention. Brain structures involved
Each individual surgeon will vary on what when confronting a stressor are the hippocampus
they identify as a potential stressor, but those (involved in retention and memory), the amyg-
commonly reported include laparoscopic (versus dala (emotional stimuli processing), and the pre-
robotic) surgery, procedural complexity, distrac- frontal cortex (part of the executive function
tions, and lack of time [14]. While distractions in control). All of these regions are connected to the
particular may lead to an increase in surgical HPA, which is responsible for the secretion of
3 The Role of Physiology and the Surgeon’s State of Mind in the Surgical Decision-Making Process 21

corticosteroids and other “stress hormones.” and mood [6, 13, 19]. Many studies also docu-
These hormones activate glucocorticoid recep- mented how these factors affect performance
tors when stress occurs to help face an immediate through memory disruption. Sleep, alcohol con-
threat as well as preparing an individual for chal- sumption, and other forms of stress will affect
lenging situations in the future. Psychological memory recall and peak performance functioning.
stressors, such as performing complex surgery,
will activate regions such as the amygdala which
promotes the memory of salient, but not neutral Sleep
information. For example, when faced with a sur-
gical procedure, a surgeon may recall key com- Sleep deprivation causes slower response times,
plex procedures more accurately than procedures reduced learning acquisition in cognitive tasks,
that are not as pressing or salient. Can one extract and loss of situational awareness [20].
a memory that has been stored somewhere in the Additionally, individuals with chronic sleep dis-
brain, under stress? turbances have significantly worse memory con-
As a junior attending surgeon, I was assisting solidation overnight as compared to control
two senior residents perform a tracheostomy in a subjects [21, 22].
morbidly obese patient with severe Acute Scoville and Milner discovered that certain
Respiratory Distress Syndrome (ARDS). I had forms of long-term memory rely on the hippo-
just joined the hospital, and I did not know the campus [23]. Explicit memory, such as memory
residents or their surgical abilities yet. The neck of facts, events, people, and places, which are all
was very large, and we used deep retractors to aspects of surgical procedures, involves human
expose the trachea. When we asked the anesthe- conscious awareness and requires the hippocam-
siologist to pull back the endotracheal tube, she pus. Sleep deprivation disrupts hippocampal
pulled it out entirely. The tracheostomy tube that function and plasticity. In particular, long-term
we had at hand would not reach the trachea. I memory consolidation is impaired by sleep depri-
asked for the tube exchanger, but the nursing vation, which suggests that a specific critical
anesthetist student (and here I thought we had an period exists following learning during which
anesthesiologist on the other side of the curtain) sleep is necessary [24].
did not know where they were. The patient’s The effects of sleep deprivation on medical
oxygen saturation was dropping, and with it his staff functioning have been studied over the years
heart rate. At this very desperate moment, I asked [21, 25–28]. Deary and Tait found that those who
for a nasogastric tube, and intubated the trachea were on-call or working rotating shifts had less
by placing it over the endotracheal tube, surely short-term memory recall and higher rates of
preventing a catastrophic event. Later I recalled mood disruption [26]. Harrison and Horne
that I had heard a surgeon talking about this pro- reported that one of the major consequences of
cedure on an audio tape, but it was many years sleep deprivation is impaired memory [29].
prior to the event. It’s amazing that I was able to Specifically, sleep deprivation affects the
access this stored information somewhere in my acquisition of memory [21, 25, 30]. Goldman,
brain precisely when I needed it most; I still McDonough, and Rosemond documented that
believe that it was the stress of the situation that junior doctors were less focused when suffering
prompted the retrieval of that specific memory. from sleep deprivation [27]. Additional studies
with clinical staff have shown that sleep depriva-
tion affects innovative thinking and verbal flu-
Inhibitors of Performance ency [28].
in Stressful Situations While the conditions that surgeons are operat-
ing under should be considered to be of primary
Numerous studies have shown that factors, such as importance, the excessive demands placed on them
sleep deprivation and alcohol consumption, can by long work schedules have only recently begun
affect glucocorticoid production, memory recall, to gain attention by the medical association.
22 R. Latifi

For example, it has been documented that sleep ratio, 1.25; p = 0.01) and feelings of depression
deprivation associated with long working hours (odds ratio, 1.48; p < 0.001) were more strongly
will affect performance in areas such as recall, associated with alcohol dependence [34].
decision-making strategies, spatial abilities, and Alcohol consumption above 0.1 levels con-
metacognitive abilities (i.e., appraisal of one’s tributes to the activation of the HPA axis and
own performance under pressure), and this sleep stimulates the production of glucocorticoids [19].
deprivation will affect individuals differently While alcohol consumption appears to reduce
[31]. Thus, there is no single formula for predict- anxiety, the activation of the HPA axis over time
ing performance in response to sleep contributes to the habituation of the body to stress
deprivation. hormones. In humans and other animals, the
In 2009, the IOM published a report entitled magnitude and duration of the glucocorticoid
“Resident Duty Hours: Enhancing Sleep, response depends on the amount of alcohol
Supervision, and Safety.” The report called for consumed [19, 37]. In response to alcohol, the
revising the requirements for hospital resident levels of cortisol, which is the main glucocorti-
working hours, time off between shifts, and more coid hormone in humans, can be substantial and
stringent training procedures because it docu- even surpass the levels typically seen in response
mented a decline in performance among residents to various stressful circumstances [38].
due to sleep deprivation [4]. Additional evidence One study documented that surgeons who had
for effects of sleep-disturbance on cognitive pro- used alcohol within a 24 h time period had higher
cessing is provided by studies that assessed mech- average time taken to respond and resolve
anistic underpinnings during cognitive activity. problems and higher error rates [39]. Additionally,
By using functional magnetic resonance imaging Dorafshar et al. reported that surgical perfor-
(fMRI) methods, Drummond and colleagues mance was impaired in the short-term after mod-
found that the anterior cingulate cortex (ACC) erate alcohol consumption, but that this effect
was active for cognitive tasks in non-sleep- was not observed during performance the day
deprived subjects, whereas it was not active in after drinking moderately [40].
sleep-deprived subjects, indicating a mechanistic A small study of five male surgeons between
explanation of how sleep patterns may disrupt the the ages of 31–40 compared the effects of alcohol
ability of surgeons [32]. Blum and colleagues and/or partial sleep deprivation on surgical dex-
issued a paper that established effective ways to terity as measured on a laparoscopic surgical sim-
implement the IOM’s suggestions [33]. ulator (by the time taken to complete tasks,
number of errors, diathermy time, and injury
time). There were three experimental states that
Alcohol Consumption and Surgeons were described: a control state where no alcohol
was consumed and subjects received a full night
A number of studies have addressed surgeons’ of undisturbed sleep; a sleep-deprived group that
and other physicians’ impairment due to alcohol consumed no alcohol, and finally sleep depriva-
[34–36]. A 2010 cross-sectional study conducted tion combined with ad libitum alcohol consump-
on 7197 members of the American College of tion. Those who underwent sleep deprivation
Surgeons on alcohol use disorders reported that averaged 3.75 h of sleep (range 3–5 h), while
15.4 % had a score consistent with alcohol abuse 10.33 units (range 6–15) of alcohol (equivalent to
or dependence. This prevalence certainly under- 100 ml of pure ethanol) were consumed on aver-
estimates the true magnitude of the issue, as only age by those during this respective treatment.
28.7 % of those surgeons originally sampled Repeated measures were taken at three time points
responded to the survey. This is not surprising for each subject, and breath alcohol analyses for
considering both the social stigma and legitimate all participants were 0 % by the next morning, but
risk to one’s professional career. The survey it is unclear if there were adequate washout peri-
also described that emotional exhaustion (odds ods or randomization of the treatment order.
3 The Role of Physiology and the Surgeon’s State of Mind in the Surgical Decision-Making Process 23

Based on these results from five individuals that 7. Driskell JE, Salas E, Johnston JH. Decision making
and performance under stress. In: Britt TW, Adler A,
demonstrated large interpersonal variation, alco-
Castro CA, series editors; Britt TW, Castro CA, Adler
hol consumption seemed to have the greatest A, editors. Military life: the psychology of serving in
adverse effect on surgical performance, particu- peace and combat, vol 1. 2006. p. 128–54.
larly with diathermy and injury time. A combina- 8. Cannon WB. The emergency function of the adrenal
medulla in pain and the major emotions. Am
tion of alcohol and sleep deprivation was seen to
J Physiol–Legacy Content. 1914;33(2):356–72.
have the greatest number of errors. The results of 9. Cannon WB. The influence of emotional states on the
the study suggested that the effect of sleep depri- functions of the alimentary canal. Am J Med Sci.
vation and prior alcohol consumption on perfor- 1909;137(4):480–6.
10. Cannon WB, Shohl AT, Wright W. Emotional gly-
mance varies with the time of the day (P = 0.02),
cosuria. Am J Physiol–Legacy Content.
and there are discernable residual effects of alco- 1911;29(2):280–7.
hol consumption the following day, despite unde- 11. Cannon WB. Studies on the conditions of activity in
tectable levels of alcohol measured on the breath endocrine glands: the isolated heart as an indicator of
adrenal secretion induced by pain, asphyxia and
the next morning [41].
excitement. V. 1919. Publisher not identified.
12. Cannon WB. Studies on the conditions of activity in
endocrine glands: the influence of motion and emo-
tion on medulloadrenal secretion. XX. 1927. Publisher
Conclusion not identified.
13. Mendl M. Performing under pressure: stress and cog-
There is ample evidence for how the physiology nitive function. Appl Anim Behav Sci.
and state of mind of surgeons, such as sleep 1999;65(3):221–44.
14. Arora S, et al. The impact of stress on surgical perfor-
deprivation and alcohol consumption, can affect mance: a systematic review of the literature. Surgery.
the surgeon and interfere with his performance 2010;147(3):318–30. e6.
during stressful events such as complex surgery. 15. Ahmed A, et al. Effect of distractions on operative
Surgeons should be more aware of these factors performance and ability to multitask—a case for
deliberate practice. Laryngoscope.
and make lifestyle changes accordingly. 2015;125(4):837–41.
16. Mentis H, et al. A systematic review of the effect of
Acknowledgements There are no identifiable conflicts distraction on surgeon performance: directions for
of interests to report. operating room policy and surgical training. Surg
The authors have no financial or proprietary interest in Endosc. 2015:1–12. [Epub ahead of print].
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(ISAT): a feasible, reliable and valid approach to
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hcupnet.ahrq.gov/. nol stress. Neuroendocrinology. 1990;52(5):481–9.
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their relationship to surgical errors: an exploratory of sleep deprivation. Semin Neurol.
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3. Mehtsun WT, et al. Surgical never events in the United 21. Abel T, Lattal KM. Molecular mechanisms of mem-
States. Surgery. 2013;153(4):465–72. ory acquisition, consolidation and retrieval. Curr Opin
4. Kohn LT, Corrigan JM, Donaldson MS. To err is Neurobiol. 2001;11(2):180–7.
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Washington, DC: National Academies Press; 2000. solidation during sleep in patients with primary
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24. Prince T-M, et al. Sleep deprivation during a specific 33. Blum AB, et al. Implementing the 2009 Institute of
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29. Harrison Y, Horne JA. The impact of sleep depriva- 38. Mendelson JH. Biochemical mechanisms of alcohol
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NeuroImage. 2013;83:658–68. cal performance. Arch Surg. 2011;146(4):419–26.
31. Rocklage M, et al. White matter differences predict 40. Dorafshar AH, O’Boyle D, McCloy R. Effects of a
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 Surgeons and Pilots: What Do
We Have in Common? 4
Rifat Latifi

Introduction near Nardaran, Azerbaijan. On 24 July 2014, Air

Algerie MD83, EC-LTV, flight AH5017, near
Flying a plane (or riding in a plane for that matter) Gossi, Mali, crashed after the pilot contacted the
can be dangerous business, but still much safer control tower to request a different route due to
than the number of things we do regularly. In fact, weather conditions, killing six crew members and
it is one the safest thing that we do. There were 119 passengers.
37.4 million flights in 2014, the highest number
ever, and this equates to more than 100,000 flights
per day. Given the low number of fatal crashes that Training of Pilots and Surgeons:
year (7), you would statistically have to fly What Does It Take to Become One?
5,342,857 times for every accident. The average
for 2010–2014 is lower, but still better than any Pilots undergo intensive training in order to fly
previous five year period: one fatal crash per commercially or privately. However, this training
2,925,000 flights. That means a 0.000034 % risk. cannot always predict who will commit errors
You have never been less likely to fly on a plane and who will handle emergency situations effec-
that will crash and experience fatalities [1]. Still tively. Numerous factors play a part in how these
the list of fatalities is extensive and often high- situations are handled. Some of these factors
profile [2]. Recent fatalities include the AF include communication with other personnel,
Andrade Empreendimentos e Participações Cessna technical skill of the pilot, mental state of the sur-
560XLS+ Citation Excel in Guarujá, Brazil, where geon, and external factors such as weather.
five passengers and a pilot were killed after crash- A recent interview with John O’Connell, a
ing into a residential area on 13 August 2014. On pilot with more than 18,000 h of pilot in com-
10 August 2014, five crew members and 18 pas- mand time, provided a brief vision of what a
sengers were killed when Sepahan Airlines HESA pilot may have to encounter, and what that pilot
IrAn 140, flight 217, crashed shortly after takeoff perceives that he has to do in emergency situa-
tions. O’Connell claims that there is a plan A,
then a B, then a C and D. More than one backup
R. Latifi, M.D., F.A.C.S. (*) plan is necessary, and it is good to have these
Department of Surgery, Westchester Medical Center,
plans mentally available during a time of crisis.
New York Medical College, 100 Woods Road,
Valhalla, NY 10595, USA The most important thing is to have the basics of
flying down to a point that you don’t even think
Department of Surgery, University of Arizona,
Tucson, AZ, USA about them. That way, in a time of crisis, you
e-mail: rifat.latifi@gmail.com address the crisis, and not the basic activity of

© Springer International Publishing Switzerland 2016 25

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_4
26 R. Latifi

flying. O’Connell states that the use of checklists being better rested (58.9 %). Interestingly, on
during specific situations is helpful. For example, univariate analysis, older age, female sex, post-
if the engine loses power, there is a standard graduate year, training in a university program,
checklist that pilots go through in order to sys- the presence of a faculty mentor, and lack of
tematically identify the problems that may be Alpha Omega Alpha status were associated with
causing engine failure [3]. serious thoughts of leaving surgical residency.
The safety of airlines is clearly multifactorial, On multivariate analysis, only female sex was
but pilots play a major role, and becoming a pilot significantly associated with serious thoughts of
takes intensive training. To get a private pilot's leaving residency (odds ratio, 1.2; P = .003).
license, you must hold an aviation medical certifi- Eighty-six respondents were from historically
cate, have a minimum of 40 flight training hours high-attrition programs, and 202 respondents
and pass several written and oral exams. To become were from historically low-attrition programs
a commercial pilot, the rules differ based on the (27.8 % vs. 8.4 % 10-year attrition rate, P = .04).
aircraft you will be flying. According to the Federal Residents from high-attrition programs were more
Aviation Administration (FAA), there are several likely to seriously consider leaving residency
certifications and exams that must be passed [4]. (odds ratio, 1.8; 95 % CI, 1.0–3.0; P = .03).
A commercial pilot is responsible for the lives of The authors [5] conclude that:
many people, so intensive flight simulation scenar- The training of surgical residents is a long and
ios are a major part of the training process. arduous process that necessitates an immense
Performing surgery is also a dangerous and investment of time for the trainee and the faculty.
extremely complex process. The training that As such, resident attrition is a tremendous loss for
all involved parties. In this multi-institutional
goes into becoming a surgeon is even more inten- survey of surgical residents, a majority seriously
sive than becoming a pilot. Surgeons typically considered leaving their training, and most had
have between 11 and 16 years of training, includ- such thoughts more than once. Given that prior
ing residency. The training is very complex and it investigations indicate that surgical residents who
think of quitting are more likely to subsequently do
is not an easy process. Such training is necessary so, the survey results herein are sobering. With the
in order for a newly graduated medical doctor to increasing number of women entering surgical
become a surgeon, an expert who is ready to deal training, the fact that female sex predicted thoughts
with the unexpected. Much like the scenario of a of quitting in the present study is similarly con-
cerning. Surgical training programs should take
pilot who does not have to think about the basics heed of these findings and work in a cooperative
when an emergency occurs, a surgeon cannot fashion to address factors that increase residents’
waste time on thinking through basics of operat- desire to leave surgical residency.1
ing when things get out of hand.
It takes many years of training before one can It is unclear what the true attrition rate is
independently take on a complex surgical case. among aircraft pilots, as the recent addition of
The training is so difficult that a recent anony- navigators of unmanned aircraft has compli-
mous survey of 371 categorical general surgery cated things a bit. However, recent articles sug-
residents and evaluation of 10-year attrition rates gest that attrition of trainees from the aviation
for 13 residency programs in the USA revealed program is a continuing concern for the US
that 58.0 % seriously considered leaving the Navy, and each late-stage navy aviator training
training program [5]. The most frequent reasons failure costs the taxpayer over $1,000,000,
for wanting to leave were sleep deprivation on a and ultimately results in decreased operational
specific rotation (50.0 %), an undesirable future
lifestyle (47.0 %), and excessive work hours on a
1
specific rotation (41.4 %). Factors most often From Cooksey AM1, Momen N, Stocker R, Burgess
SC. Identifying blood biomarkers and physiological pro-
cited that kept residents from leaving were support
cesses that distinguish humans with superior performance
from family or significant others (65.0 %), support under psychological stress. PLoS One. 2009 Dec
from other residents (63.5 %), and perception of 18;4(12):e8371.
4 Surgeons and Pilots: What Do We Have in Common? 27

readiness of the fleet [6]. Over the past 20 years, To my great surprize surprise, he admitted that
the attrition rate of incoming aviation students he had a depth perception problem that could not
has been between 15 and 25 %. As with surgical be fixed. Since then I have wondered why we do
trainees, attrition among pilot trainees occurs not give a real comprehensive screening examine
for a variety of reasons including medical prob- for our future surgeons.
lems. However, most attritions result from aca- Human performance under psychological
demic or flight performance failures or requests stress has been studied extensively, and it has
to be dropped from the program. Naval aviation been primarily done psychometrically or using
is a highly stressful occupation requiring the reductionist biological methods such as blood
ability to respond quickly and appropriately in cortisol measurements [7]. Moreover, a study
dangerous situations. While there is no measure published in 1999 that looked at the neuroendo-
of the impact of psychological stress on attrition crine responses among students suggested that
from the program, it makes a clear contribution neuroendocrine reactions as a response to the
to academic/flight performance failures and psychological workload of military flying could
drop out request. Biological screening of poten- be used for identifying stress tolerance in mili-
tial aviators based on performance under psy- tary pilots [8]. Both pilots and surgeons work
chological stress could reduce all of the major under highly stressful jobs, so identifying spe-
contributing factors of attrition, thus saving the cific biomarkers to predict who will make it
Navy millions of dollars. through training and identify those who will not
would be quite useful. Such work would also
provide potential biomarkers for screening
Selection of Surgical Residents humans for capability of superior performance
and Future Pilots under stress. If this testing is proved in the future
to predict who will be able to adapt better to high
There is a difference between how surgical resi- intensity situation, we believe that such protocols
dents and pilots are selected. Potential aviators should be extended to future surgeons as well.
are currently selected using the Aviation While there are a number of similarities
Selection Test Battery (ASTB). The ASTB is a among pilots and surgeons, still there are some
written test designed to evaluate math and verbal other significant differences between surgeons
skills, mechanical comprehension, aviation and and pilots with respect to public involvement.
nautical information and spatial apperception. Every pilot error is recorded, scrutinized, ana-
The ASTB has a strong predictive validity lyzed and often made public; rarely are the errors
through primary flight training. While the ASTB of surgeons made public, unless there is a major
evaluates many skills necessary for aviation, and lawsuit or clear negligence. There is no recording
it is correlated with performance, it does not of the procedures, and thus it is impossible or
account for the natural genetic variation in physi- very difficult to replay them and make them pub-
ological stress response. Once selected by the lic. Furthermore, because of privacy issues, only
ASTB, all naval pilot trainees undergo water sur- a few major mistakes by surgeons ever make it to
vival training in the Modular Egress Training the news.
Simulator (METS) device a highly demanding
and stressful test. In contrast, potential surgical
residents are interviewed, and have to demon- Pilots and Surgeons: The Dangerous
strate that they have done well in the past educa- Jobs
tion, show dedication, but there is no physical
test. Actually, once I observed a chief resident Both pilots and surgeons have dangerous jobs;
struggling while removing a gallbladder. I asked these types of careers take the lives of other peo-
him to see an optometrist, as I thought his glasses ple in their hands while engaging in tasks that are
were old and maybe he needed a new prescription. played out in dynamic, ever-changing contexts.
28 R. Latifi

Paying attention to all available cues is of the goal of this chapter is to establish what may be
utmost importance. After all, people’s lives occurring when a surgeon or pilot seemingly
depend on it! Like pilots, surgeons work in makes a “gut-level” decision. There is a whole
dynamic environments, while taking responsibil- host of other factors that the operator is not aware
ity for the lives of individuals and managing to of, such as the integration of the information they
complete difficult tasks such as a pancreaticodu- have learned through training and experience.
odenectomy, liver or lung resection, or takedown This phenomenon can be called situational
of complex multiple fistulas. While these and the awareness (SA), sense-making, or unconscious
countless other surgical procedures may seem processing of environmental cues. Regardless of
very difficult for non-surgeons or novice and the term used, the concept has been reviewed in a
inexperienced surgeons, the well-trained surgeon number of ways, particularly in the literature on
can complete these procedures safely, but when a the abilities of pilots [10–13].
crisis arrives things change dramatically. Maybe
as we surgeons we have a bit “more time” to
address our crises, as our operating room is not Situational Awareness and
flying at 1000 km/h. Still, the environments of Sense-Making
surgeons and pilots are considered dynamic,
meaning there is continual change occurring Situational Awareness is a concept that has been
within the environment. studied extensively for pilots and can be applied
When broken down by steps, work within to surgeons in the operating room. Military strat-
dynamic environments can be fit into three major egists have applied this concept to operating air-
categories. First, the pilot or surgeon must con- craft, ships, and in emergency military situations.
tinually monitor and assess the situation. While As described in Chap. 2 of this book, situational
this is the first step in the process, it is also con- awareness can briefly be described as “the per-
tinual. The pilot or surgeon has to assess the situ- ception of elements within a volume of time and
ation with each development in order to process space, the comprehension of their meaning, and
how to respond and which step to take next. He the projection of their status in the near future
or she must then take appropriate reactions based [9].” Numerous studies looking at the effects of
on assessment. Once appropriate action is taken, situational awareness in virtual and real environ-
evaluation of results must be made. The cycle ments among military personnel have been con-
then repeats itself [9]. These jobs are intensely ducted [9]. Few studies have been conducted that
stressful, not only because people’s lives are look at how situational awareness can be applied
dependent upon decisions that are made, but in the medical field.
there is no “down-time” while performing these Of the few studies that investigate situational
jobs. A surgeon can’t go take a break during a awareness in the medical field, either communi-
long and intense surgery. A pilot can’t stop flying cation among surgical team members or the use-
a plane if he doesn’t feel well. Additionally, a fulness of the concept of situational awareness
key aspect to functioning successfully in com- has gained most attention; these aspects are also
plex dynamic environments is the ability not only termed non-technical skills. Postgraduate train-
to observe and seek information, but to under- ing in the medical field is extensive. With this
stand what that information means in the larger post-graduate training, a whole host of technical
context of a task goal [10]. Moreover, an ability skills are acquired from how to approach and
to then anticipate events in that environment examine the patient and identifying problems
leads to better prediction and understanding of that need an intervention to highly technical pro-
future events. The cognitive components of these cedures for various operations. However, non-
processes are of interest to researchers and will technical skills are somewhat individually based,
briefly be discussed in this chapter. While these and not every surgeon is trained the same,
cognitive components are of interest, a major although the basics fairly similar. These skills are
4 Surgeons and Pilots: What Do We Have in Common? 29

just as valuable as technical ones, and are a com- to characteristics of individuals, the design of a
mon subject of investigation for surgical never- system, for example, how patient information
events. As described in Chap. 3, surgical flows to the surgeon prior to surgery, and the
never-events are events that include operating on team environment can affect SA.
the wrong patient, performing the incorrect sur-
gery, operating on the wrong limb, etc. These
errors are substantially high and are easily reme- Situation Awareness, Perception,
died if the proper precautions are taken [14]. Comprehension, Projection
Specifically, the use of non-technical skills, such
as communication and organization, is required The three main factors that drive or underlie SA
in order to prevent surgical never-events. are perception, comprehension, and projection
The concept of situational awareness has been [17–19]. These can easily be mapped onto the
investigated in order to prevent these forms of levels described by Endsley. These concepts
errors. For example, Gaba et al. discuss potential allow for awareness to be parceled out into trac-
application of the concept among anesthesiolo- table portions for further understanding. One of
gists [15]. Flin et al. make the case for applying the cognitive processes associated with SA is that
decision-making analysis concepts (i.e., natural- of working memory. Working memory can be
istic decision-making) in a two-step process that defined as the system that actively holds multiple
includes: assessing and diagnosing the situation, pieces of transitory information in the mind,
then using one of four strategies to make a deci- where they can be manipulated. Working mem-
sion. These strategies are selected based on a ory includes subsystems that store and manipu-
continuum of urgency, and include intuitive rec- late visual images or verbal information, as well
ognition, rule-based, analytical, and creative as a central executive that coordinates the sub-
decision-making. When the need to make a deci- systems. It includes visual representation of the
sion is urgent, intuitive recognition decision- possible moves, and awareness of the flow of
making is used, whereas when the need to make information into and out of memory, all stored
a decision is not urgent, creative decision-making for a limited amount of time. Working memory
is used [16]. For example, creative decision- tasks require monitoring, which is a component
making requires more time and less urgency. It of SA, as part of completing goal-directed actions
appears that there is a blend of intuitive recogni- in dynamic environments. The cognitive pro-
tion decision-making and creative decision- cesses needed to achieve this include the execu-
making during surgery. tive and attention control of short-term memory,
According to Mica Endsley, a pioneer in the which permit interim integration, processing, dis-
field of SA, there are different levels of SA [11, posal, and retrieval of information. These pro-
12]. At the lowest level of SA, a person needs to cesses are sensitive to age: working memory is
perceive relevant information (Level 1 SA). associated with cognitive development, and
Integrating various pieces of information while research shows that its capacity tends to decline
keeping the overall objective of the task in mind, with old age. In addition, neurological studies
allows the individual to form an understanding of demonstrate a link between working memory and
the meaning of that information within context, learning and attention as well as being an under-
forming Level 2 SA. Based on this understand- lying component of SA [17].
ing, future events can then be predicted (Level 3),
allowing for timely and effective decision-
making. Several processing mechanisms have Conclusion
been hypothesized to be related to SA, including
attention and working memory limitations, atten- Both pilots and surgeons have to make serious
tion distribution, current goals, mental models, decisions that are time-dependent and may have
schemata, and automaticity [10–12]. In addition serious consequences. While the pilot is supported
30 R. Latifi

by the most sophisticated technologies of the flying residency programs: a multi-institutional study.
JAMA Surg. 2014;149(9):948–53.
machine, the surgeon has to make decisions that
5. Cooksey AM, Momen N, Stocker R, Burgess
are dependent a lot on his or her experience, SC. Identifying blood biomarkers and physiological
knowledge, and often this decision is gut based. processes that distinguish humans with superior
Overall, these decisions are made in dynamic performance under psychological stress. PLoS One.
2009;4(12):e8371.
environments. Awareness of individual state of
6. Schedlowski M, Wiechert D, Wagner TO, Tewes
the surgeon and pilot is crucial, together with U. Acute psychological stress increases plasma levels
awareness of the operating environment, such as of cortisol, prolactin and TSH. Life Sci. 1992;50:
communication dynamics among the teams. Not 1201–12051.
7. Leino TK, Leppäluoto J, Ruokonen A, Kuronen
being aware of certain subtleties in communica-
P. Neuroendocrine responses to psychological work-
tion may be detrimental to both surgical and load of instrument flying in student pilots. Aviat
piloting outcomes. Additionally, extensive train- Space Environ Med. 1999;70(6):565–70.
ing will allow for a surgeon and a pilot to be pre- 8. Endsley MR. Towards a theory of situation awareness
in dynamic environments. Hum Factors. 1995;
pared for unexpected events. Checklists, while
37:32–64.
possibly viewed as something to be used by nov- 9. Endsley MR. A survey of situation awareness require-
ices only, have been shown to be helpful with ments in air-to-air combat fighters. Int J Aviat Psychol.
pilots and surgeons [20–21]. Finally, there is 1993;3:157–68.
10. Endsley MR. Measurement of situation awareness in
much to learn regarding how and why individu-
dynamic systems. Hum Factors. 1995;37:65–84.
als make decisions, particularly decisions that 11. Endsley MR. The application of human factors to the
appear to be gut-level or unconscious. The development of expert systems for advanced cockpits.
research in this field is valuable and informa- In Proceedings of the 7th international symposium on
aviation psychology. Columbus: Ohio State
tive for professions that make decisions in
University; 1987, p. 167–71.
dynamic environments that will affect the lives of 12. Durso FT, Sethumadhavan A. Situation awareness:
other individuals. understanding dynamic environments. Hum Factors
J Hum Factors Ergon Soc. 2008;50:442–50.
13. Mehtsun WT, et al. Surgical never events in the United
Acknowledgements There are no identifiable conflicts
States. Surgery. 2013;153(4):465–72.
of interests to report.
14. Gaba DM, Howard SK, Small SD. Situation aware-
The authors have no financial or proprietary interest in
ness in anesthesiology. Hum Factors J Hum Factors
the subject matter or materials discussed in the
Ergon Soc. 1995;37:20–33.
manuscript.
15. Flin R, Youngson G, Yule S. How do surgeons make
intraoperative decisions? Qual Saf Health Care.
2007;16:235–9.
16. Gutzwiller RS, Clegg BA. The role of working mem-
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Mak. 2013;7(2):141–54.
1. Garfors G. Is it safe to fly? Globetrotting galore. 17. Durso FT, Sethumadhavan A. Situation awareness:
http://www.garfors.com/2015/03/is-it-safe-to-fly-- understanding dynamic environments. Hum Factors
dangerous.html. Accessed 20 Oct 2015. J Hum Factors Ergon Soc. 2008;50:44.
2. ABC News. In wake of emergency landings, pilot 18. Bedny G, Meister D. Theory of activity and situation
simulates situations. http://www.abc-7.com/ awareness. Int J Cogn Ergon. 1999;3:63–72.
story/26293414/in-wake-of-emergency-landings- - 19. Smith D. Introduction to aeronautical decision mak-
pilot-simulates-situations#.VibA6H6rSUl. Accessed ing (2002). Accessed 8 Oct 2009 from World Wide
20 Oct 2015. Web: ADM.
3. Federal Aviation Administration (FAA). Federal 20. Aircare. An aviator’s guide to good decision making.
Aviation Administration (FAA). http://www.faa.gov/. Wellington: Aircare; 2006.
Accessed 20 Oct 2015. 21. Gawande A. The checklist manifesto: how to get
4. Gifford E, Galante J, Kaji AH, et al. Factors associ- things right. New York: Metropolitan Books, Henry
ated with general surgery residents’ desire to leave Holt and Company, LLC; 2009.
 A Surgeon’s Decisions
as the Leader 5
of an Interdisciplinary Action
Team

Rifat Latifi, John A. Stroster,

and Katherine E. Center

Introduction collective actions to achieve a common objective

[2]. Such teams can include military combat
A large amount of research on how teams make units, firefighters, hazardous chemical cleanup
decisions has been conducted on stable teams companies, professional sports teams, and avia-
with well-defined, static tasks [1]. However, in tion crews; however, while these groups are often
order to explain the decision-making structure of composed of people with similar training, surgi-
teams functioning in unpredictable situations cal teams are instead interdisciplinary [1]. By
with changing goals, such as a surgical team, a their nature, any action team has to respond to
different approach must be taken. When describ- unexpected events in a coordinated manner, and
ing the fast-paced coordination of a dynamic this usually requires real-time communication to
team to achieve a common goal, like saving a facilitate orchestrated actions in response to
patient’s life, it is more appropriate to consider a changing circumstances. Often performing in
surgical team alongside other types of “action novel environments that their previous training
teams.” An action team is one that is composed and experiences have not necessarily prepared
of members with specialized skills who must them, the specific performance requirements and
constantly improvise and respond to rapidly strategic approaches that influence the decisions
changing situations in order to coordinate their of an action team are often difficult to study. An
effective action team has both knowledge and
R. Latifi, M.D., F.A.C.S. (*) expertise distributed among its members, as well
Department of Surgery, Westchester Medical Center, as the ability to adapt to their changing environ-
New York Medical College, 100 Woods Road, ment. Not only do action teams adapt to novel
Valhalla, NY 10595, USA
environments, but they also influence and change
Department of Surgery, University of Arizona, their environments in order to alter the circum-
Tucson, AZ, USA
e-mail: rifat.latifi@gmail.com stances to potentially achieve success [3]. As the
leader of an interdisciplinary action team in the
J.A. Stroster, Ph.D.
Department of Surgery, Banner University operating theater, it is the responsibility of the
Medical Center, 172 S. Bonanza Ave., surgeon to prevent breakdowns in the team’s
Tucson, AZ 85748, USA coordination by minimizing miscommunication,
e-mail: stroster@surgery.arizona.edu interpersonal conflict, and poor judgment during
K.E. Center, Ph.D. crises. This is particularly important when the
Department of Obstetrics and Gynecology, University surgeon, such as a trauma, in addition to caring
of Arizona College of Medicine, 1501 N. Campbell
Ave., Tucson, AZ 85724, USA physically for the patient, has to orchestrate a
e-mail: katherine@obgyn.arizona.edu number of other surgical teams to work on a

© Springer International Publishing Switzerland 2016 31

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_5
32 R. Latifi et al.

trauma victim. See the case discussion at the action team, such as one in an operating theater,
end of this chapter. Once you read the case, it will is the ability for members to rapidly synchronize
become very clear that decisive surgical decision, with their teammates in novel or unfamiliar
close collaboration with other teams (in this case situations, without necessarily having prior
anesthesia and orthopedics), and the decision to knowledge of the most effective strategies
return the patient to the operating theater in a required for successful outcomes. A shared char-
timely fashion, and without any hesitance, saved acteristic of successful action teams seems to be
this severely injured patient. the flexibility to quickly and accurately shift
knowledge structures and actions in a coordi-
nated way when facing changing circumstances.
Communication Within Surgical As an action team leader, the role of the surgeon
Action Teams is to provide the contextual information to allow
other team members the opportunity to orient
The novel situations experienced by any action themselves to new surroundings, supply cues that
team (including those in the operating theater) signal the need for adaptation, and then expand
can range from very familiar to completely unfa- upon prior knowledge and experiences to facili-
miliar, and therefore determining how a team tate their mental model development. One vari-
adapts to new situations is central to studying able that may influence the growth and expansion
their decision-making processes. The fast-paced of mental models within an action team is how
coordination demonstrated by a surgical team the team leader conveys information about their
requires real-time communication that cannot be task environment [3, 5].
scripted and rehearsed in advance. Alterations of Leader communication is a critical factor in
these communication routines and mental models the formation of a team's mental models, espe-
can occur when there are changes in the situation, cially in novel environments. Briefings in all their
equipment, or team members [3]. When per- formats provide a means by which a leader can
formed actions become increasingly habitual effectively communicate vital information to
over time, it may become more difficult to impro- their team before an event or mission, and help
vise and coordinate when the context of a situa- develop the necessary flexibility to adapt to the
tion changes. For example, the introduction of a potentially evolving situations that they may
new piece of surgical technology may require soon face [3]. Our patient was brought to the CT
additional skills and routines that inspire a transi- scan after complex operation with the idea to take
tion across the entire team in the operating the- him to the ICU for further care. However, his CT
ater. The quality of the information conveyed by scan demonstrated re-accumulation of fluid
the team leader can provide crucial knowledge (blood in this case in the abdomen), and decision
that the rest of the team can use to adapt to was made to take him back to the operating the-
the demands of the changing situation. ater at once.
Implementation of new practices on any level One successful briefing model that has been
can thereby be seen as a learning process that adapted to many other action teams was origi-
involves collective discussion and experimenta- nally developed as a routine procedure by mili-
tion, with the surgical leader sharing both techni- tary personnel more than 30 years ago. Before
cal and situational knowledge to assist the team each mission or event, the team conducts a brief-
in forming a mental model for the operation [4]. ing session to clarify its tasks, goals, and the cur-
Mental models provide an action team with a rent conditions of the situation. After the event or
common framework that can be utilized to recog- procedure, the team meets again for a post-action
nize, interpret, and react to novel environments. reflective analysis, otherwise known as a debrief-
Any team may excel when they are performing in ing or after-action review. Research on leader
a familiar environment, where every member has briefings has demonstrated that the content of the
a similar and accurate understanding of how to briefing has greater effect on team performance
complete their assigned tasks. What separates an than the duration of the briefing; these meetings
5 A Surgeon’s Decisions as the Leader of an Interdisciplinary Action Team 33

are also important opportunities for leaders to because the associated differences in status,
clarify and make sense of novel situations and training, language, and organizational norms can
unfamiliar elements, and to help the team orga- impede communication and shared understand-
nize and interpret new information and create ing [1]. For surgical teams, the surgeon is often in
accurate mental models [3]. The post-action the unique position of providing perspective to
debriefing is meant to be an open exchange of the rest of the team, and understanding how the
opinions from all members of the team, but some expertise of each team member fits together in
organizational structures may prevent an equal order to help the team share a common vision
exchange of ideas, particularly when there are regarding the situations they encounter. However,
differences in rank or power between team mem- differences in power or status among the team
bers [6]. Ideally, the status or rank within the members increase the interpersonal risk faced by
organizational hierarchy should not influence the those who wish to share ideas or concerns. When
feedback an action team member receives or an action team must adapt to a new situation or
delivers; given that lives are at stake, the focus routine, members may feel anxious about the
should be on continuous attention to detail that change, reducing their willingness to get clarifi-
will improve team effectiveness [7]. cation or voice their opinion. This reluctance can
Since the briefing-–debriefing model requires be magnified or mitigated by the amount of
a meeting of all action team members prior to the power that particular member possesses within
operation, it is not generally embraced fully the group. Defined as the capability of a team
within the surgical setting, as the chief surgeon is member to direct the behavior of others, power
rarely present at the very beginning or end or the tends to inhibit the flow of information upward
procedure [7]. This is different from trauma set- through the team’s hierarchy [10]. Those team
tings, when trauma surgeon is consistently members with less power tend to protect them-
together with the team, and, in the practice of the selves through the practice of self-censorship,
senior author, briefings and debriefings happen and often defer their opinion to those with more
almost always, although in less formal settings. power.
A team leader’s actions and example can there- Multiple disciplines come together within an
fore affect whether others on the team willingly operating theater: surgeons, anesthesiologists,
share information, particularly when the input nurses, and various technicians work together to
may be critical of the actions of another team treat a patient. Each role is clearly defined, and
member. While it may be safer for the individual since the other members of the team are attempt-
to remain silent, this act undermines opportuni- ing to anticipate the actions of the surgeon, this
ties for learning and improvement, and erodes makes the surgeon the natural leader of this
overall team effectiveness [8]. Through their action team. Given each member of an interdisci-
actions, whether symbolic or otherwise, leaders plinary surgical team has specialized expertise,
shape the culture of an action team. Their prefer- omitting the contribution of one team member
ences become the preoccupation of the rest of the from the discussion may negatively affect a
team, because all rewards, punishments, and patient’s life. As the team leader, a surgeon is
resources abide by the leader’s priorities [9]. therefore in the position to address such barriers
through the act of mentoring or coaching [1].
Coaching is a direct interaction with the team
Leading Through Interpersonal intended to foster changes to either individual or
Conflict team activities and improve overall effectiveness
[11]. It may include the provision of feedback
While we have established that unrestricted com- and clarification of a situation, seeking the input
munication is important among members of an of others within the team, and explaining why the
action team, such openness may prove challeng- feedback of others is essential for the team’s suc-
ing for teams that include various disciplines cess [1]. Without support from the surgeon, the
34 R. Latifi et al.

other team members in the operating theater may cians perform tasks in an inefficient manner that
find it difficult to declare their concerns related to may be jeopardizing the life of the patient for
a particular set of actions; therefore, the style of which the attending is ultimately responsible.
leadership that the surgeon adopts ultimately As the leader of an action team, it is imperative
contributes to both the communication and suc- that the surgeon provide strategic direction to the
cess of the entire team. team, monitor the entire situation, provide hands-
Within the example of a trauma team, there on treatment, and teach the other team members
are three potential leaders: the attending surgeon, in order to reduce the risk of errors during emergent
the surgical fellow or chief resident, and the crises [12].
admitting resident; each individual differs in
their expertise, experience, and tenure. Because
leadership of a trauma team resides in no single Guiding a Surgical Action Team
individual or position, it can be stated that leader- Through Crises
ship is shared; however, active leadership is not
shared simultaneously, and one voice will ulti- Identifying the organizational, team, and human
mately guide the patient’s treatment. Providing causes that contribute to adverse events in the
strategic guidance and direction is perhaps the operating theater are of particular interest to
most important function of the team leader, but researchers. Specifically fascinating are the
active leadership may shift along the tenure of an human factors associated within the operating
individual, or even during the course of care for theater itself, such as: the surgeon’s leadership
an individual patient. A shift in active leadership style, the attitudes among the surgical team, the
occurs when a senior leader (i.e., the attending impact of new technology or technique on team
surgeon or the fellow) takes over the strategic performance, and the intraoperative decision-
direction of the team, assuming a more influential making by the surgeon [13]. “Near-miss” report-
role, or when that senior leader assumes a more ing systems are widely used by action teams in
passive role and delegates responsibility to a the aviation, chemical, nuclear, and railway
more junior team member. These rapid and industries, but can also be applied to surgical
repeated transfers of active leadership up and teams as well. Conceptually, near misses imply
down the organizational hierarchy have been that some form of adaptation and recovery
referred to as dynamic delegation [12]. Often the occurred to avert one or more negative conse-
more urgent and uncertain the patient’s condition quences; the cascade of events initiating the
is, the less likely that there will be shifts of power adaptation could have been caused by chance, by
out of the senior leader’s control. Conversely, the an outside factor, or even through the actions of
more routine the case is, or the more confident one of the team members. Analysis of such
the senior leader is with their junior members, the occurrences can highlight the need for modified
more likely they are to delegate tasks of leader- procedures, enhance risk awareness, and demon-
ship. During the process of dynamic delegation, strate a model for how to handle a potentially
especially during a highly stressful environment critical situation. These types of reporting sys-
that accompanies emergent situations, it would tems are already in place for anesthesia and
seem logical that there may be considerable con- transfusion medicine, but in surgery there is a
flict among the potential leaders. Admitting resi- need to distinguish between a “near-miss” and
dents and fellows seeking opportunities to learn serious perioperative and/or postoperative com-
and advance within their field might resent and plications [13].
resist the intervention of attending surgeons who As a team leader, surgeons coordinate the
assume the care of the patient. The attending sur- actions of the entire team during intense and
geons might become equally resentful that they unfamiliar situations, and the behavior and the
are expected to stand on the sidelines, while decision-making of the surgeon in a crisis defini-
watching less experienced or competent physi- tively influences the team performance. The con-
5 A Surgeon’s Decisions as the Leader of an Interdisciplinary Action Team 35

fident and knowledgeable surgical leader with Guiding a Surgical Action Team
clear plan of action even in worse situation Through Uncertainty
injects confidence in the entire team. Scared or
uncertain team leader is a disaster for the moral Surgical decisions happen in settings that include
of the entire team. Members of action teams uncertainty, ambiguity, missing data, continually
require ongoing learning and problem solving, changing conditions (such as in trauma patient),
and this is why the experience of an action team as well as real-time reactions to those changing
leader provides them with a greater distance in conditions; time stress, high stakes, and multiple
power and status compared to their more junior players are difficult and require experience, intu-
counterparts than in other fields with self-man- ition, and most importantly require one team
aged work teams (such as industries involving leader. Settings like this are typically not condu-
production or sales) [1]. To improve the quality cive for long analytical decisions.
of surgical training, curricula are moving away Uncertainty exists in situations whenever
from immersion learning, and are instead doubt results in delaying action [15]. Uncertainty
embracing more structured competency-based includes both the event the decision maker is
assessment programs. Challenging cases can uncertain about and questions about the source
now be deconstructed to analyze the surgeon’s that caused this event [15]. Typically, uncertainty
non-technical skills, specifically their judgment stems from having incomplete information [16].
of risks, assessment of the situation, clinical However, uncertainty can also occur when infor-
competency, and communication with the rest of mation is unclear and conveys conflicting mean-
the team. Deconstruction of the difficult surgical ings, thus delaying decision makers [17].
case while on rounds or other settings and infor- Additionally, even when decision makers have
mal discussion have long lasting effects on train- adequate information and understand the situa-
ees. One intuitive method to develop a mental tion, they still may not have a clear option and
model for surgeons is recognition-primed deci- must choose between equally attractive—or
sion-making, where a problem is recognized and unattractive—alternatives.
the solution is quickly recalled from a memo- As uncertainty exists in the operating theater,
rized rule or previously observed technique. the question becomes how does a surgeon work
When using this method, a course of action is with uncertainty and plan a course of action.
likely to be nearly automatic, with little delibera- There are three strategies people typically use
tion. However, when there is uncertainty, the sur- when making decisions in uncertain situations
geon will likely employ analytical or rational [15]. The first strategy to reduce uncertainty by
choice decision-making, where they recall a using tactics such as collecting additional infor-
number of potential courses of action and then mation, delaying action until more information is
choose the option that seems to fit the current gathered, or extrapolating information from what
situation the most closely [14]. Ultimately the is known (e.g., using knowledge and reasoning to
path chosen is influenced by the mental models make assumptions). The second strategy to
and prior experiences of surgeon, and this is reduce uncertainty is to acknowledge it. By
where the senior surgeon teaching subordinate acknowledging uncertainty, surgeons can take it
members of the action team can have a large into account when choosing a course of action
impact. Surgeons can provide directive leader- and by choosing a course of action that aims to
ship to less experienced junior surgeons when avoid or minimize potential risks. A third strat-
their tasks seem to be unstructured and complex. egy to reduce uncertainty is to suppress it. This
Not only does the surgeon monitor the team’s strategy includes denying, ignoring, or distorting
performance and search for potential threats to undesirable information or going through the
team effectiveness, but they motivate and motions of acknowledging uncertainty or reduc-
enhance the team’s overall commitment to ing it). Such an example is a patient with necro-
accomplish the tasks at hand [12]. tizing soft tissue infection of the operative wound
36 R. Latifi et al.

whom a young surgeon decided to “watch”; the use their detailed knowledge, coupled with their
senior author had a chance to manage it. Anyone assessment of the current situation, to construct
who ever has dealt with these conditions knows simulations of how the situation is going to
or should know what will happen. The dead develop, and to generate predictions and
wound needs debridement. Not observation. expectations.
Although suppressing uncertainty is a plausi- Expertise is necessary to recognize when situ-
ble strategy to reduce uncertainty, it is clearly ations are typical and when they have deviated
less desirable in general, but particularly in the from the norm. Expertise is also crucial in devel-
operating theater. However, there is one group of oping both the mental simulations of plausible
decision makers who have been shown to plan a explanations and in evaluating possible courses
course of action quickly and effectively with of action. Expertise is valuable; however, in case
very little information, and we tend to label these of surgeons, it can take years of experience for
individuals as “experts” [18]. Clearly, trauma one to become an expert. What can be done to
surgeons should be in this group. enable each surgeon to develop the decision-
making skills of an expert? Creating an expert
out of surgical resident takes times. This is no
Expertise in Decision-Making different from creating an athlete, a writer or any
other skilled professional, for that matter, who
Increasing evidence suggests that experts make practices day-in and day-out. Surgeons, in order
decisions differently than non-experts [19]. For to be able to make decision clearly and without
example, while novices spend more time choos- hesitation have to undergo years of training, and
ing their plan of action—looking for the best continuous practice once they are on their “own.”
decision—experts spend that time analyzing the
situation [20]. Experts also demonstrate increased
self-reliance and the ability to form new strate- Developing Expertise
gies [21], they show a much deeper, functional in Decision-Making
understanding of the problem [22], and they look
for an effective course of action, not necessarily In order to improve the quality of decision-
the best action. This is an effective strategy in making, we need to increase the level of exper-
situations that are subject to intense time pres- tise of the decision maker. People become experts
sures [23]. Typically, experts visualize a likely by engaging in deliberate practice; compiling
plan of action, and this first option by an expert is extensive experience banks; obtaining feedback
typically of high quality [19, 23]. that is accurate, diagnostic, and reasonably
In situations of time pressure and uncertainty, timely; and by enriching their experiences by
experts show several distinct patterns of decision- reviewing prior experiences to derive new
making [24, 25]. First, experts assess if a situa- insights [26]. Klein recommends using skills and
tion is a typical case. In typical cases, routine tactics experts as approaching strategy [27].
actions are usually warranted, and they are usu- Of course the principal strategy in thinking
ally successful. Second, when experts are con- like an expert is developing extensive experience
fronted by something unusual in the situation, in a field. Although experience is earned primarily
they tend to mentally simulate the events leading through direct practice (surgical residency pro-
up to the observed features of the situation. This gram), it also can be developed vicariously
mental simulation allows experts to make deci- through experiences described by others and by
sions and plan their course of action. In addition simulating experiences. Furthermore, experi-
to mentally simulating what lead to the current ences can be enriched by reflecting on them and
situation, experts also mentally simulate their looking for incorrect assumptions and missed
course of action in order to evaluate outcomes opportunities or signals. Reviewing decision-
and anticipate consequences. In this way, experts making processes can be very valuable, espe-
5 A Surgeon’s Decisions as the Leader of an Interdisciplinary Action Team 37

cially when opportunities for experience may be are important resources for improving expertise
limited [26, 27]. in a field [27].
Experience alone is not enough to develop
strong decision skills; practice needs to be delib-
erate. Experts practice with a goal in mind, which Case Discussion
allows them to evaluate their practice. Practicing
deliberately includes articulating goals and iden- A 35-year-old motorcyclist collides with a fast
tifying the types of judgment and decision skills moving car and sustains major injuries, what we
that need improvement. In addition to deliberate call handle bar injuries, where he breaks severely
practice, decision-making expertise develops his pelvic bones, perforates his perineum, widely
from obtaining accurate, diagnostic and timely communicating with both his inner thighs, and
feedback. Gaining experience without this kind bleeds a large amount of blood at the scene. He is
of feedback is not sufficient to develop decision brought to the trauma room in state of shock,
expertise [27]. clearly dying from blood losses, and in severe
pain from all the injuries. The trauma surgeon, as
captain of the ship, makes a decision to start
Summary emergency blood transfusion, directs intubation
emergently and obtains a chest X-ray and pelvic
A surgeon’s leadership of the interdisciplinary X-rays as “work up.” The chest X-ray is normal,
team has major consequences and often requires so he is not bleeding in his chest. However, as
out-of-the-box thinking and decision-making. suspected, the pelvic X-ray demonstrates mas-
While these decisions can be decisive, there sive fractures of pelvic bones that are felt while
always room for flexibility and team input. True packing the patient’s perineum to stop the mas-
experts show flexibility in scanning situations sive bleeding. There is blood in the urinary cath-
[19, 26, 27]. This skill can be developed by prac- eter, and, on FAST exam, the abdomen is full of
ticing attentional control in order to scan various blood and the urinary bladder is empty. While the
aspects of a situation and increase awareness of images are displayed on the screen of US
the situation as a whole. Another strategy is to machine, the trauma surgeon knows this means
practice different tactics. Experts have a large only one thing: his urinary bladder is ruptured.
repertoire of actions to choose from and are able His low blood pressure and heart rate in the 150s
to imagine the consequences of one action over do not allow the team to obtain any more studies,
another. Practicing different options improves such as a CT scan. A large pelvic binder is tight-
experts’ ability to shift between options and pre- ened around his pelvis, and the patient is moved
vents them from being locked into a less success- to the operating theater. The real drama of the
ful option. However, not all options can be evening starts in room 7 that is reserved mostly
rehearsed, so another strategy is to build rich for trauma cases.
mental models of situations. By building rich Act 1. In the operating theater (less than
mental models of the situations they commonly 10 min from his arrival to trauma room), the
experience, experts become adept at understand- abdomen is found to be full of blood is packed.
ing what factors can cause various situations to Blood is given back to the patient, in addition to
develop as well as in understanding the effects of a massive transfusion protocol, which includes
future actions. A final habit common among packed RBC, fresh frozen plasma, and platelets.
experts is to work with a mentor—someone who The surgery team finds that the patient has sus-
will aid in developing specific goals to work on tained complex blowout of his urinary bladder,
and criteria to evaluate decisions, who will give rupture of the mesentery of sigmoid colon, and
diagnostic feedback and discuss individual expe- has a large retroperitoneal hematoma. The trauma
riences. In this way, mentors help develop mental team, led by this (RL) trauma surgeon, resects
models and improve decision processes. Mentors quickly the sigmoid colon, repairs the urinary
38 R. Latifi et al.

bladder, and asks the orthopedic surgeon to place training for team adaptation to novel environments.
J Appl Psychol. 2000;85(6):971.
an X-fix to bring together the severely broken
4. Edmondson AC, Bohmer RM, Pisano GP. Disrupted
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 Planning and Preparing
for the Operation: Guidelines 6
and the Evidence-Based Decision
Tree

Wilson Dario Rodríguez Velandia,

Patrizio Petrone, Hans Fred García Araque,
Soraya SMolero Perez, and Corrado Paolo Marini

Introduction standpoint of all possible outcomes including

mortality, functional results, and quality-
Planning and preparing for any operation adjusted life years, as opposed to the realistic
involves undertaking an in-depth analysis of the expectations based on the patient’s overall phys-
risk–benefit ratio associated with the particular iological conditions and the specific preopera-
pathological condition that is being addressed tive findings. Clearly, planning and preparing
surgically. When planning the most appropriate appropriately for any operation, and in particu-
surgical treatment for a patient, it is important to lar for very complex surgical operations, plays a
have a firm understanding of what we expect major role on the ultimate outcome of the patient
from the operative treatment of the specific sur- by minimizing untoward intraoperative events
gical pathology affecting the patient from the and by optimizing the physiologic organs’
reserve of the patient to withstand the operative
insult associated with the planned operation.
W.D.R. Velandia, M.D. Planning and preparing for an operation has
Department of Surgery, Westchester Medical Center evolved over time from the application of per-
University Hospital, New York Medical College, sonal experience and intuition, and from what
Valhalla, NY, USA
some would call the “gut-feeling” of the operat-
Complejo Hospitalario Universitario de Ferrol, ing surgeon, toward the use of predictive models
A Coruña, Spain
that can quantify the risks, namely the morbidity
e-mail: Ananias162@hotmail.com
and mortality associated with a particular proce-
P. Petrone, M.D., M.P.H., M.H.A., F.A.C.S.
dure using probabilistic models. The aim of this
S.S. Perez, M.D. • C.P. Marini, M.D., F.A.C.S. (*)
Department of Surgery, Westchester Medical Center review is to highlight some of the more important
University Hospital, New York Medical College, aspects of planning and preparing for an opera-
Valhalla, NY, USA tion and to provide guidelines based on the best
e-mail: petronep@wcmc.com; patrizio.petrone@
available evidence on the subject.
gmail.com; sorayamsmp@gmail.com; marinic@
wcmc.com
H.F.G. Araque, M.D.
Hospital Militar Central, Bogotá, Colombia Assessment of Surgical Risk
Westchester Medical Center University Hospital,
and Anesthetic Considerations
Valhalla, NY, USA
Surgical interventions induce a stress response
Department of Surgery, New York Medical College,
Valhalla, NY, USA whose magnitude depends on the pathology
e-mail: hafregar@gmail.com being treated, the position of the patient on the

© Springer International Publishing Switzerland 2016 41

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_6
42 W.D.R. Velandia et al.

operating table, the surgical approach, namely, an Predictive Models

open versus a laparoscopic or endovascular for the Estimation of Cardiac-
approach, the acuity type of surgery, namely Related Morbidity and Mortality
emergent (life or limb threatened if not in the
operating room (OR) in less than 6 h), urgent (life Clinicians have used different predictive models
or limb threatened if not in the OR in between 6 to estimate perioperative cardiac risks for patients
and 24 h), time-sensitive (OR in 1–6 weeks) or undergoing non-cardiac surgery starting with the
elective surgery (in OR up to one year), the intra- use of the Goldman Multifactorial Risk Index
operative blood loss and fluid sequestration, as developed in 1977, subsequently progressing to
well as the fluid requirements associated with the the use of the Detsky’s Cardiac Risk Index in
planned operation, the temperature changes 1986, the Eagle’s Cardiac Risk Index in 1989,
occurring during the procedure, and finally, the and more recently to the Revised Cardiac Risk
type, depth, and duration of anesthesia. An Index (RCRI) popularized by Lee in 1999
appropriate prediction of risk can direct the sur- (Table 6.1) [3–6]. These static models have been
geon towards making the right decision as to and remain useful in predicting preoperatively
whether to select an operative or non-operative the perioperative cardiac morbidity, defined as
approach and more importantly in planning the the development of acute pulmonary edema,
operative approach based on the overall patient’s arrhythmias requiring treatment for greater than
fitness from the standpoint of the organs’ func- 24 h, ST changes, and myocardial infarction
tional reserve, the expected operative insult, the (MI), and the cardiac mortality associated with
underlying pathology, and the presence or non-cardiac surgery. The quantification of the
absence of comorbid conditions. patient’s risk of cardiac complications has led to
A low-risk procedure is one with combined an algorithmic approach to minimize the occur-
surgical and patient-specific characteristics of rence of cardiac complications using a combina-
perioperative cardiac morbidity or all-cause mor- tion of noninvasive and invasive preoperative
tality of less than 1 %. Procedures with a risk of testing, and interventional procedures when
perioperative cardiac morbidity and mortality necessary, as well as the use of pharmacological
greater than 1 % are considered intermediate risk, control of the risk factors known to be associated
very high-risk procedures are those with an asso- with increased cardiac morbidity.
ciated morbidity and mortality between 5 and 19 The predictive models used to estimate the
%, and extremely high risk procedures are those risk of perioperative cardiac morbidity and mor-
associated with a mortality of 20 % or more. tality take into account a combination of histori-
However, while cardiac-related mortality cal and clinical findings, including the history of
accounts for approximately 30 % of deaths in previous MI, the time of the occurrence of the MI
patients undergoing non-cardiac surgery, mortal- in relation to the planned operation, episodes of
ity from non-cardiac causes accounts for the pulmonary edema, presence of angina, presence
greater portion of perioperative deaths [1, 2]. of aortic stenosis and the associated severity of
Therefore, it is important to understand the the stenosis, as well as the planned procedure,
difference between the predictive models that which is stratified in low, intermediate, and high risk
quantify the risk of cardiac complications and based on the operative insult that the procedure
cardiac mortality in patients scheduled to undergo will impose on the patient. All models, based on
non-cardiac surgery, which were not designed to the values assigned in aggregate, stratify the risk
predict all-cause mortality in surgical patients, of complications and mortality in classes that are
and the more comprehensive surgical mortality then used by the cardiologist to decide about the
probability models, which are designed to predict best preoperative optimization of the cardiovas-
all-cause mortality in patients undergoing non- cular status of the patient, by the anesthesiologist
cardiac surgery. to decide about the ideal anesthetic management
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 43

Table 6.1 Multifactorial cardiac risk indices

Lee revised cardiac
Goldman Destky Eagle risk index
Factors Points Factors Points Factors Factors
S3 or JVD 11 Age > 70 5 Age ≥ 70 High risk surgery
MI ≤ 6 months 10 MI ≤ 6 months 10 H/O angina H/O IHD
NSR or PACs 7 MI > 6 months 5 H/O ventricular H/O HF
ectopy
>5 PVCs 7 AS 20 DM H/O IDDM
Age ≥ 70 7 Unstable angina ≤ 6 10 Q waves on H/O CVD
months ECG
Emergency surgery 4 Canadian angina 10 Cr ≥ 2.0 mg/dL
class 3
Aortic stenosis 3 Canadian Angina 20
Class 4
Intraperitoneal, intrathoracic or 3 PE ≤ 1 week 10
aortic operation
General status 3 PE ever 5
PO2 < 60 or PCO2 > 50 mmHg, K
<3.0 or HCO3 < 20 mEq/L, BUN
>50 or Cr >3.0 mg/dL
NSR or PACs or 5
PVCs > 5
Emergency surgery 10
General status as per 3
Goldman
Total 53 100 5 6
JVD Jugular venous distension, MI myocardial infarction, NSR normal sinus rhythm, PACS premature atrial contrac-
tions, PVCs premature ventricular contractions, AS aortic stenosis, PE pulmonary edema, DM diabetes mellitus, IHD
ischemic heart disease, HF heart failure, IDDM insulin-dependent DM, CVD cerebrovascular disease

associated with the least increase in myocardial ing surgical procedures tend to be older, there-
oxygen consumption, and by the surgeon to fore, with compromised functional reserve of
select the appropriate surgical strategy based on many organs, including the cardiac and pulmo-
the estimated risk (Table 6.2). Of note, the addi- nary functional reserve, both of which play a
tion of thallium imaging and of the dipyridamole very important role in the response of the patient
stress test to patients with 1–2 Eagle’s risk factors to major operations. It is the responsibility of the
has increased its accuracy in stratifying patients surgeon to have a good understanding of the
from the standpoint of cardiac morbidity. Patients physiological changes associated with aging in
with thallium redistribution or with ischemic order to avoid underestimating the impact of the
ECG changes during dipyridamole infusion with age of the patient on the overall response of the
1–2 Eagle’s risk factors have a 29.6 % risk of patient to the planned operation. While the
perioperative complications. impact of age is modest in patients undergoing
Due to the increasing age of the population in low- and intermediate-risk operations, it becomes
the USA and the surgical pathology more likely much more important when patients require
to be encountered in the elderly, patients requir- high-risk procedures.
44 W.D.R. Velandia et al.

Table 6.2 Predicted cardiac-related morbidity and mortality by cardiac risk indices
Goldman Detsky Eagle RCRI
Class Morbidity Mortality Class Morbidity Factors Mortality Factors Morbidity
I (0–5) 0.7 1 I (0–5) 6 0 0.4 0 0.4
II (6–12) 5 2 II (6–12) 7 1 1.0 1 0.9
III (13–25) 11 2 III (13–25) 20 2 2.4 2 7
IV (≥26) 22 56 IV (26–100) 100 ≥3 5.4 ≥3 11

ing these limitations its use as the sole tool of

Predictive Models of Outcome overall 30-day mortality has been associated with
a C-index of 0.889 indicating a very acceptable
American Society of Anesthesiologist predictive capability of mortality at 30 days [7].
Physical Status Classification

It is the most widespread tool used by anesthesi- Functional Capacity Metabolic

ologists that stratifies patients in six classes: Equivalents

I Normal healthy patient. The patient’s functional capacity can be measured

II Patient with mild systemic disease. by metabolic equivalents (METs); one MET
III Patient with severe disease that limits activity equals the oxygen consumption of a 70-kg,
but is not incapacitating. 40-year-old man in a resting state. The measured
IV Patient who has incapacitating disease that is MET reflects the patient’s ability to increase his/
a constant threat to life. her oxygen consumption when performing work.
V Moribund patient not expected to survive 24 A patient who gets tired climbing two flights of
h with or without an operation. stairs, or is unable to perform basic daily activities
VI A declared brain-dead patient whose organs (eating, bathing, dressing) without feeling tired, is
are being removed for donor purposes. deemed to have a functional capacity <4 METs. In
contrast, if he is capable of performing cycling,
The E prefix is used for patients undergoing swimming, and jogging, he is considered to have
emergency procedures. functional capacity >10 METs. When the func-
The goal of the ASA-PS system is to assess tional capacity measured in METs is high, the
the overall physical status of the patient before prognosis of the patient from the standpoint of
surgery and not to assess the surgical risk per se cardiac-related morbidity and mortality is excel-
because it neglects the impact of the surgery lent even in the presence of cardiac disease or car-
itself on the patient’s outcomes. While the diac risk factors. The MET functional capacity is
ASA-PS system is practical and easy to use, it used in the algorithm of cardiac evaluation.
lacks specificity, which leads to inconsistent rat-
ings between anesthesiologists and imprecise
clinical interpretation. The most recent reported Factors to Be Considered
mortality in a study that used the NSQIP database to Decrease the Overall Risk
to validate the ASA-PS system for patients clas- of Morbidity and Mortality
sified as I, II, and III, which typically include 95
% of patients, is 0 %, 0.2 ± 0.1 %, and 2.2 ± 0.4 %, Type of Anesthesia
whereas the mortality for patients in class IV and
V is 15.2 ± 2.4 % and 70.0 ± 10.5 %, respectively The type of anesthesia selected depends on the
[7]. The ongoing limitations of the ASA-PS sys- kind of the surgical intervention planned and on
tem include the lack of precision and its poor the overall condition of the patient from the
inter-rater consistency. However, notwithstand- standpoint of the organs’ functional reserve and
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 45

on the presence of associated comorbid condi- of mortality associated with surgical intervention
tions. General anesthesia is defined by the pres- of 63 % and a 51 % risk of readmission during
ence of adequate analgesia, muscle relaxation, the first 30 days of discharge from the hospital
amnesia, and a low level of consciousness. [11]. The main predictor of mortality in patients
General anesthesia is required when paralysis of with cardiovascular disease is a left ventricular
the abdominal muscles or lung isolation and ejection fraction (LVEF) less than 35 %. Current
hyperventilation are needed. Other indications evidence suggests that patients with HF sched-
for the use of general anesthesia include cardio- uled to undergo a high- or intermediate-risk non-
vascular instability or procedures requiring cardiac surgical operation should undergo
extended duration of anesthesia which cannot be evaluation of their ventricular function by trans-
accomplished safely with regional anesthesia. thoracic ultrasonography and should have blood
Regional anesthesia provides adequate control work for measurement of the level of natriuretic
of pain both intra- and postoperatively. More peptide [12]. Their left ventricular function
recently, the use of a combination of regional and should be optimized pharmacologically with a
general anesthesia has become more prevalent combination of beta blockers, ACE and angioten-
due to the benefits associated with its use. The sin II inhibitors, in addition to mineral-corticoids
improved intraoperative and postoperative man- antagonists and diuretics as needed. A scheduled
agement of pain, a reduction in the incidence of surgical intermediate- or high-risk intervention
postoperative ileus, a decreased rate of pulmo- should be postponed for at least three months in
nary complications, as well as a reduced inci- patients with a recent episode of HF requiring
dence of renal and heart failure (HT) are among hospitalization and treatment. Documentation of
the benefits of regional anesthesia [8]. Of particu- improvement in LFEF of at least 5 % should pre-
lar interest is the decreased rate of thrombotic cede the planned intervention. In the event that
complications requiring redo surgery in patients the LVEF remains severely compromised,
undergoing peripheral vascular surgery reported namely, less than 25 %, then the surgeon in con-
in patients undergoing regional epidural anesthe- junction with the cardiologist should discuss the
sia when compared to the same procedures done necessity of the planned surgical intervention in
under general anesthesia in non-randomized con- view of the predicted high morbidity and mortal-
trolled trials [9]. However, prospective random- ity associated with it. Emphasis should be placed
ized controlled trials have failed to show the on the benefits of the planned procedure taking
superiority of regional anesthesia over general into consideration the life expectancy of the
anesthesia in patients undergoing vascular proce- patient based on the presence of HF not amenable
dures from the standpoint of reduced cardiac to improvement either pharmacologically or with
morbidity and mortality [10]. The selection of the resynchronization therapy. Among elderly
anesthetic management of the patient must take patients (>80 years of age) who have been hospi-
into account the preoperative conditions of the talized with HF, the one-year mortality rate is
patient including the preoperative cardiac risk about 33 %, with a five-year mortality rate as
assessment and the magnitude and duration of high as 79 % in men and 70 % in women [13].
the planned operation. Therefore, any intermediate- or high-risk elective
surgical procedure in this subset of patients
should be evaluated in the context of the expected
The Impact of Organ Specific one-year and five-year survival, as well as on the
Pathology on the Planned Operation expected QALY.
Once a decision has been made to proceed
Cardiovascular Disease with the planned surgical procedure, it is recom-
Cardiovascular disease is highly prevalent world- mended to continue the administration of beta
wide, with an increase in patients older than 65 blockers throughout the perioperative period,
years. Patients with heart failure (HF) have a risk suspending the administration of ACE and angio-
46 W.D.R. Velandia et al.

tensin II inhibitors on the morning of the planned tions. Patients with MET less than 4, presence of
procedures in order to minimize the incidence of COPD, and those with forced expiratory volume
hypotensive episodes requiring vasopressor sup- in 1 s less than 0.8 L/s and a percentage of diffu-
port during the operation. sion capacity of the lung for carbon monoxide
with the single-breadth method less than 70 %
Cerebrovascular Disease have an increased risk of postoperative pulmo-
The incidence of stroke in patients undergoing nary complications particularly when undergoing
non-cardiac surgery ranges between 0.05 and 3 surgical procedures that require thoracotomy.
%; while the incidence is very low, the associated Smokers have a relative risk of 1.4–4.3 of pul-
mortality can be as high as 20 %. The most com- monary complications associated with surgery;
mon cause of perioperative stroke is the develop- however, the risk of pulmonary complications
ment of new onset atrial fibrillation or the decreases significantly almost reaching the level
presence of preexistent chronic atrial fibrillation of nonsmokers after cessation of smoking for at
requiring anticoagulation. Patients should be least eight weeks before the scheduled surgery. A
questioned about symptoms suggestive of TIA or subset of patients at increased risk of pulmonary
stroke in the six months preceding the planned and cardiac complications includes those with
operation, and patients with documented history COPD and pulmonary artery hypertension (mean
of TIA and/or CVA from carotid artery disease PA > 35 mmHg) associated with right ventricular
should be kept on antiplatelets agents up to 2–5 dysfunction [14]. These patients require invasive
days before the operation depending on the monitoring including the use of oximetric pulmo-
bleeding risk associated with the planned nary artery catheters and/or TEE monitoring in
operation. order to optimize their cardiac function during
high-risk procedures.
Peripheral Vascular Disease
Patients with peripheral vascular disease (ankle/ Hepatic Disease
brachial index <0.9) or with a history of endovas- Patients with liver dysfunction and in particular
cular or surgical revascularization usually have those with cirrhosis have increased perioperative
lesions in other vascular beds including the coro- morbidity and mortality. Approximately 10 % of
nary circulation which increases surgical risk. patients with cirrhosis will require non-hepatic
Patients with peripheral arterial disease associ- surgical procedures during their shortened life
ated with history of myocardial ischemia, HF, expectancy [15]. The reported mortality in
TIA or prior stroke, renal insufficiency with cre- patients with cirrhosis undergoing non-hepatic
atinine level >2 mg/dL, or with insulin-dependent surgical procedures ranges from 9.8 to 28 %
diabetes should undergo risk stratification using when non-stratified by either the Child-Pugh
appropriate stress testing. (CP) class or the Model for end-stage liver dis-
ease (MELD) [16]. Historically, the severity of
Pulmonary Disease cirrhotic liver disease has been calculated using
Pulmonary complications remain common in the the CP class; this classification includes level of
postoperative period occurring with higher inci- bilirubin, albumin, International Normalized
dence in patients with predisposing factors, such Ratio, presence and severity of ascites, and pres-
as the use of tobacco and the preexistent presence ence and severity of encephalopathy. The CP
of COPD. Other factors that increase the risk of class has been shown to be useful in determining
pulmonary complications include the placement the survival of cirrhotic patients undergoing
of thoracic or upper midline abdominal incisions, medical management and has also been useful as
operating time greater than three hours, and the a prognostic tool of postoperative complication
use of general anesthesia. Functional capacity and mortality (Table 6.3). However, more recent
and the ASA class are the best predictors of the data support the use of the MELD score as a
probability of developing pulmonary complica- superior prognostic tool for cirrhotic patients
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 47

requiring abdominal operations [17, 18]. The Patients with mild and moderate renal dysfunc-
reported c-statistics of 0.80 for the MELD score tion require appropriate intraoperative and post-
for patients undergoing intra-abdominal surgery operative fluid management in order to avoid
in the study by Northup and associates suggests periods of renal hypoperfusion that may predis-
its usefulness when advising patients about the pose the patient to the progression to either severe
mortality associated with intra-abdominal sur- renal insufficiency or dialysis-dependent renal
gery. However, while based on the work of failure. While the presence of mild and moderate
Northup and colleagues, a MELD score ≥20 renal dysfunction does not increase cardiac-
appears to be the inflection point for increased related morbidity and mortality, as well as all-
mortality, we advise against using a specific cause surgical mortality, severe renal
MELD score number as a cutoff for the decision- insufficiency and dialysis-dependent renal failure
making process regarding intra-abdominal pro- are associated with increased cardiac-related
cedures [19]. morbidity and mortality in high-risk surgical
Clearly, cirrhotic patients remain at a much procedures.
increased risk of death from abdominal surgery
even with a low MELD score of 10; therefore, the Hematologic Diseases
decision to operate upon these patients should The aim is to estimate the bleeding and throm-
take into consideration the expected benefits of botic risk. The best tool to achieve the proper
an elective operation in view of the patient’s life assessment of hematologic risk is taking the his-
expectancy, as well as the morbidity and mortal- tory of bleeding disorders, as well as the history
ity associated with the planned operation. regarding the patient having required transfusion
Avoiding intra-abdominal surgery may be the of blood products, anticoagulation or any other
better option in the majority of these patients. treatment to correct any coagulation abnormality
during and following surgical intervention. Some
Renal Disease conditions are known to be associated with
From the standpoint of determination of renal hypercoagulable states, such presence of malig-
function, patients should be grouped according to nancy, protein C and protein S deficiency (5 %
the level of renal function as follows: normal or each), activated protein C resistance (33 %), anti-
mildly reduced renal function (estimated GFR 60 thrombin deficiency (5 %), prothrombin
mL/min/1.73 m2), moderate renal insufficiency G20210A mutation (18 %), and plasminogen
(estimated GFR 30–59 mL/min/1.73 m2), severe deficiency (1 %). Von Willebrand disease or
renal insufficiency (estimated GFR 30 mL/ platelet dysfunction must undergo complete
min/1.73 m2), and dialysis-dependent renal fail- screening to assess their individual risk, and a
ure. Patients with normal renal function are at hematologic consultation in order to minimize
increased risk of acute kidney injury if they have the perioperative risk of bleeding.
one or more of the following risk factors: age >56
years, male gender, presence of diabetes, acute Diabetes
heart failure, ascites, hypertension, in addition to Diabetes affects 7 % of the US population [20].
undergoing emergency abdominal surgery. However, the proportion of surgical patients with
diabetes is 20 %. Diabetic patients have a signifi-
cantly higher risk of infectious complications as
Table 6.3 Predicted survival by the Child-Pugh class well as of postoperative cardiac morbidity and
1-year 2-year Abdominal mortality as a result of their micro and macrovas-
survival survival surgery cular pathology [21]. To reduce the risk of infec-
Points Class (%) (%) mortality (%) tious complications and more specifically
5–6 A 100 85 10 surgical site infections following surgery,
7–9 B 81 57 30 patients with diabetes should have their blood
10–15 C 45 35 82 glucose level controlled well before surgery and
48 W.D.R. Velandia et al.

should have their HbA1c lowered to <7.0 % NSQIP model may be better at predicting cardiac-
before surgery. There is an independent relation- related morbidity and mortality [23]. The NSQIP
ship between HbA1c, which is associated with risk model has been used to develop an interac-
chronic glycemic control, and non-cardiac surgi- tive risk calculator available on the Internet that
cal outcomes in diabetic patients. Since severe can be utilized by surgeons to discuss the risks of
and prolonged glycopenia from attempts at con- complications and mortality of the specific pro-
trolling acute hyperglycemia is associated with cedure when obtaining the consent for the proce-
more damage than acute hyperglycemia itself, it dure [24].
is important to understand the added value
afforded by having an HbA1c level <7.0 % indi-
cating a good chronic control which in turn may Predictive Models of All-Cause
minimize the rate of acute hyperglycemic events Surgical Morbidity and Mortality
requiring treatment [22].
The most accurate predictive model of 30-day
mortality and morbidity remains the ACS-NSQIP
Patient Specific Clinical Variables model, which is too complicated to be used at the
and Surgery Specific Clinical Risk bedside [25]. Furthermore, the cost associated
with its implementation has limited its applica-
The recent submission of surgical data from a tion to only approximately 3 % of the US hospi-
large number of hospitals to the American tals. It is for this reason that there have been
College of Surgeon National Surgical Quality many attempts at developing simplified scoring
Improvement Program (NSQIP) database has models that can be used at the point of care with-
allowed the development of valid predictive out the assistance of a web-based calculator by
models of morbidity and mortality in surgical incorporating some of the variables used in the
patients. Due to the high number of patients NSQIP model in addition to the RCRI model. A
included in the database, the NSQIP has per- valid model useful to predict all-cause surgical
formed extremely well because the beta coeffi- morbidity and mortality combines six of the vari-
cients of each of the predictive variables can be ables incorporated into ACS-NSQIP, namely,
reassessed on an ongoing basis, thus improving American society of anesthesiologists physical
the receiver operating characteristics (ROC) status (ASA PS), age, creatinine level, type of
curve for the overall model. Of the 211,410 surgery, body mass index and functional capac-
patients analyzed in 2007 NSQIP database, 1371 ity, with four of the variables of the RCRI of Lee,
(0.65 %) developed perioperative myocardial namely, history of ischemic heart disease, heart
infarction or cardiac arrest. On multivariate failure, cerebrovascular disease, presence of
logistic regression analysis, five variables were insulin-dependent diabetes mellitus, and the fol-
identified as predictors of perioperative myocar- lowing additional factors: wound status, ventila-
dial infarction or cardiac arrest: type of surgery, tor dependency, cancer, hypertension, dyspnea,
dependent functional status, abnormal creatinine, current smoker, ascites, COPD, AKI, dialysis-
American Society of Anesthesiologists’ class, dependent ESRF, and body mass index. The
and increasing age. The risk model developed 9-point surgical, mortality probability model
from the 2007 data set was subsequently vali- (S-MPM) that uses only three risk factors,
dated prospectively in 2008 on a sample of namely, ASA-PS, surgery risk class (low, inter-
257,385 patients. The model performance did not mediate, or high), and emergency status, can be
differ between the original data set and the subse- used at the point of care at the bedside to estimate
quent validation data set with ROCs of 0.884 and the 30-day mortality risk with a good degree of
0.874, respectively. Of note, the application of accuracy without the need of a calculator [26].
the Revised Cardiac Risk Index to the 2008 The Surgical Apgar Score proposed by Gawande
NSQIP data set yielded a relatively lower C sta- to predict major surgical complications and mor-
tistic (0.747), therefore, suggesting that the tality incorporates heart rate, blood pressure, and
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 49

estimated blood loss but it does not adjust for lar resistance especially when the patient is
preoperative risk factors and complexity of the placed in a Trendelenburg position. Elevation in
surgical procedure, therefore, in our opinion is pulmonary artery pressure from the increased
not a useful model from the standpoint of overall pulmonary vascular resistance may impose a sig-
accuracy [27]. We believe that the S-MPM is the nificant increase in the afterload (impedance to
most useful and easy to use tool available at the ejection) of the right ventricle causing a dilata-
bedside and that it should be used to estimate the tion of the right ventricle with a subsequent left-
30-day mortality risk when obtaining the consent ward shift of the interventricular septum due to
for the planned surgical operation. the restraining effect of the pericardium; this in
turn may compromise the preload recruitment of
the left ventricular stroke volume because of
Choice OF Surgical Approach: decreased compliance of the left ventricle (a left-
Laparoscopic Versus OPEN ward and upward shift of the pressure–volume
relationship). These changes may cause hypoten-
A decreased risk of intraoperative and postopera- sion and cardiac rhythm abnormalities, as well as
tive complications has been reported in patients the development of myocardial ischemia.
with multiple comorbid conditions who undergo Patients in whom laparoscopy is absolutely
minimally invasive surgical approaches when contraindicated and in patients affected by surgi-
compared to open procedures. The use of mini- cal pathology not amenable to the laparoscopic
mally invasive techniques, namely, laparoscopic approach require an open approach. It is impor-
approaches to surgical pathology, has been asso- tant to understand the impact of pre-existing pul-
ciated with a reduced length of hospital stay, a monary pathology, and in particular the presence
decreased incidence of superficial and deep sur- of COPD in patients undergoing laparotomy.
gical site infections, decreased pulmonary com- Good clinical judgment is required to identify the
plications, and a decreased incidence of subset of patients with COPD who may benefit
postoperative pain. However, the appropriate use from further investigations such as pulmonary
of laparoscopic techniques requires avoidance of function tests, as well as from optimization of the
a “tunnel vision” approach to the surgical pathol- pulmonary status before exposing them to the
ogy affecting the patient. For example, increas- open planned procedure. Patients with COPD
ing the duration of a procedure extensively may require modified approaches to their surgi-
because the surgeon is unwilling to convert rap- cal pathology, which may include laparotomies
idly to an open procedure may be associated with done through transverse incisions and ideally
an increased risk of complications as a result of through infra-umbilical transverse incisions.
the extended duration of the procedure. These incisions are known to be associated with
Furthermore, it is important to emphasize that fewer pulmonary complications from the lesser
certain patients may be more prone to the devel- effect on residual volume, functional residual
opment of cardiac complications when undergo- capacity, total lung capacity, and vital capacity
ing laparoscopic instead of open procedures. The which are known to be affected by the perfor-
insufflation of CO2 into the abdominal cavity to mance of midline laparotomy and requiring
obtain an adequate pneumoperitoneum at a pres- approximately a week before return to baseline
sure of 15 mmHg is associated with hemody- following open procedures done via upper mid-
namic changes which may not be tolerated well line laparotomies. The changes in lung volumes
by a patient with a significant history of cardiac observed after midline laparotomy are the result
dysfunction whose cardiac function depends on of the change in the breathing pattern caused by
the appropriate preload. The increased intra- the pain associated with the distracting forces
abdominal pressure from the pneumoperitoneum that occur when the patient attempts to sigh;
causes several hemodynamic effects, including therefore, the patient changes his/her breathing
decreased venous return, increased central pattern to a rapid shallow breathing pattern with
venous pressure, and increased pulmonary vascu- loss of the 6–8 sigh breadths per hour of the normal
50 W.D.R. Velandia et al.

breathing pattern. The loss of the sigh breadths angitis. She undergoes an uneventful endoscopic
causes the loss of FRC with the subsequent retrograde cholangio-pancreatography (ERCP), a
development of atelectasis and infectious pulmo- 15 mm sphincterotomy, and common bile duct
nary complications. Obviously, a pain control stone extraction (CBDSE). She is asymptomatic
strategy that may allow the patient to breathe at following the ERCP and CBDSE. She has chole-
vital capacity can offset the detrimental effects of lithiasis but she has never had symptomatic cho-
a midline laparotomy on pulmonary function. lelithiasis up to this point. She has decided not to
undergo correction of her aortic valve stenosis.
We must decide whether she should undergo
The Surgical Decision-Making laparoscopic cholecystectomy either during the
Process same hospitalization, or possibly following dis-
charge and readmission at a later time, or con-
Developing a checklist approach to each segment versely she can be observed reserving the
of an operation starting from the decision to oper- appropriate surgical treatment only if she
ate may provide a standard foundation for mini- becomes symptomatic with either biliary pain or
mizing the occurrence of untoward perioperative from acute cholecystitis since she is unlikely to
events. Once the decision to proceed with a experience recurrent cholangitis based on the fact
planned operation has been made taking into that she has had an adequate sphincterotomy. The
consideration the probability of death and com- evidence used to proceed with our decision tree is
plications including the value (utility) of the provided by prospective and retrospective trials
desired outcome for the planned operation, each of similar patients that have identified the risk of
member of the operating team should be aware of death associated with immediate surgery and the
the critical steps of the planned procedure and of risk of the developing symptomatic cholelithiasis
the appropriate steps that may be required in the in the form of either biliary symptoms or acute
case of untoward intraoperative events. The deci- cholecystitis with an observation strategy and the
sion tree of every major operation can be broken available evidence regarding the impact of severe
down in segments, each one of which having one aortic stenosis on cardiac-related morbidity and
or more components. mortality in patients undergoing non-cardiac sur-
The decision to operate stems from the analy- gery, as well as the predicted life expectancy
sis of the desired outcome (a live patient, disease without surgical or interventional correction of
free) starting from the choice of no treatment as the aortic valve stenosis [28–30].
opposed to the treatment itself in view of the pre- For the purpose of this decision tree, we assign
dicted life expectancy of the patient. This step a value of 0 to death and 100 to being alive and
requires an understanding of the probabilities symptom free with values of 65 for minor com-
associated with each decision node including plications and 45 for major complications. Shown
major and minor complications and the mortality in Fig. 6.1 is the decision tree based on the patient
associated with our procedure and the value undergoing immediate treatment as opposed as to
assigned to each possible outcome. Of note, the delaying the treatment to when she becomes
probabilities of death, complications, and favor- symptomatic with probabilities and gravity
able outcome are established by the surgeon (value) assigned to minor, major complications
based on the best available evidence, consensus, as well as to each outcome. Since as shown in the
or expert opinion. Value is the patient’s assigned decision tree, the patient has a value of 100 now
value to the offered therapeutic choices based on with the risk of death of 5–10 % (value 0) and a
his/her preferences. Two specific examples of major morbidity of 45 % (value 35) and only a
this step of the decision tree follow. 45–50 % probability of value 100 with surgery, it
An 85-year-old woman with a history of is clear that the best course of action at this time
severe aortic stenosis (aortic valve area <1 cm2 is to observe the patient and accept that the
and jet velocity >4 m/s) presents with acute chol- patient has a 5–10 % per year chance of requiring
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 51

Death (2-5%)
(0)

Major (25%)
LC Morbidity
(45)

Alive (25%)
S/P ERCP No Complications
CBDSE (100)
Death (15%)
(0)
No Progression
Major (25%)
(100)
PC Morbidity
(45)
OBSERVE
Alive (60%)
(100) (90)
Progression (5-10%)
Death (2-5%)
(0)

Major (25%)
LC
Morbidity

Alive (70%)
(100)

Death (15%)
(0)

OC
Major (25%)
Complication
(45)

Alive (60%)
(100)

Response (70%)
(90)
Medical
RX No Response (30%)
(90)

PC OC LC

Fig. 6.1 Decision tree for patient with cholangitis S/P bile duct stone extraction, LC laparoscopic cholecystec-
ERCP and CBDSE. S/P status post, ERCP endoscopic ret- tomy, PC percutaneous cholecystostomy, OC open
rograde cholangio-pancreatography, CBDSE common cholecystectomy

one of the treatment modalities highlighted in the decision here involves whether immunosup-
diagram in the future. pressed patients have a higher risk of recurrent
The second example involves a 54-year-old episodes of acute diverticulitis, and in particular
woman with a body mass index of 40 with a his- whether they are more prone to have Hinchey III
tory of Lupus on methotrexate and prednisone or IV episodes if they experience recurrent diver-
who has had an episode of diverticulitis (Hinchey ticulitis and more importantly the mortality and
II) that has resolved on medical treatment. The morbidity associated with these events. These
52 W.D.R. Velandia et al.

probabilities must be weighed against the risk of with a proximal defunctioning stoma (PRADS),
death and major complications associated with an and PRADS with drainage and no resection, as
elective sigmoid resection in a morbidly obese well as from the reversal of a possible colostomy
patient on immunosuppressive drugs. Since the and/or loop ileostomy available from randomized
reported mortality for patients on chronic cortico- and non-randomized controlled trials including a
steroids therapy who are operated on acutely for review of a NSQIP study regarding emergency
diverticulitis is 23 % based on a systematic review surgery for diverticulitis [33–35] (Fig. 6.2). Her
of diverticulitis in transplants patients and patients preference is to have a PRA notwithstanding the
on chronic corticosteroid therapy, to proceed with increased risk of death and of major complica-
an elective operation in the patient discussed in tions potentially associated with this choice.
this example, we need to know what is the inci- However, she agrees to allow you to make the
dence of diverticulitis as well as the expected judgment as to the best choice at the time of the
Hinchey classification in the patient if treated laparotomy. You decide to accept a threshold of
without a sigmoid resection [31]. Since in studies complications including death of ≤35 % for your
with duration of follow-up ranging from 1 month surgical choice. Based on the surgical findings,
to 17.3 years, the overall incidence of diverticuli- the severity of the peritonitis, and the conditions
tis is approximately 1 %, it is not justified to pro- of the rectum, you decide that in your judgment
ceed with an elective sigmoid resection in this the rectum is suitable for a primary anastomosis
patient because of a reported mortality in excess but you wish to have a lower chance of complica-
of 5 % and an increased rate of anastomotic leak tions, therefore, you proceed with a PRA and
as well as of wound dehiscence associated with PDS. The example provided here assumes that all
the chronic use of corticosteroids [32]. data available for the surgical decision are read-
Once the decision to operate has been made, ily available and easily interpretable at the point
the second segment of the process includes the of care to help you decide. However, as surgeons
selection of the appropriate monitoring and anes- we do not have always available the appropriate
thetic management of our specific patient based data applicable to the individual patient neces-
on the preoperative assessment of the patient’s sary to make the right decisions.
risk factors and the risk category of our planned Unfortunately, despite the abundance of evi-
procedure. The next segment involves the time- dence of variable quality available to make the
out and proceeding with the checklist of all steps best decision regarding the procedure associated
necessary to prepare the team for the planned with the least mortality and the lowest chance of
operation including the few critical steps typi- complications and the best functional outcome
cally associated with each operation to optimize for the patient, ultimately, the surgeon is left to
situational awareness. The intraoperative seg- make case-by case decisions based on the suit-
ment of the operation includes technical choices, ability of the rectum for a primary anastomosis,
as well as the value analysis of the operative the overall clinical condition of the patient in the
choices based on available evidence applicable to OR, the technical challenges encountered based
our patient. The following clinical example will on the patient’s body habitus, and the severity of
highlight the decision tree for this segment of an pelvic and generalized peritoneal inflammation
operation. and the bowel wall edema surrounding a poten-
A 52-year-old woman presents with Stage IV tial anastomosis.
Hinchey diverticulitis. She is hemodynamically
stable and she is able to discuss the available sur-
gical options at laparotomy, which she requires. Technical Decisions
You review the probabilities of death and com-
plications from the four available choices, The technical choices in many operations involve
namely, a Hartmann’s procedure (HP), a primary decisions based on a variety of elements such as
resection with anastomosis (PRA), a PRA and anatomic considerations, the anatomic type of
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 53

Mortality (7.3%)

Mortality (2%)

HP Complications (29%)
Stoma Reversal (73%) Complications (15%)

No Complications (64%) No Complications (83%)

No Stoma Reversal (27%)

Mortality (4.6%) Mortality (15%)

Complications (25%)
Choices of
Operation PRA Complications (40%)

No Complications (60%)
Hinchey IV
No Complications (54%)

Mortality (1.6%)

Mortality (0%)

PRA/PDS Complications (26%) Stoma Reversal (90%) Complications (4%)

Well (96%)
No Complications (72%)

No Stoma Reversal (27%)

Mortality (20%)

No
Resection
PDS
Peritonitis (24%) Additional Surgery

Fig. 6.2 Decision tree for patient undergoing surgery for Hinchey IV diverticulitis. HP Hartmann’s procedure, PRA
primary resection with anastomosis, PRA+PDS primary resection with anastomosis and proximal defunctioning stoma

reconstruction of the gastrointestinal tract in the must be interpreted regarding its internal and
case of intestinal resection, the choice of tech- external validity, and more importantly regarding
nique such as stapling versus hand sewing, the its applicability to our specific patient.
size of the staples as opposed to the type of hand While it will not be possible to explore the
sewn anastomoses (one layer as opposed to two technical issues that pertain to the many opera-
layers, suturing material and type of suturing tions that surgeons perform, we will review one
technique) all based on available evidence that clinical scenario involving a patient with an ade-
54 W.D.R. Velandia et al.

nocarcinoma of the rectum requiring a low ante- anatomic plane during the posterior dissection of
rior resection. We will focus on the anatomic and the rectum in order to avoid potential catastrophic
technical issues associated with the decision pro- bleeding from the presacral veins. Unfortunately,
cess to highlight the elements of the decision tree despite the merit of these anatomic consider-
that are applicable to the many operations that a ations, very little level I evidence is available
surgeon will perform during his professional life. regarding the best way to address most of the
anatomic issues described. Therefore, the sur-
geon typically relies on his knowledge base
Low Anterior Resection for Cancer derived from textbook and reading of pertinent
literature and from the experience accumulated
Anatomic Considerations during his training as well as from his personal
experience as an attending surgeon.
The performance of a LAR for cancer includes
many decision points from the standpoint of ana-
tomic decisions starting with the choice of ligat- Technical Points
ing the inferior mesenteric artery (IMA) at its
takeoff from the aorta as opposed to ligating it The technical choices pertain mostly to the recon-
just distal to the origin of the left colic artery struction of the gastrointestinal tract. They
(LCA), understanding the impact of the water- involve whether to perform an end-to-end or a
shed area at the junction of the ascending branch side-to-end (Baker) anastomosis and whether the
of the LCA and the left branch of the middle colic anastomosis should be hand sewn or stapled and
artery (Griffith’s point) on the possibility of inad- in the case of a stapled anastomosis whether it
equate blood flow to the colon being anasto- should be a circular stapled anastomosis or a dou-
mosed to the rectum unless there is robust ble stapled type of anastomosis. Additional
pulsatile flow in the marginal artery of Drummond choices include mobilization of the splenic
via the left branch of the middle colic artery flexure in order to avoid tension on the suture line
which of note is absent in 5 % of the population. and the addition of a diverting loop ileostomy
Furthermore, in up to 43 % of the population, the selectively or in all cases.
connection at Griffith’s point of the marginal With so many choices available how does a sur-
artery of Drummond may be completely absent geon decide? Ideally, the surgeon should have an
or diminutive leaving the proximal colon vulner- in-depth understanding of each choice available to
able to ischemic necrosis when anastomosed to him with its associated limitations and benefits and
the rectum. To confirm the validity of this ana- then apply the correct choice to his patient based on
tomic consideration, we can refer to a prospec- the specific anatomic, tissue, fat distribution,
tive observational study regarding risk factors for edema, depth of the pelvis, and the many character-
anastomotic leak after colon and rectal surgery istics present at the time of his procedure.
that has identified ligation of the IMA proximal Is a 2-0 Prolene® (Ethicon, Edinburgh, UK)
to the LCA as an incremental risk factor for anas- continuous over- and over whip-stitch suture
tomotic leak after LAR [36]. In this study, high done with a cut and saw technique while the
ligation of the IMA, namely, proximal to the proximal colon is still attached to the rectum
LCA had a 3.8 times higher rate of anastomotic applicable to all size rectums? Is there a possibil-
leak than a low ligation (distal to the LCA). ity of failure to compress adequately around the
Additional anatomic considerations include the shaft of the stapling device the tissue if the rec-
point of ligation of the inferior mesenteric vein at tum is too bulky? In this case, should we apply a
the level of the duodeno-jejunal angle just below second inner pursue string to optimize the
the pancreas in order to maximize the lympho- approximation of the tissue around the shaft or
nodal dissection, the identification and protection conversely should we have considered closing
of both ureters, as well as identifying the correct the rectum with a liner stapler and proceed with a
6 Planning and Preparing for the Operation: Guidelines and the Evidence-Based Decision Tree 55

double stapled technique based on the size of the nical principles. Clearly, with the reported rate of
rectum [37]? anastomotic leak ranging from 8 to 26 % for
If we are considering an end-to-end anasto- LAR, one must conclude that in addition to the
mosis (EEA) with a circular stapler, are we con- specialty-related skills of the surgeon (colorectal
sidering the effect of the size of the EEA stapler versus general surgeons), other factors such ana-
that the anatomy of the colon and rectum will tomic and technical factors must play a role in
permit on the rate of stricture of the anastomosis, accounting for such a large difference in the rate
particularly if we are considering diverting the of anastomotic leak. The same applies to the
fecal stream for 2–6 weeks for anastomosis done reported incidence of stricture (3–30 %) after
between 6 and 8 cm from the anal verge? If we stapled anastomoses after LAR.
are limited to use a 29 mm EEA stapler and are
planning to perform a diverting loop ileostomy,
does evidence suggest an unacceptably high rate Conclusions
of postoperative anastomotic stricture [38]?
Should we instead opt for a Baker type anasto- The example used to discuss the intraoperative
mosis to limit the possibility of anastomotic stric- decision tree highlights the many anatomic, tech-
ture? Should we proceed with a hand sewn Baker nical, and decision points that we must confront
anastomosis with interrupted posterior horizontal when planning and preparing for an operation.
mattress sutures in 3-0 silk and simple anterior Ideally, checklists similar to those used for rou-
3-0 silk sutures or conversely proceed with a cir- tine and emergency conditions by pilots, that
cular stapled technique? The incidence of anasto- contain preoperative risk assessment, anatomic
motic stricture after an EEA done with the and technical decision points, critical steps spe-
circular stapler varies depending on the definition cific to each operation, and the benefits and dis-
of stricture. If rectal stricture is defined by the advantages of possible choices applicable to our
inability to pass a 12.3 mm sigmoidoscope operation could reduce variability which has
through the stenosis, then the stricture rate can be been shown to be one of the most common cause
as high as 30 %. Furthermore, diversion of the of errors and improve the outcomes of surgical
fecal stream increases the incidence of anasto- patients.
motic stricture, particularly when the EEA has In conclusion, planning and preparing for any
been done with a 29 mm circular stapler. With operation starts with the assessment of the risk
respect to diverting low anterior anastomoses (≤7 and benefits of the planned operation based on
cm) from anal verge, there is evidence supporting the preoperative evaluation of the patient as
a decreased rate of symptomatic anastomotic opposed to the outcome expected in the absence
leakage when a loop ileostomy is done in con- of treatment followed by the appropriate prepara-
junction with LAR [39]. Similar supporting evi- tion to handle all intraoperative aspects of an
dence applies to testing the integrity of the suture operation including the correct anatomic, techni-
line with either betadine irrigation of the bowel cal, and overall choices necessary to guarantee
or with the “bubble test” (air insufflation) [40]. the best possible outcome for our patients.
Unfortunately, there is no level I evidence
available to incorporate in our memory bank, nei-
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 The Decision-Making Process
in Sepsis and Septic Shock 7
Michelle H. Scerbo and Laura J. Moore

myocardial infarction and pulmonary embolism

Introduction [3]. Further, surgical patients account for nearly a
third of all sepsis patients [4].
Despite increased attention, research, and dedi- This is particularly concerning in the elderly
cated task forces, sepsis continues to be problem- patients, who have prolonged hospital stays,
atic in surgical patients. Severe sepsis and septic more diagnoses upon discharge, and higher mor-
shock are the leading cause of death in non- talities from sepsis compared with younger
cardiac Intensive Care Units (ICUs), costing patients [2, 4]. With an anticipated increase in the
$24.3 billion [1] and contributing to 17 % of all incidence of sepsis of 1.5 % per year and the pro-
hospital deaths per year in the United States [2]. jected growth of the elderly population in the
A recent analysis of the American College of United States, this is expected to increase the
Surgeons National Surgical Quality Improvement number of estimated cases from 934,000 in 2010
Project (NSQIP) Database demonstrated that to 1.1 million in 2020.
sepsis and septic shock are ten times more fre- Risk factors for death from sepsis in the gen-
quent and have a higher associated mortality in eral surgery population include age greater than
surgical patients compared with perioperative 60, the need for emergency surgery, and the pres-
ence of comorbid diseases [5]. When septic
shock occurs in surgical patients, it has an associ-
M.H. Scerbo, M.D. ated mortality of 39 % in emergent cases and
Department of General Surgery, The University of 30 % in elective cases [5].
Texas Health Science Center at Houston,
Despite these harrowing figures and increas-
6431 Fannin Street, MSB 4.331, Houston,
TX 77030, USA ing rates of hospitalization and mortality, recent
e-mail: Michelle.l.scerbo@uth.tmc.edu evidence-based advancement in critical care
L.J. Moore, M.D. (*) practices have led to a decrease in case fatality
Department of General Surgery, The University of rate for severe sepsis [6].
Texas Health Science Center at Houston, The tenets to successfully treating a patient
6431 Fannin Street, MSB 4.331, Houston,
with sepsis rely on early recognition, early inter-
TX 77030, USA
ventions, and the implementation of the proper
Texas Trauma Institute, Memorial Hermann Hospital,
evidence-based care. However, early recognition
6431 Fannin Street, MSB 4.292, Houston,
TX 77030, USA and consistent implementation of evidence-based
e-mail: Laura.j.moore@uth.tmc.edu care are not consistently accomplished.

© Springer International Publishing Switzerland 2016 59

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_7
60 M.H. Scerbo and L.J. Moore

Definitions of Systemic septicemia and septic syndrome were recom-

Inflammatory Response Syndrome, mended to be dropped from the lexicon of those
Sepsis, Severe Sepsis, Septic Shock, describing SIRs, sepsis, severe sepsis, septic
and Surgical Sepsis shock, and MODS. A decade later, these terms
were revisited to expand the list of signs and
Balk and Bone originally defined sepsis syndrome symptoms of sepsis [9].
as the systemic response to infection [7]. The
American College of Chest Physicians and the
Society of Critical Care Medicine (ACCP/SCCM) SIRS and Sepsis
held a consensus conference in 1991 to define the
systemic inflammatory response syndrome SIRS is the clinical manifestation of the innate
(SIRS), sepsis, septic shock, and multiple organ immune system. It is intentionally nonspecific
dysfunction syndrome (MODS) [8]. The goal was and can be a result of infectious or noninfectious
to provide definitions in order to facilitate the ease pathology, including pancreatitis, traumatic
of early detection, implementation of early thera- injury, hemorrhagic shock, or ischemia. Sepsis is
peutic intervention, and the standardization of SIRS in response to an infection. The definitions
research in order to compare protocols and thera- of SIRS, sepsis, severe sepsis, and surgical sepsis
peutic interventions. Subsequently, the terms are outlined in Table 7.1.

Table 7.1 Definitions of SIRS, sepsis, severe sepsis, septic shock, and MODS
Criteria
SIRS Two or more of the following
Body temperature <36 °C (96.8 °F) or >38 °C (100.4 °F)
Heart rate >90 beats per minute
Respiratory rate >20 breaths per minute
OR
Hyperventilation Arterial carbon dioxide tension (PaCO2) <32 mmHg
Leukocyte count <4000 cells/μL
OR >12,000 cells/μL OR
The presence of >10 % immature neutrophils (bands)
Sepsis SIRS as a result of an infection
Severe Sepsis associated with:
sepsis Organ dysfunction See Table 7.2
OR
Hypoperfusion One of the following:
1. Urine output < 0.5 mg/kg of IBW
2. MAP < 65 mmHg
3. GCS < 14
4. Serum lactate ≥ 4 mmol/L
OR
Hypotension Systolic blood pressure <90 mmHg or a reduction of >40 mmHg from baseline
in the absence of other causes of hypotension
Septic Sepsis with acute Acute cardiac dysfunction (must meet both criteria):
shock cardiac dysfunction 1. IV fluid challenge ≥ 20 mL/kg of IBW, CVP ≥ 8 mmHg, or
PCWP ≥ 12 mmHg
2. Requires, vasopressors to increase MAP to ≥ 65 mmHg
MODS Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained
without intervention
MAP mean arterial pressure, IV intravenous, IBW ideal body weight, CVP central venous pressure, PCWP pulmonary
capillary wedge pressure
7 The Decision-Making Process in Sepsis and Septic Shock 61

Table 7.2 Criteria for organ function for defining severe sepsis
Organ system Criteria Caveat
Neurologic Glasgow Coma Scale (GCS) < 13 Upon recognition of sepsis
OR
Deteriorating GCS to <13 Within recognition of sepsis
Pulmonary Ratio of Arterial oxygen tension (PaO2) to <200 if the lung is the primary site of infection and
fraction of inspired oxygen (FIO2) < 250 PCWP is not suggestive of fluid overload (<18 mmHg)
Renal One of the following: Cutoffs are despite adequate volume resuscitation,
which is defined as one of the following:
1. Urine output < 0.5 mL/kg for ≥1 h • Minimum IV fluid infusion of 20 mL/kg of IBW
2. Increase in serum creatinine at • CVP ≥8 mmHg or greater
least 0.5 mg/dL from in baseline
within 24 h of starting resuscitation
3. Increase in serum creatinine • PCWP ≥12 mmHg
≥0.5 mg/dL during the first 24 h of
sepsis management
Hematologic One of the following: Coagulation abnormalities must be in the absence of
1. INR > 1.5 chronic liver disease
2. Platelet count < 80,000 μL
3. ≥50 % decrease in platelet count
in the first 24 h of instituting sepsis
resuscitation
Tissue Lactate > 4 mmol/L
hypoperfusion
IV intravenous fluid, IBW ideal body weight, CVP central venous pressure, PCWP pulmonary capillary wedge pressure,
INR international normalized ratio

Severe Sepsis authors of this text define surgical sepsis as

(1) SIRS plus an infection within 14 days or a
Severe sepsis is defined as SIRS with the pres- major surgical procedure or (2) SIRS plus an
ence of an infection and evidence of acute organ infection requiring surgical intervention for
dysfunction. Criteria for organ dysfunction by source control. A major surgical procedure is
system are listed in Table 7.2. any procedure requiring general anesthesia for
more than 1 h.

Septic Shock
Management of the Septic Patient
Septic shock is the progression of severe sepsis to
include acute cardiac dysfunction. The criteria The work of Rivers and Colleagues over a decade
for acute cardiac dysfunction includes vasopres- prior to the publication of this text has largely
sor requirement for maintenance of MAP above changed the way that sepsis is identified and man-
65 mmHg despite adequate volume resuscitation. aged. The original trial consisted of 263 patients
These parameters are more specifically defined in the emergency department who were random-
in Table 7.1. ized to standard therapy or early (within 6 h) goal-
directed therapy. Implementation of this early
goal-directed therapy (EGDT) showed a decrease
Surgical Sepsis in 28 day (49 % compared to 33 %) and 60 day
(57 % compared to 44 %) mortality (p < 0.05).
The most recent conference of the ACCP/ This study coined the terms “golden hours of
SCCM did not define surgical sepsis [9]. The resuscitation,” referred to as the first 6 h for the
62 M.H. Scerbo and L.J. Moore

Table 7.3 Early goal-directed therapy sepsis bundles Goal 1: Screen for Sepsis and Identify
Sepsis bundles Sepsis Early
Sepsis resuscitation bundle (initiate immediately and
complete within 6 h) Sepsis Screening
Measure serum lactate Rivers et al. emphasized the importance of early
Obtain blood cultures prior to administering intervention during the “golden hours” of sepsis
antibiotics
[10]. Early recognition of sepsis is paramount to
Administer broad-spectrum antibiotics within
preventing patient morbidity and mortality;
• 3 h (ED admission)
however, surveys of ward nurses and physicians
• 1 h (non-ED ICU admission)
reveal this to be a difficult task [11, 12]. Rivers
If hypotensive (SBP <90 mmHg) and/or lactate
>4 mmol/L et al. was further corroborated by Kumar and
• Infuse a minimum of 20 mL/kg crystalloid or colleagues, who demonstrated that administra-
colloid equivalent tion of appropriate antimicrobial therapy within
• Include vasopressors if initial fluid resuscitation the first hour of documented hypotension was
does not maintain a MAP ≥65 mmHg associated with a survival rate of 80 % from sep-
If septic shock and/or initial lactate >4 mmol/L tic shock. The authors additionally revealed that
• Goal CVP ≥ 8 mmHg each additional hour delay in therapy was asso-
• Goal ScvO2 ≥ 70 % or SvO2 ≥ 65 % ciated with an average decrease in survival by
Sepsis management bundle (initiate immediately and 7.6 % [13]. These interventions cannot be expe-
complete within 24 h)
ditiously employed without first identifying sep-
Administer low-dose steroids for septic shock
sis. Therefore, the Surviving Sepsis Campaign
Maintain inspiratory plateau pressures <30 cm H2O
advocates the routine screening for sepsis to
Maintain glucose ≥ lower limit of normal but
<150 mg/dL (8.3 mmol/L) facilitate early identification of sepsis and early
Used with permission from Kreiner LA. Early manage- implementation of sepsis therapy (Grade 1C)
ment of sepsis, severe sepsis, and septic shock in the sur- [14]. A shorter time to implementation of evi-
gical patient. In Common Problems in Acute Care Surgery. dence-based therapies has been shown to
Moore LJ, Turner KL, Todd SR, eds. New York: Springer improve outcomes and decrease sepsis-related
Science+Business Media; 2013
mortality [15]. Of note, the ideal screening inter-
val has not been determined. Using SIRS criteria
to screen for sepsis has proven impractical and
“resuscitation bundle” and first 24 h for the “man- insensitive [16, 17], and it is even more chal-
agement bundle.” The goal is to perform all indi- lenging in a perioperative patient. The early
cated tasks 100 % of the time within the first 6 h signs and symptoms, including tachycardia,
for the sepsis resuscitation bundle or first 24 h for tachypnea, and hyper- or hypothermia are non-
the sepsis management bundle upon the diagnosis specific, particularly in a postoperative patient
of severe sepsis. The components of these bundles who is also subject to pain, perioperative fluid
are outlined in Table 7.3. shifts, sensible fluid losses, and narcotic admin-
istration. Additional indicators of sepsis, includ-
ing oliguria and altered mental status, are also
Management Goals for Sepsis, Severe often attributed to volume imbalance or narcotic
Sepsis, and Septic Shock administration. When these signs are misinter-
preted, this causes delays in the implementation
The goals for managing a patient with sepsis, of early therapy, which can lead to increased
severe sepsis, or septic shock are on a continuum (>30 %) likelihood of mortality.
that is reflective of the critical status of the A sepsis screening tool has been developed by
patient. Concordantly, all patients will need the the author of this text for screening specifically in
initial steps, but the latter will only apply to the a surgical population (Fig. 7.1). Validation in
more critically ill. nearly 5000 surgical ICU patients has demonstrated
7 The Decision-Making Process in Sepsis and Septic Shock 63

SICU Bedside Nurse

patient label
SIRS score
current heart rate time
T min time
T max time
current resp rate time 04162007
latest WBC count date, time

points 0 1 2 3 4
heart rate 55 – 69 40 - 54 ≤ 39
(bpm) 70 - 109 110 – 139 140 - 179 ≥ 180
T (°C) min 34 – 35.9 32 – 33.9 30 – 31.9 ≤ 29.9
max 36 – 38.4 38.5 – 38.9 39 – 40.9 ≥ 41
resp rate 10 – 11 6-9 ≤5
(br / min) 12 - 24 25 - 34 35 – 49 ≥ 50
latest WBC 1 – 2.9 ≤1
(kcell / mm3) 3 – 14.9 15 – 19.9 20 – 39.9 ≥ 40
score
(total points)

If SIRS score ≥ 4, then notify SICU Nurse Practitioner to complete sepsis screening form.

SICU
overflow MICU NICU CCU

Completed by: .RN Date / time:

Fig. 7.1 Sepsis screening tool. SICU surgical intensive care unit, CCU cardiac care unit. (Used with permission
care unit, SIRS systemic inflammatory response syn- from Moore LJ, Jones SL, Kreiner LA, et al. Validation of
drome, resp respiratory, WBC white blood cell count, a screening tool for the early identification of sepsis. J
MICU medical intensive care unit, NICU neuro intensive Trauma. 2009;66(6):1539–1546; discussion 1546–1547)

a sensitivity of 96.5 %, specificity of 96.7 %, Goal 2: Initiate Resuscitation

positive predictive value of 80.2 %, and a nega- Immediately Upon Recognition
tive predictive value of 99.5 %. This has been of Sepsis and Prior to Transfer
similarly validated in general surgical floor to Higher Level of Care
patients as well as trauma patients [18, 19]. The
sepsis screening tool has been implemented in a Monitoring and Invasive Devices
three step tool which includes (1) initial score
calculation of sepsis screening score by the bed- Establish Intravenous (IV) Access
side nurse, (2) notification of the mid-level pro- Upon the identification of sepsis, two large-bore
vider for a score of four or greater for investigation peripheral IV catheters should be placed for ini-
of the physiologic derangements (Fig. 7.2), and tiation of fluid resuscitation and administration of
(3) notification of the surgical intensivist and antibiotics. If the patient has merely sepsis (i.e.,
implementation of a sepsis management protocol no evidence of tissue hypoperfusion or end-organ
in the case that sepsis is suspected. Implementation dysfunction), a large-bore peripheral IV is appro-
of this three step tool has been demonstrated to priate. In the case that the patient has evidence of
decrease mortality from 35.1 to 23.3 % in surgi- tissue hypoperfusion, end-organ dysfunction,
cal patients [18]. or a peripheral IV cannot easily be obtained, a
64 M.H. Scerbo and L.J. Moore

SICU Nurse Practitioner/Resident Physician

Sepsis Screening
1. Vascular access? Yes No Suspicion of:
type dialysis triple / quad PICC port tunneled other (IV, art) line infection?
date placed
site
Yes No
local finding
blood culture finding

2. Clinical pulmonary infection score (CPIS)

Variable points score pneumonia?
temperature (°C) time (hhmm)
36.5 − 38.4 0 Intubated / Yes No
38.5 − 38.9 1 mech vent
>39.0 or <36.0 2 support?
blood leukocyte count (# per mm3) time (hhmm)
4,000 − 11,000 0 Yes No
<4,000 or >11,000 1
tracheal secretions time (hhmm) date intubated:
small 0
moderate 1
large 2
purulent (add 1 point if purulent) +1
oxygenation (PaO2/FiO2) time (hhmm)
≥240 or presence of ARDS 0
<240 and absence of ARDS 2
chest radiograph time (hhmm)
no infiltrate 0
patchy or diffuse infiltrate 1
localized infiltrate 2

3. Abdomen
recent abdominal surgery? Yes No abdominal
abdominal pain? Yes No infection?
abdominal distention? Yes No
purulent drainage from surgical drains? Yes No Yes No
intolerance to enteral nutrition? Yes No

4. Skin / soft tissue cellulitis / soft

erythema / drainage from other surgical site? Yes No tissue infection?
site
Yes No
5.Urinary tract
urinary catheter? Yes No
date placed
UTI?
latest urinalysis / urine culture results
Yes No
6. other site other infection?
site
Yes No
Completed by: Date / time:

Fig. 7.2 Two-part Sepsis screening tool. SICU surgical tress syndrome, UTI urinary tract infection. (Used with
intensive care unit, SIRS systemic inflammatory permission from Moore LJ, Jones SL, Kreiner LA,
response syndrome, resp respiratory, WBC white blood et al. Validation of a screening tool for the early identi-
cell count, PICC peripherally inserted central catheter, fication of sepsis. J Trauma. 2009;66(6):1539–1546;
IV intravenous, art arterial, ARDS acute respiratory dis- discussion 1546–1547)
7 The Decision-Making Process in Sepsis and Septic Shock 65

central venous catheter (CVC) should be placed therapy. If a patient needs renal replacement ther-
in order to expeditiously administer fluid. apy, placement of dialysis catheters in the subcla-
vian vein should be avoided as it has been
Establish a Baseline demonstrated to be associated with stenosis and
If it has not been done already, a complete blood preclude the placement of permanent dialysis
count should be obtained to assess changing access in the future [24]. The Stuivenberg
white blood cell (WBC) and platelet count. A Hospital Acute Renal Failure (SHARF) study
baseline serum lactate should be sent upon the demonstrated that continuous and intermittent
identification of sepsis, with a repeat measure- renal replacement therapies for treatment of acute
ment drawn 4 h later to monitor the progress of kidney injury had similar effects on mortality
resuscitation. In addition, a baseline Creatinine (62.5 % intermittent, 58.1 % continuous,
should be drawn to assess for kidney injury and p = 0.430) [25]. A patient with labile blood pres-
an INR should be assessed to determine if the sures will tolerate continuous renal replacement
patient has evidence of coagulation dysfunction. therapy better than intermittent therapy.

Monitor Hemodynamic Parameters Therapy (Sepsis, Severe Sepsis, and Septic

CVCs can be used to monitor central venous Shock)
pressure (CVP) and central venous oxygen satu-
ration (ScvO2). These measurements can be used Fluid Resuscitation
to guide the administration of intravenous fluids, The goal of initial resuscitation is to restore intra-
vasopressors, blood products and inotropes to vascular volume. According to the Frank-Starling
target mean arterial pressure (MAP), CVP, and curve, administering fluid increases the stroke
ScvO2. CVCs placed into the subclavian vein volume until an optimal preload is obtained. The
have been demonstrated to have fewer infectious endpoints of fluid resuscitation are list in
complications compared to the internal jugular Table 7.4.
and femoral veins [20]. Initial fluid resuscitation should begin with a
If the vasopressors are required to maintain an 30 cm3/kg (ideal body weight, IBW) bolus of
adequate blood pressure, then an arterial line crystalloid. There are no randomized controlled
should be place to allow for titration of drips. The trials demonstrating the superiority of crystal-
routine use of a pulmonary artery catheter is not loids or colloids in surgical patients with sepsis.
always needed as there are less invasive and more The Colloids Versus Crystalloids for the
dynamic measurements, such as stroke volume Resuscitation of the Critically Ill (CRISTAL)
variation (SVV) or continuous transesophageal trial randomized 2857 medical (~70 %) and sur-
doppler, that can provide the practitioner with
similar information in regards to preload. SVV Table 7.4 Endpoints of fluid resuscitation
has limited interpretation in the case of arrhyth- Endpoint Caveat
mias or in patients on mechanical ventilation Central venous 8–12 mmHg Nonintubated
with either low tidal volume ventilation or spon- pressure (CVP) 12–15 mmHg Mechanically
taneous respirations [21–23]. ventilated [26]
Mean arterial ≥65 mmHg
Monitor Urine Output pressure (MAP) [27]
Strict measurement of urinary output should Urine output ≥0.5 mL/
kg/h
always occur when sepsis is suspect or recog-
Central venous ≥70 %
nized. In severe sepsis and septic shock, a Foley oxygen saturation
catheter should be inserted to reliably measure (ScvO2)
urinary output and guide fluid resuscitation. OR
Persistence of acidosis, electrolyte imbalances, Mixed venous oxygen ≥65 % [10]
or oliguria is an indication for renal replacement saturation (SvO2)
66 M.H. Scerbo and L.J. Moore

gical ICU patients with hypovolemic shock min to maintain target serum levels; however, the
secondary to sepsis (54 %), trauma, or neither, to patients receiving albumin had a shorter duration
volume resuscitation with either colloids or crys- of vasopressors or inotropes by 1 day (p = 0.007)
talloids. There was no difference in the primary [31]. The Early Albumin Resuscitation during
outcome of all-cause 28-day mortality between Septic Shock study (France) has been completed
the two groups. Colloids were associated with a as of 2011, but had not yet reported outcomes at
reduction in the all-cause 90-day mortality the time of publication of this text. [32].
(30.7 % vs. 34.2 %; number needed to treat = 29). While the benefit of colloids or crystalloids
Although this suggests a lack of harm with the continues to be investigated, it is well under-
use of colloids as the resuscitation fluid in septic stood that the use of hydroxyethyl starch (HES)
shock, the authors caution interpreting this find- solutions should be avoided. The 6S Trial is a
ings as anything other than exploratory, mainly multicenter, parallel-group, blinded trial in
because of the null findings at 28 days [28]. which 804 patients with severe sepsis were
These findings were additionally found in the randomized to receive either 6 % HES 130/0.42
Effects of Voluven on Hemodynamics and (Tetraspan) or Ringer’s acetate. The 6 % HES
Tolerability of Enteral Nutrition in Patients with group had increased 90-day mortality (51 %
Severe Sepsis (CRYSTMAS) trial, conducted in vs. 43 % p = 0.03) and renal replacement
patients with septic shock, which demonstrated requirements (22 % vs. 16 % p = 0.04). The
no difference in mortality with hydroxyethyl increased need for renal replacement therapy
starch (HES) compared with 0.9 % Normal in patients that received 6 % HES was further
Saline (NS) (31 % vs. 25.3 %, p = 0.37); however, demonstrated in a trial randomizing 7000
this study was underpowered to detect the 6 % patients to 6 % HES vs. (7.0 % vs. 5.8 %;
difference in absolute mortality observed [29]. Relative Risk 1.21; 95 % Confidence Interval
The Saline versus Albumin Fluid Evaluation 1.00 − 1.45; p = 0.04) [33]. Finally, a Cochrane
(SAFE) study randomized 6997 ICU patients Review of 42 studies including 11,399 patients
(18 % with severe sepsis) to receive either albumin concluded that HES solutions increase the risk
or normal saline for fluid resuscitation. No differ- of acute kidney injury and the need for renal
ence in mortality was identified between the two replacement therapy [34].
groups (20.9 % vs. 21.1 %, Relative Risk 0.99, Therefore, initial fluid resuscitation of a patient
95 % Confidence Interval 0.91–1.09). Evaluation with severe sepsis or septic shock should begin
of the patients with severe sepsis revealed a non- with a bolus of 30 mL/kg (IBW) of crystalloid.
significant trend towards reduced mortality in the Albumin may be considered if the patient contin-
albumin group (Relative Risk of death 0.87, 95 % ues to have high volume requirements for resusci-
Confidence Interval 0.74–1.02) [30]. tation. HES should not be used for fluid resuscitation
The trend of improved mortality with the use in severe sepsis and septic shock as it has been
of albumin as a resuscitation fluid has been sub- demonstrated to have an increased risk of death
sequently investigated in two trials. In the and the need for renal replacement therapy. A sum-
Volume Replacement with Albumin in Severe mary of the results of these trials and resulting
Sepsis (ALBIOS) trial, 1818 patients in 100 Surviving Sepsis Campaign (2012) recommenda-
Italian ICUs with severe sepsis or septic shock tions are outlined in Table 7.5.
were randomized to receive both 20 % albumin
and crystalloid or crystalloid alone. The patients Therapy (Septic Shock)
receiving albumin continued to receive daily IV
albumin to maintain a goal serum albumin of Vasopressors
≥3 g/dL while both groups received crystalloid The goal for administering vasopressors is to tar-
for further volume expansion as necessary. The get an MAP of 65 mmHg (Grade IC); however,
authors found no difference in all-cause 28- or the comorbidities of the patient should be consid-
90-day mortality with the administration of albu- ered when assessing this target. For example, a
7 The Decision-Making Process in Sepsis and Septic Shock 67

Table 7.5 Surviving sepsis campaign 2012 fluid therapy tionally concluded that while there was not suf-
guidelines
ficient evidence to show that norepinephrine
Surviving sepsis campaign 2012 fluid therapy guidelines compared to dopamine or epinephrine was supe-
Crystalloids should be used as the initial fluid of choice rior in terms of mortality, dopamine was shown
for the resuscitation of severe sepsis and septic shock
(Grade 1B)
to be more associated with arrhythmias [35].
HES should not be used for fluid resuscitation of
More recently, a meta-analysis of 2811
severe sepsis and septic shock (Grade 1B) patients from 14 randomized clinical trials (nine
Albumin should be used in the fluid resuscitation of comparing four different vasopressors and five
severe sepsis and septic shock when patients require examining the effects of two different inotropes)
substantial volume of crystalloid (Grade 2C) demonstrated improved 28-day mortality with
Data from Dellinger, R. P. et al. Surviving Sepsis norepinephrine alone compared to dopamine for
Campaign: international guidelines for management of
severe sepsis and septic shock, 2012. Intensive Care
the treatment of hypotension in septic shock
Med 2013; 39:165–228 (Odds Ratio 0.8, 95 % Confidence Interval 0.65–
0.99). Additionally, adjunctive therapy of low-
dose vasopressin with norepinephrine reduced
patient with atherosclerosis and uncontrolled mortality (Odds Ratio 0.69, 95 % Confidence
hypertension may require a higher MAP to Interval 0.48–0.98) compared with dopamine
achieve end-organ perfusion, and this can be [36]. This effect was not appreciated with the use
assessed by using other indicators of end-organ of epinephrine or the addition of an ionotropic
perfusion, such as mental status and urinary out- agent such as dopexamine or dobutamine.
put [15]. The beneficial adjunctive effect of vasopressin
Septic shock causes an initial increase in car- was challenged in the Vasopressin and Septic Shock
diac output and decreased systemic vascular Trial (VASST). The VASST trial randomized 779
resistance, resulting in decreased blood pressure. subjects in septic shock on 5 μg/min of norepineph-
The treatment for refractory hypotension despite rine for at least 6 h to receive either a higher dose of
adequate fluid resuscitation should therefore norepinephrine (5–15 μg/min) or adjunctive vaso-
focus on restoring vascular tone. pressin (0.01–0.03 U/min). The overall cohort did
not show a difference in 28- or 90-day mortality;
First-Line Therapy however, when the patients were stratified into
It has long been the consensus that either norepi- severity of septic shock, the less severe strata
nephrine or dopamine was acceptable first-line showed decreased 28-day (26.5 % vs 35.7 %,
vasopressor agents for septic shock. However, p = 0.05) and 90-day (35.8 % vs 46.1 %, p = 0.04)
recent evidence has demonstrated that norepi- mortality in the vasopressin group compared to the
nephrine is superior to dopamine in the treat- escalating norepinephrine group.
ment of shock because of a decreased incidence Therefore, it is recommended to start with
of cardiac arrhythmias. Norepinephrine is an norepinephrine (5 μg/min) as a first-line vaso-
α-adrenergic receptor agonist; it increases con- pressor and add vasopressin in patients that
traction of smooth muscle cells, increasing vas- continue to be hypotensive despite maximum
cular resistance and consequently blood pressure. doses of norepinephrine (15 μg/min). Vasopressin
Little effect is appreciated in heart rate and stroke can be started at a dose of 0.03 U/min and should
volume. In contrast, dopamine has dose- not exceed 0.04 U/min due to the risk of decreased
dependent effects on α-, β- and dopaminergic cardiac output and myocardial ischemia [37].
receptors. Dopamine initially acts on β1-receptors Phenylephrine, a central α-adrenergic vasocon-
to increase heart rate and stroke volume, causing strictor, has been demonstrated to decrease stroke
an increase in cardiac output and blood pressure. volume. For this reason, phenylephrine is only rec-
At higher doses, dopamine activates α-receptors ommended when norepinephrine has caused seri-
and causes vasoconstriction. A 2011 Cochrane ous arrhythmias or when target blood pressure is
Review of ten randomized controlled trials addi- not maintained despite first-line vasopressor and
68 M.H. Scerbo and L.J. Moore

inotrope therapy and the patient has maintained lation of the production of anti-inflammatory
their cardiac output [15]. cytokines, and locally acting to decrease inflam-
mation. Cardiovascular effects include increasing
Inotropic Therapy: Severe sepsis and septic blood pressure by increasing vascular smooth
shock result in defective cellular oxygen utiliza- muscle sensitivity to catecholamines and angio-
tion rather than impaired tissue oxygenation [38]. tensin II. Metabolic effects are appreciated as an
Therefore, there is no benefit to using inotropic increase in blood glucose through potentiation of
agents to raise oxygen delivery to supranormal gluconeogenesis and lipolysis, as well as through
targets in patients with severe sepsis or septic upregulation of epinephrine and glucagon [44].
shock [14]. Conversely, patients with known or In response to critical illness and stress, cortisol
suspected cardiac dysfunction should be started production increases sixfold. In septic shock, relative
on inotropic therapy. Dobutamine (20 μg/kg/min) adrenal insufficiency has been noted to be as preva-
is the first-line agent for management of cardiac lent as in 60 % of patients [45]. Increased levels of
dysfunction in these patients. Dobutamine is a circulating inflammatory cytokines, decreased recep-
β1-receptor agonist and weak β2-receptor ago- tor sensitivity to cortisol, and hypothalamic-pituitary-
nist. The β1 stimulation increases stroke volume adrenal axis suppression all contribute to this adrenal
while the β2 stimulation results in peripheral insufficiency. The result is a catecholamine-dependent
vasodilation. Heart rate may be increased or patient who is no longer able to maintain his or her
decreased depending on the response in sympa- own vascular tone via endogenous cortisol.
thetic tone to the change in cardiac output.
Diagnosis of Adrenal Insufficiency: Traditionally,
Later stages of sepsis can progress to myocar-
adrenal insufficiency in critically ill patients is
dial depression, which is characterized by non-
best diagnosed by either (1) random total cortisol
ischemic, reversible depression of the left and
level of <10 μg/dL or (2) delta cortisol of <9 μg/
right ventricles [39, 40]. As the myocardium
dL after administering 250 μg of cosyntropin
stretches, B-type natriuretic peptide (BNP) is
(ACTH) (Grade 2B). Additionally, a low random
secreted. A retrospective review on 231 surgical
cortisol level (<18 μg/dL) in a patient with shock
sepsis patients demonstrated a correlation
should be regarded as an indication for initiating
between increasing BNP and sepsis severity,
steroid therapy [14].
early systolic dysfunction and death [41]. This
supports the monitoring of BNP in early sepsis in Due to limited accuracy [46] and potential
order to identify occult left ventricular dysfunc- interfering therapies in the patient with septic
tion and possibly prompt an earlier administra- shock, current guidelines recommend against
tion of inotropes. performing a low-dose ACTH stimulation test to
identify patients who should receive glucocorti-
Steroids coids. For instance, etomidate is an induction
The use of steroids, the definition of relative agent commonly used for rapid-sequence intuba-
adrenal insufficiency, and the gold standard to tion in patients that decompensate quickly.
diagnose adrenal insufficiency in patients with Etomidate is known to cause a transient suppres-
septic shock have been long debated and remain sion of the hypothalamus-pituitary-adrenal axis
controversial [42, 43]. and resultant adrenal insufficiency for approxi-
mately 24 h [47]. However, the impact of this
The Role of the Adrenal Gland in Sepsis: In adrenal insufficiency on mortality is not well
response to a stressful trigger such as critical ill- understood [48–50]. In addition, patients who
ness, the hypothalamic-pituitary-adrenal axis is have received steroids in the 6 months prior to
stimulated to synthesize cortisol in the adrenal their episode of septic shock will have inconsis-
cortex. Cortisol then exerts metabolic, cardiovas- tent results when testing their adrenal function.
cular, and immune effects to restore homeostasis Therefore, in these patients with known altera-
during illness. The immune effects include the tions of their hypothalamic-pituitary-adrenal
inhibition of proinflammatory cytokines, stimu- axis, empiric steroid therapy should be initiated
7 The Decision-Making Process in Sepsis and Septic Shock 69

regardless of the baseline adrenal function as all patients with septic shock, and had a placebo
demonstrated by the ACTH stimulation test. mortality of over half of that of the Annane and
colleagues study. Finally, the CORTICUS study
Evidence of the Benefit of Steroid Therapy in was underpowered for their primary outcome.
Septic Shock: After the abandonment of the use Therefore, low-dose steroids (≤200 mg/day
of high-dose steroids for septic shock, the use of hydrocortisone or equivalent) have been demon-
low-dose steroids has been intensely studied. strated to be beneficial in septic shock by increas-
In 2002, Annane and colleagues conducted a ing both systemic vascular resistance and MAP,
multicenter randomized, double-blind, placebo- resulting in a decrease in the duration of vaso-
controlled parallel-group trial of 300 patients pressor use and a decrease in the risk of death.
with septic shock receiving either placebo or Low-dose steroids should only be used in patients
50 mg of hydrocortisone IV every 6 h and 50 μg with septic shock who cannot maintain hemody-
of oral fludrocortisone. The authors concluded namic parameters with fluid resuscitation and
that the patients receiving steroids had decreased vasopressors [14]. Steroids should be tapered to
mortality (Hazard Ratio 0.67, 95 % Confidence discontinuance if vasopressor dependency has
Interval 0.47–0.92, p = 0.02) as well as decreased not improved within 48 h of glucocorticoids or in
duration of vasopressor therapy [51]. patients who are no longer vasopressor depen-
A systematic review of 17 randomized and dent [44].
quasi-randomized trials comparing corticosteroids
to placebo in patients with severe sepsis or septic Goal 3: Reverse Hypoperfusion
shock found that corticosteroids did not affect According to the ACCP/SCCM definitions, tis-
28-day mortality. However, a subgroup of 12 trials sue hypoperfusion indicates that a patient has
with prolonged (≥5 days) low-dose (<300 mg progressed from sepsis to severe sepsis [9]. The
hydrocortisone or equivalent) treatment suggested presence and degree of tissue hypoperfusion can
a favorable effect on all-cause mortality [52]. This be assessed via the blood pressure, urine output,
benefit of low-dose hydrocortisone or equivalent mental status, or serum lactate. The specific
was corroborated by an additional meta-analysis parameters for defining tissue hypoperfusion are
of eight (six randomized) studies [53]. outlined in Table 7.6.
Conversely, the Corticosteroid Therapy of
Septic Shock (CORTICUS) trial was another Goal 4: Diagnose the Source of Infection
multicenter, randomized, double-blind, placebo- Immediately following the initiation of fluid
controlled trial that evaluated the use of low-dose resuscitation, the source of infection should be
steroids in septic shock [46]. The results from identified. Cultures should be drawn prior to, but
this study failed to show a difference in 28-day without delaying, initiation of empiric antimicro-
mortality between the two groups; however, it bial therapy. Blood cultures should be obtained in
was again displayed that the steroid group had a all patients with sepsis; current recommendations
decreased time to shock resolution by approxi- include obtaining a minimum of two blood cul-
mately 2 days. tures. A blood culture should be obtained from
Differences between the results of the two each vascular access device (i.e., indwelling
studies have been largely attributed to time to
randomization, placebo group mortalities, patient
baseline characteristics, and power. The study by Table 7.6 Indicators of tissue hypoperfusion
Annane and colleagues randomized patients Parameter Cutoff value
within 3 h of the onset of septic shock, enrolled Mean arterial pressure (MAP) <65 mmHg
only patients with vasopressor-dependent septic Urine output <0.5 mg/kg of IBW
shock, and had a placebo group mortality of Glasgow coma score <12
63 %. The CORTICUS trial randomized up to Serum lactate ≥4 mmol/L
72 h after the diagnosis of septic shock, included IBW ideal body weight
70 M.H. Scerbo and L.J. Moore

CVC, dialysis catheter) as well as from periph- sepsis [15, 61]. Current guidelines from the
eral puncture. If there are no vascular access Surviving Sepsis Campaign recommend the initi-
devices in place upon the recognition of sepsis, ation of empiric antimicrobial therapy within the
two peripheral cultures should be obtained. A first hour of the recognition of sepsis [14]. Empiric
vascular access device can be identified as a site therapy is defined as the inclusion of antimicrobi-
of infection if there is a differential time to posi- als that have activity against all likely pathogens
tivity of at least 120 min from the vascular access while considering local antibiotic susceptibility
device prior to positivity from a peripheral punc- patterns [14]. It should be emphasized that the
ture [54, 55]. In this case, it is recommended that expeditious administration of the correct antibiot-
the device is removed and a new, distant site is ics has a profound impact on survival; Kumar and
accessed for continual vascular access. colleagues demonstrated that every hour delay in
Furthermore, if the site of the vascular access administration of antimicrobials from the obser-
device displays clinical signs of infection (cellu- vation of hypotension was associated with a 7.6 %
litis, purulence), then it should be removed. increase in mortality [13]. Failure to administer
Recent evidence recommends against the routine correct antimicrobials also contributes to a five-
replacement of CVCs for the prevention of fold increase in risk of death [58]. This is further
catheter-related infections [24, 56]. highlighted in a prospective cohort study in 2000
Blood culture and gram stain is the current medical and surgical patients which demonstrated
standard for diagnosing bacteremia, yet this has an the association between inadequate antimicrobial
estimated overall positivity of 60 % despite appli- therapy and hospital mortality (Odds Ratio 4.27,
cation in the correct clinical context, standardized 95 % Confidence Interval 3.35–5.44) [62].
procedures, and optimal volume of blood collec- Antimicrobial selection can be a complex process
tion [13, 57–59]. For instance, failure to collect at and should take into account the patient’s history
least 10 mL of blood significantly compromises and comorbid conditions, recent antimicrobial
the ability to detect bacteremia when present. The exposure, and probable source of infection. With
use of molecular methods to detect bacteremia the recent emergence of several virulent, drug-
may have advantages in comparison to the tradi- resistant pathogens, the length of the patient’s
tional blood culture and gram stain analysis as hospital course and the potential for infection
they are more rapid, can identify and quantitate with such organisms should be taken into consid-
pathogens directly from clinical samples, and have eration. Empiric antibiotic protocols have been
reduced variability associated with organism-spe- developed in order to improve mortality by
cific growth requirements. Molecular pathogen administering appropriate antibiotics (Table 7.7).
detection techniques have been developed that Compliance with such empiric antibiotic proto-
rely on mass spectroscopy, microscopy, or nucleic cols was demonstrated to decrease ICU length of
acid testing such as polymerase chain reaction. stay by 6 days (14.5 versus 8.4, p = 0.014) in a
The clinical application of these techniques is still single-center study of patients with surgical sepsis
under investigation [60]. [63]. The best practice is to provide broad cover-
Additional cultures from other sites (respiratory, age initially and de-escalate antimicrobial therapy
urinary tract, surgical wound) and radiographic based upon culture data.
imaging should be guided by clinical suspicion. In
the surgical population, this may include obtaining Goal 6: Obtain Source Control
cultures from surgical drains and performing perti-
nent imaging to identify an undrained abscess. Soft Tissue Infections

Goal 5: Initiate Broad-Spectrum Necrotizing Soft Tissue Infections

Antimicrobial Therapy Necrotizing soft tissue infections include necro-
Early administration of empiric antibiotic therapy tizing cellulitis, myositis, and fasciitis. Early rec-
has been demonstrated to improve mortality from ognition and source control of a necrotizing
7 The Decision-Making Process in Sepsis and Septic Shock 71

Table 7.7 Sample empiric antibiotic protocol, assuming normal renal and hepatic function
Suspected site of infection First-line drug regimen Second-line drug regimen
CAP Ceftriaxone 1 g IV every 24 h Levofloxacin 750 mg IV every 24 h
azithromycin 500 mg IV/PO every 24 h
Suspected aspiration CAP regimen + clindamycin 600 mg IV Ceftriaxone to piperacillin/
every 8 h tazobactam 4.5 g IV every 6 h
Early VAP (<5 days) Cefepime 2 g IV every 24 h
Late VAP (pseudomonal Cefepime 2 g IV every 24 h vancomycin Ciprofloxacin 400 mg IV every 12 h
risk) 15 mg/kg IV every 12 h tobramycin vancomycin 15 mg/kg IV every
7 mg/ kg IV 12 h tobramycin 7 mg/kg IV
UTI/urosepsis Piperacillin/tazobactam 4.5 g IV every 6 h Ciprofloxacin 400 mg IV every 12 h
Line infection Remove line + vancomycin 1 g IV every
12 h + fluconazole 800 mg IV every 24 h
(if risk for candidemia)
Necrotizing fasciitis Piperacillin/tazobactam 4.5 g IV every 6 h Ciprofloxacin 400 mg IV every 12 h
vancomycin 15 mg/kg IV every 12 h vancomycin 15 mg/kg IV every 12 h
clindamycin 900 mg IV every 8 h clindamycin 900 mg IV every 8 h
Surgical site infections Piperacillin/tazobactam 4.5 g IV every 6 h Ciprofloxacin 400 mg IV every 12 h
vancomycin 15 mg/kg IV every 12 h vancomycin 15 mg/kg IV every 12 h
Intra-abdominal Imipenem/cilastatin 500 mg IV every 6 h Ciprofloxacin 400 mg IV every 12 h
vancomycin 15 mg/kg IV every 12 h metronidazole 500 mg IV every 8 h
fluconazole 800 mg IV every 24 h vancomycin 15 mg/kg IV

infection are imperative to avoid multiple organ resistant Staphylococcus aureus has also been
failure, potential loss of limb(s), and death. Risk implicated in cases of necrotizing fasciitis [69].
factors for developing a necrotizing soft tissue
Diagnostic Considerations: Typical physical exam
infection include obesity, diabetes, peripheral
findings of a necrotizing soft tissue infection may
vascular disease, immunosuppression, recent
be difficult for the novice to appreciate, but
trauma or surgery, and intravenous drug use. In
include cellulitis/ecchymosis, crepitus, bullae,
necrotizing fasciitis, the infection spreads along
skin necrosis, local anesthesia, or pain out of pro-
the fascia due to its poor blood supply; overlying
portion to physical exam [65].
muscle and soft tissue appear unaffected, making
necrotizing fasciitis difficult to diagnose without The presence of gas declares the need for sur-
surgical investigation [64]. Therefore, surgical gical debridement. Obligate anaerobes, such as
exploration should be considered for any concern Clostridial species, flourish in oxygen-poor envi-
of a necrotizing infection. ronments. Similarly, facultative anaerobes, such
as Staphylococcus spp. and Streptococcus spp.,
Type I Necrotizing Fasciitis: Type I infections are are capable of utilizing nonoxidative metabolic
polymicrobial, usually due to a mixed infection of pathways when stressed by their environment. In
anaerobic species, facultative anaerobic strepto- anaerobic respiration, these pathogens rely on
cocci (not group A), and Enterobacteriaceae [65]. denitrification, fermentation, or deamination to
produce hydrogen and nitrogen [70]. Unlike CO2,
Type II Necrotizing Soft Tissue Infections: Type II which is the waste product of oxidative metabolic
necrotizing fasciitis is monomicrobic. The most pathways, hydrogen and oxygen are relatively
common offending pathogen is beta-hemolytic insoluble and collect in the tissue. This is appre-
streptococci (group A streptococcus); however, ciated as crepitus on physical exam or gas on
cases of Aeromonas hydrophila [66] and Vibrio diagnostic imaging. Therefore, the finding of gas
vulnificus [67, 68] have been associated with implies the existence of tissue without oxygen,
injuries occurring in fresh water and seawater, that is, it is non-perfused, devitalized, or dead,
respectively. Community-acquired methicillin- and warrants debridement.
72 M.H. Scerbo and L.J. Moore

The Laboratory Risk Indicator for Necrotizing When patients present with diffuse peritonitis
Fasciitis (LRINEC) was developed to aid the cli- and severe sepsis, careful consideration, plan-
nician in distinguishing necrotizing fasciitis from ning, and coordination of care should occur to
non-necrotizing infections. The score considers ensure that all necessary diagnostic imaging,
total white cell count, hemoglobin, sodium, resuscitation, and operative intervention are per-
glucose, serum Creatinine, and C-reactive protein. formed as expeditiously as possible.
A score greater than or equal to 6 has a positive In the case of septic shock, operative interven-
predictive value of 92.0 % and negative predic- tion should not precede resuscitation if feasible
tive value of 96.0 % for predicting the presence and should only take as long as necessary for
of a necrotizing infection [71]. The score, how- source control. It is currently our practice to admit
ever, should never replace the surgical investiga- the patient to the ICU, implement the sepsis resus-
tion of a concerning lesion. In addition, the citation bundle, and once the patient has received
LRINEC score should not be interpreted as a antibiotics, appropriate volume resuscitation, and
dynamic score. Improvements in the LRINEC placement of central venous access (typically 3 or
score after resuscitation do not obviate the need 4 h), the patient is taken to the operating room for
for surgical investigation and/or intervention. an abbreviated laparotomy. The goal at the time
Rather, this should be regarded as perioperative of laparotomy is to address the intra-abdominal
optimization of a patient that is more likely to tol- source of infection (i.e., dead or perforated bowel)
erate necessary operative intervention. followed by temporary abdominal closure. The
patient should then be returned to the ICU for
Treatment: Surgical source control is the hall-
continued resuscitation and stabilization prior to
mark of therapy. Delay to achieving source con-
any subsequent operative procedures. For intra-
trol has an associated mortality as high as 30 %.
abdominal sepsis, this is referred to as performing
Debridement should be aggressive, removing all
a damage control, or abbreviated, laparotomy.
devitalized tissue and extending into healthy
This technique has been recently regarded as an
tissue [70]. The wound should be continually
alternative treatment for definitive surgical care
reassessed for repeat debridement. Antibiotic
for a patient in extremis.
therapy should initially be broad and should con-
tinue until no further debridement is needed.
The Abbreviated Laparotomy
Appropriate regimens include (1) a carbapenem
An abbreviated laparotomy was first introduced
or beta-lactam-beta-lactamase inhibitor plus, (2)
into the surgical theater as a means to control
Clindamycin, and (3) coverage against MRSA.
hemorrhagic shock in patients that were traumat-
ically injured [73–75]. This method includes con-
Intra-abdominal Infections
trolling hemorrhage and contamination followed
The abdomen is the site of infection in nearly
by intra-peritoneal packing and rapid, temporary
half of the patients with surgical sepsis. This is
abdominal closure in patients with severe physi-
usually due to hepatobiliary disease, appendici-
ological derangements such as coagulopathy, aci-
tis, diverticulitis, inflammatory bowel disease,
dosis, and hypothermia. The concept of
infected pancreatic necrosis, perforation of a
abbreviated laparotomy has now evolved to
gastric or duodenal ulcer, or large or small
include critically ill patients with surgical sepsis.
bowel perforation from obstructive carcinoma.
Much like the patients with trauma having severe
Additionally, intra-abdominal infections can
physiological compromise, many patients with
occur postoperatively due to injury to the bowel,
septic shock present in a similar fashion.
anastomotic leak, or contamination of the peri-
toneal cavity. A postoperative intra-abdominal Assessing the Need for an Abbreviated
infection is considered an organ/space surgical Laparotomy: For those patients presenting with
site infection if it occurs within 30 days of the septic shock due to an intra-abdominal infection,
procedure [72]. the utilization of an abbreviated laparotomy can
7 The Decision-Making Process in Sepsis and Septic Shock 73

be lifesaving. The decision to utilize an abbrevi- Postoperative Optimization and Considerations:

ated laparotomy is not a bailout, rather it is a Postoperatively, volume resuscitation should con-
deliberate decision to truncate the surgical proce- tinue, as well as correction of other physiological
dure in order to minimize the time away from the derangements. Patients should be continually
ICU. The decision to pursue an abbreviated lapa- assessed for their restoration of these physiologi-
rotomy is often made prior to arriving in the OR cal parameters. Additional operative procedures
and is based on the combination of the patient’s should be considered as necessary. During this
medical and surgical history, severity of the phase, consideration and planning for eventual
patient’s physiologic derangements at the time abdominal closure should occur.
of presentation, and type of definitive surgery
Planned Staged Laparotomy: It should be men-
required. To date, there are no specific, validated
tioned that abbreviated laparotomy for the man-
physiologic cutoffs that define a patient appropri-
agement of intra-abdominal sepsis is not the same
ate for an abbreviated laparotomy. However, the
as a planned, staged laparotomy. Patients with
presence of hypothermia (<35 °C), acidosis (base
established peritonitis frequently require repeat
deficit <8, pH < 7.20), or the laboratory and clini-
laparotomy for washout of persistent peritonitis
cal evidence of coagulopathy is commonly
and/or new foci of infection. In these cases, two
regarded as indicators [76].
approaches can be considered. The first approach
Preoperative Optimization: The first priority is to is to perform a repeat laparotomy to lavage, drain,
initiate resuscitation. The tenets to sepsis survival and inspect the peritoneal cavity every 48 h; this is
still apply to this patient; they need to undergo considered the planned approach. The planned
preoperative optimization during which time the approach theoretically reduces the risk of progres-
airway is secured, central venous and arterial sion to multi-organ failure; however, it may also
lines are placed, volume resuscitation and broad- cause multiple unnecessary procedures in a
spectrum antimicrobials are : administered, and patient that is already critically ill. The alternative
vasopressors are titrated to the appropriate end approach is to wait until the patient’s condition
points. Once the patient displays restoration of necessitates it; this is considered “on demand.”
cardiac contractility, and optimization of preload With the combination of advances in computer
and afterload, he or she is taken to the OR for tomographic scan technology to detect intra-
emergency laparotomy. abdominal infections with improved sensitivity
and the ability of interventional radiologists to
Operative Procedure and Repeat Assessment: The
access these foci of infection, it is reasonable to
surgeon needs to assess the degree of physiologic
expect that the majority of residual infections can
derangement early in the operation and if the
be successfully treated without repeat laparotomy.
severe derangements exist, then the operative
Thus, repeat and excessive laparotomies can be
interventions need to be truncated. The primary
avoided unless it is again a true surgical emer-
aim in the operating room is to control the source
gency. This may also reduce healthcare utilization
of infection, resect nonviable bowel, close bowel
and cost. [78] There are disadvantages to this
perforations, and wash out the abdomen. No defin-
approach as well. Entering the abdomen within 6
itive procedures should occur during this opera-
weeks of the original operation is challenging as
tion, including anastomosis and abdominal
dense adhesions are being formed during this
closure. An anastomosis is likely to fail in the set-
time; this increases the risk of additional enteroto-
ting of extreme physiological derangements and it
mies and the sequelae that can follow. Both of
is unlikely that the patient appropriate for this
these methods are reasonable to consider in a
abbreviated laparotomy will tolerate such a fail-
patient that is not in septic shock; however, they
ure. The abdomen is then quickly and temporarily
do not constitute the definition of a damage con-
closed, with the goal to contain the viscera, avoid
trol, or abbreviated, laparotomy.
potential injury and contamination, and control the
peritoneal effluent [77]. The patient is then rapidly Other reasons for a planned, staged laparot-
returned to the ICU for continued resuscitation. omy include:
74 M.H. Scerbo and L.J. Moore

1. Reassessment of bowel viability. Patients that hypertension >20 mmHg associated with new
undergo resection of ischemic bowel should organ dysfunction or failure, such as hypotension,
be left in discontinuity and reassessed 24 h increased ventilator pressures, or oliguria [80].
later. The viability of the remaining bowel Achieving Abdominal Closure: Once source
should be assessed during this repeat proce- control has been achieved and the patient has
dure, and if viable, an anastomosis should be received restoration of bowel continuity, the
performed at this time. Allowing a “second midline fascia can be definitively closed.
look” operation affords these patients the Unfortunately, bowel distension from aggressive
chance to have restoration of intestinal conti- fluid resuscitation and multiple subsequent lapa-
nuity and avoids their need for a temporary rotomies commonly causes lateral migration of
ostomy and an additional (future) procedure the fascia and proves abdominal closure to be dif-
for reversal. In the case that an anastomosis is ficult. In addition, if the bowel becomes adherent
not feasible, an ostomy should be created in to the peritoneum of the anterior abdominal wall
order to resume alimentary nutrition. and into the lateral gutters, the abdomen will
2. Avoidance of abdominal hypertension. In become “frozen,” preventing the ability to bring
patients with massive bowel distension, pre- the fascia back to the midline. Therefore, gentle
mature closure of the abdomen can cause blunt lysis of adhesions, or finger dissection, is
abdominal hypertension which can lead to imperative during each laparotomy to prevent the
abdominal compartment syndrome (ACS), an formation of a “frozen” abdomen and facilitate
incredibly morbid complication. Abdominal future abdominal closure. If the abdomen remains
hypertension is defined as sustained intra- “frozen,” the traditional method for closure
abdominal pressure of ≥12 mmHg. includes mobilizing skin flaps to cover the defect,
3. Abdominal Compartment Syndrome. The creating a large hernia to be repaired at a later
Eastern Association for the Surgery of Trauma date. This procedure is considerably comorbid,
(EAST) recommends the patients who with a rate of enterocutaneous fistula in nearly a
develop ACS to receive a decompressive lap- third of patients, development of additional intra-
arotomy (level I), with temporary abdominal abdominal abscesses, deep soft tissue infections,
closure and continued monitoring. persistent ventral incisional hernia requiring
4. Necrotizing pancreatitis. EAST recommends delayed complex abdominal wall reconstruction
an abbreviated laparotomy and open abdomen and future risk of hernia recurrence [66].
technique for the management of infected The use of biological mesh and vacuum-
pancreatic necrosis [78]. assisted devices has been separately investigated
for achieving abdominal closure; however, this is
Abdominal Compartment Syndrome: While the beyond the scope of this text.
patient is in the postoperative optimization phase,
judicious monitoring for abdominal compartment
syndrome should occur via bladder pressure Discussion
measurements.
The presence of a temporary abdominal closure Activated Protein C
should not eliminate the possibility of abdominal
compartment syndrome [79]. In these critically ill Following the 2001 Prospective Recombinant
patients that are heavily volume resuscitated, Human Activated Protein C Worldwide
abdominal hypertension and abdominal compart- Evaluation in Severe Sepsis (PROWESS) study,
ment syndrome is a morbid complication that can recombinant human activated protein C was used
result in Acute Respiratory Distress Syndrome for the treatment of severe sepsis and was advo-
(ARDS) or multiple organ failure. The World cated by the Surviving Sepsis Campaign. The
Society of the Abdominal Compartment Syndrome PROWESS study was a phase 3 international,
2004 defined ACS as sustained intra-abdominal randomized controlled trial that was stopped
7 The Decision-Making Process in Sepsis and Septic Shock 75

early (after enrolling 1690 patients with severe The multicenter trial randomized 1341 adult
sepsis) due to its efficacy; absolute mortality in patients presenting to academic emergency
the intention-to-treat population was reduced by departments with septic shock. The patients were
6.1 % [81]. Following the results of this study, randomized to three arms: early goal-directed
the Food and Drug Administration approved the therapy, protocol-based standard therapy without
use in patients with a high risk of death. This was a CVC or arterial line, and usual care. The
due to a subgroup analysis that suggested the protocol-based therapy group was administered
mortality benefit was limited to patients with an intravenous fluids to goal systolic blood pressure
APACHE II score >24 or with at least one organ and shock index (ratio or heart rate to systolic
system dysfunction. Subsequent placebo- blood pressure); there was no ScvO2 goal, as it
controlled trials were unable to produce the same was not measured. The usual care group was at
results as the PROWESS trial [82]. Therefore, a the varied discretion of the bedside physician.
decade later, the Prospective Recombinant There were no significant differences between
Human Activated Protein C Worldwide either groups with respect to 60- or 90-day mor-
Evaluation in Severe Sepsis and Septic Shock tality; however, the EGDT group did receive
(PROWESS-SHOCK) was undertaken to evalu- more vasopressors, inotropes, and blood transfu-
ate the efficacy of recombinant human activated sions [86]. This led to the conclusion that per-
protein C specifically in patients with septic haps, in academic emergency departments in the
shock. There was no benefit in mortality in the United States, patients presenting with septic
drug group compared with placebo [83]. shock can be safely managed with an approach
Following the results of this study, recombinant that focuses on patient response to resuscitation,
human activated protein C was removed from the early antibiotic use, and continued observation
market and is no longer included in the Surviving [12]. Of note in this study, randomization
Sepsis Guidelines [14]. occurred after the initiation of volume resuscita-
tion, making the “6 h” initial resuscitation bundle
of EGDT [10] longer than 6 h. Additionally, most
Disputes of Early Goal-Directed (>75 %) patients received antibiotics prior to
Therapy randomization.

Despite the successes demonstrated by Rivers

et al. with early goal-directed therapy (EDGT) ARISE
lowering mortality from septic shock at a single
center from 46.5 to 30.5 %, there have been chal- In a similar effort, the Australasian Resuscitation
lenges to both the necessity and safety of in Sepsis Evaluation (ARISE) randomized 1600
EGDT. A retrospective, cohort study of 405 patients with severe sepsis or septic shock in both
medical ICU patients with severe sepsis or septic academic and community centers throughout
shock suggested that EGDT may increase the Australia, New Zealand, Finland, Hong Kong,
risk of fluid overload, the need for subsequent and Ireland to EGDT therapy or variable
medical inventions (thoracentesis and diuresis), physician-guided care. Like the ProCESS trial,
and mortality [84]. no survival benefit at 90 days was appreciated
(Relative Risk 0.98, 95 % Confidence Interval
0.80–1.21, p = 0.90). Additionally, no differences
ProCESS Trial in ICU length of stay, in-hospital mortality, need
for renal replacement therapy, or duration of
The objectives of the Protocolized Care for Early vasopressor support were appreciated [87]. In
Septic Shock (ProCESS) trial were to determine this study, the mortality was only approximately
if EGDT therapy is generalizable and which 18 % in both groups, which is considerably lower
components of the protocol are necessary [85]. than the overall mortality from sepsis. Also, due
76 M.H. Scerbo and L.J. Moore

to the wide-spread acceptance of EGDT, it was comparing these new trials to the original study
difficult to ascertain how different the usual care by Rivers et al. The Rivers et al. trial had a higher
was from the EGDT protocol. mortality that is reflective of the expected mortal-
ity from sepsis, despite having similar APACHE
II scores and baseline lactate values. In addition,
ProMISe Trial while the ProCESS, ARISE, and ProMISe trials
appear to be more IV-fluid conservative, each
Finally, the Protocolised Management in Sepsis group was administered nearly 2 l of fluid prior to
(ProMISe) Trial randomized 1260 patients in 56 randomization. This was not included in the 6- h
hospitals in England to early goal-directed therapy resuscitation bundle.
or usual care. There was no difference in all-cause
90-day mortality (Odds Ratio 0.95, 95 % Confidence
Interval 0.74–1.24, p = 0.73). Additionally, this trial Meta-Analysis of EGDT Compared
demonstrated a greater mean Sequential Organ to Usual Care
Failure Assessment (SOFA) score at 6 h, a greater
proportion of patients receiving cardiovascular sup- A meta-analysis of ten randomized controlled trials
port, and a greater median length of stay in the early comparing EGDT to usual care over 10 years
goal-directed therapy group [88]. Comparable to the (2004–2014) including 4157 patients found that
ProCESS trial, all patients did receive antibiotics EGDT did not show a survival benefit in patients
prior to randomization. with severe sepsis or septic shock (Relative Risk
The ProCESS, ARISE, and ProMISe trials all 0.91, 95 % Confidence Interval 0.79–1.04,
attempted to compared EGDT to usual care in p = 0.17). In addition, patients receiving EGDT
academic, community, and National Health compared to their controls received more inotropic
Service (England) settings, respectively. agents, and a greater volume of fluid, including red
Differences between the trial by Rivers et al., the cell transfusion. EGDT did not benefit patients by
ProCESS, ARISE, and ProMISe trials are out- decreasing vasopressor support, ICU length of stay,
lined in Table 7.8. This highlights the difficulty in hospital-free days, or ventilator-free days [89].

Table 7.8 Comparison of Rivers et al. with ProCESS [85], ARISE [87] and ProMISe [88] study characteristics
Rivers EGDT (2001) ProCESS (2014) ARISE (2014) ProMISe (2015)
APACHE II
Usual Care 20.4 ± 7.4 20.8 ± 8.1 15.8 ± 6.5 18.0 ± 7.1
EGDT 21.4 ± 6.9 20.7 ± 7.5 15.4 ± 6.5 18.7 ± 7.1
Serum lactate mmol/L (Baseline)
Usual care 6.9 ± 4.5 5.0 ± 3.6 6.6 ± 2.8 6.8 ± 3.2
EGDT 7.7 ± 4.7 4.8 ± 3.1 6.7 ± 3.3 7.0 ± 3.5
IV fluids (mL) in first 6 h
Usual care 3499 ± 2438 2279 ± 1881a 1713 ± 1401b 1784 (1075, 2775)c
EGDT 4981 ± 4984 2805 ± 1957a 1964 ± 1415b 2000 (1150, 3000)c
28-day Mortality
Usual care (%) 49 18.9d 15.9 24.8
EGDT (%) 33 21d 14.8 24.5
Plus-minus values are means ± standard deviation. Patients in the ProMISe trial received an additional 1790 (1000,
2500) mL in the usual care group and 1600 (1000, 2500) mL in the EGDT group prior to randomization.
a
Patients in the ProCESS trial received 2083 ± 1405 mL in the usual care group and 2254 ± 1472 mL in the EGDT group
prior to randomization
b
Patients in the ARISE trial received an additional 2591 ± 1331 mL in the usual care group and 2515 ± 1244 mL in the
EDGT group prior to randomization
c
Values are expressed as median (interquartile range)
d
60-day mortality
7 The Decision-Making Process in Sepsis and Septic Shock 77

Finally, a meta-analysis including 13 trials for patients and hospitals. NCHS Data Brief.
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Acknowledgment There are no identifiable conflicts of
microbiologically confirmed infection in hospitalised
interests to report.
patients with suspected sepsis. Crit Care Resusc
The authors have no financial or proprietary interest in the
J Australas Acad Crit Care Med. 2011;13:146–50.
subject matter or materials discussed in the manuscript.
17. Churpek MM, Zadravecz FJ, Winslow C, Howell M,
Edelson DP. Incidence and prognostic value of the
systemic inflammatory response syndrome and organ
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 Intraoperative Endpoints
of Resuscitation 8
Hans Fred García Araque, Patrizio Petrone,
Wilson Dario Rodríguez Velandia,
and Corrado Paolo Marini

surgical procedures. Therefore, the perioperative

Introduction evaluation and management of the patient has
become a major focus of the strategy needed to
The number of surgical procedures performed in minimize the risk of complications and to
the USA is continuously rising as a result of the decrease the all-­cause surgical mortality.
increasing life expectancy of the population and Recently, an acceptably low all-cause mortal-
of the pathology typically associated with aging. ity ranging between 1 and 4 % has been reported
As a result, it is more common for the surgeon to in 230 million patients undergoing surgical pro-
be confronted with planning and operating on cedures as a result of the improvements in moni-
older patients who have multiple comorbid toring, safety, and the development of surgical
conditions that increase the risk of complica- checklists [1]. However, the increasing number
tions and the mortality associated with major of surgical patients categorized as high-risk with
predicted mortality exceeding 10 % demands
standardization of the perioperative evaluation
H.F.G. Araque, M.D. and management, as well as the development of
Hospital Militar Central, Bogotá, Colombia
specific protocols targeted to preoperative, intra-
Westchester Medical Center University Hospital, operative, and postoperative endpoints that can
Valhalla, NY, USA
decrease morbidity and mortality in this subset of
Department of Surgery, New York Medical College, patients. In view of a worldwide yearly number
Valhalla, NY, USA
of 25 million surgical procedures in high-risk
e-mail: hafregar@gmail.com
patients with a potential loss of three million
P. Petrone, M.D., M.P.H., M.H.A., F.A.C.S.
lives each year, it is imperative that the periopera-
C.P. Marini, M.D., F.A.C.S. (*)
Department of Surgery, Westchester Medical Center tive evaluation and management becomes the
University Hospital, New York Medical College, major focus of the overall strategy aimed at
Valhalla, NY, USA reducing the risk of complications affecting the
e-mail: petronep@wcmc.com;
functional outcome and death in the high-risk
patrizio.petrone@gmail.com; marinic@wcmc.com
surgical patients. Failure to evaluate appropri-
W.D.R. Velandia, M.D.
ately high-risk surgical patients and to utilize
Department of Surgery, Westchester Medical Center
University Hospital, New York Medical College, principles of critical care monitoring preopera-
Valhalla, NY, USA tively, intraoperatively, as well as postoperatively
Complejo Hospitalario Universitario de Ferrol, has been shown to be associated with increased
A Coruña, Spain mortality and morbidity [2].

© Springer International Publishing Switzerland 2016 81

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_8
82 H.F.G. Araque et al.

In this chapter, we will focus on specific patients represents a condition for the develop-
intraoperative hemodynamic and biochemical ment of tissue oxygen debt despite the presence
endpoints of resuscitation in order to decrease of adequate or even supra-normal DO2. Despite
postoperative morbidity and mortality based on the reduction in metabolic demands from hypo-
the best evidence available. thermia and anesthesia, the reduction in oxygen
consumption during the intraoperative period of
approximately 23 % compared with the preoper-
 ndpoints of Intraoperative
E ative oxygen consumption leads to an increase in
Resuscitation base deficit and lactate levels as a result of the
incurred oxygen debt. Therefore, the intraopera-
The endpoints of intraoperative resuscitation tive trend of base deficit and arterial lactate level
depend heavily on the patient’s preoperative con- can be used as markers to identify the develop-
dition, including his/her comorbid conditions, the ment and magnitude of the oxygen debt.
type of surgery being performed and the duration While Shoemaker and his collaborators have
of the surgery itself. However, notwithstanding suggested that the intraoperative oxygen debt
the type of the planned procedure, certain physi- could be responsible postoperatively for the
ological principles apply to all patients undergo- development of multiple organ dysfunction syn-
ing general anesthesia from the standpoint of the drome (MODS), and ultimately, multiple organ
relationship between cellular oxygen delivery failure (MOF), if not repaid postoperatively
and consumption during major surgical proce- within 12–24 h in high-risk surgical patients,
dures. Furthermore, the endpoints of intraopera- other authors do not believe that there is a proven
tive resuscitation depend on the depth and correlation between the development of the intra-
duration of anesthesia, the magnitude of the operative oxygen debt, the time to its repayment,
planned procedure and more importantly, on the and the subsequent development of MODS [4–6].
risk stratification of the patients with its associ- Therefore, it remains controversial whether the
ated predicted mortality. minimization of the intraoperative oxygen debt
It is well known that during general anesthesia and its early repayment is a valid endpoint of
there is an uncoupling between oxygen delivery intraoperative and postoperative resuscitation.
and oxygen consumption as a result of the anes- Clearly, depending on the type and duration of
thetic regimen on the ability of cells to extract surgery, attention should be directed to the intra-
oxygen appropriately [3]. Despite the decreased operative variables that may affect the postopera-
metabolic rate that results from a combination of tive course of the patient. The degree and type of
the temperature changes that occur during sur- hemodynamic monitoring should be selected
gery and the direct effect of anesthesia, most based on the preoperative condition of the patient
patients incur a significant intraoperative oxygen and the type of surgery being performed. Simple
debt manifested by increased base deficit and lac- endpoints that could assure a safe intraoperative
tate levels as a result of a global cellular failure to and postoperative course in a standard low-risk
extract oxygen even in the presence of increased patient undergoing for example a colon resection
oxygen delivery (DO2). Lugo and associates such as measurement of heart rate, blood pres-
reported that high-risk surgical patients undergo- sure, central venous pressure, and urine output
ing general anesthesia have compromised tissue may be inadequate in an operation in a high-risk
ability to extract oxygen; they showed that oxy- patient associated with massive fluid shift and
gen extraction decreased to approximately 14 % blood loss. Patients undergoing operations asso-
from the normal value of 25 % observed preoper- ciated with massive fluid shift and blood loss
atively. During anesthesia, venous oxygen satura- maybe primed to the activation of a more pro-
tion (SvO2) increased to 86 % from the nounced inflammatory response in the absence of
preoperative normal value of 75 % [3]. Therefore, optimization of cellular oxygen delivery and uti-
the intraoperative period for high-risk surgical lization; therefore, these patients may benefit
8 Intraoperative Endpoints of Resuscitation 83

from the measurement of flow-based variables, will provide an intracytosolic oxygen tension of 6
such as cardiac output and oxygen extraction and mmHg, which in turn will result in a mitochon-
utilization, which may be more sensitive indica- drial oxygen tension of 1.2 mmHg, the value
tors of the balance between DO2 and oxygen con- needed for all oxidative processes.
sumption (VO2) than the traditional measurements The maintenance of the intracytosolic oxy-
of blood pressure and central venous pressure, as gen tension is the key regulatory mechanism
well as of urine output. associated with a downregulated response of the
It is well known that during surgery there is hypoxia inducible factor α and β (HIF-α, HIF-β).
the development of a functionless third space that In the presence of adequate oxygen tension
causes sequestration of extracellular fluid into a within the cytosol, the HIF-α will undergo pro-
space that does not contribute to the dynamic teasomal degradation after enzymatic hydroxyl-
fluid exchange at the level of the microcircula- ation by the 4-prolyl-hydroxylases (PHDs);
tion. The volume of the third space is propor- therefore, there will not be an upregulated pro-
tional to the degree of injury and to the type of duction of TNF-α and IL-1 via this oxygen sens-
surgery being performed ranging from 3 mL/kg ing pathway. Conversely, in the setting of
per hour for relatively minor procedures such as cellular hypoxia, the HIF-α and HIF-β subunits
an open cholecystectomy to greater than 20 mL/ translocate to the nucleus, where they bind as
kg per hour for major procedures such as open heterodimers to a hypoxia response promoter
repair of aortic aneurysm, a pancreaticoduode- element (HRE), inducing transcription of
nectomy, and/or major trauma related proce- numerous genes, including those of nuclear
dures. Its composition is similar to that of plasma.factor κB (NF-­ κB) and toll-like receptors
In addition to the development of the third space, (TLRs) [7]. The result is an upregulated inflam-
large insensitive losses due to evaporation occur matory response. It is now well accepted from
in procedures with an open abdomen and/or open studies of the hypoxia signaling pathway that
chest. The evaporative losses increase with hypoxia can induce inflammation in the absence
increasing duration of surgery and in general are of any other stimulus, including endotoxemia
in the order of 1 mL/kg/h. and/or bacteremia.
We believe that under-resuscitation of patients
manifested by increasing base deficit and lactate
Oxygen Delivery and Oxygen levels during major surgical procedures associ-
Consumption ated with massive fluid shift and blood loss
primes the patient to an upregulated inflamma-
Under normal physiological conditions, VO2 at tory response, which may in turn be responsible
the cellular level is independent of DO2; it is for the development of MODS, via the oxygen
maintained constant by a balance between oxy- sensing pathway. Therefore, we believe that one
gen supply and demand at the organ level through of the more important endpoints of intraoperative
complex autoregulatory mechanisms directed at resuscitation is the avoidance of cellular hypoxia
matching oxygen supply to the local metabolic by monitoring and attempting to avoid large
demands. It is noteworthy that autoregulation of increases in the surrogate markers of cellular
blood flow (QB) at organ level occurs through hypoperfusion, namely, base deficit and lactate
changes in capillary density, namely, the number level. While it may not be possible to maintain
of open capillary with red cells transit, which both within normal range during major surgical
were originally defined in relation to the regula- procedures due to the effects of anesthesia on cel-
tion of QB and not to the regulation of tissue lular oxygen utilization, we suggest that attempts
oxygenation. should be made to have a downward trend of both
Under normal physiological conditions, high-­ base deficit and lactate levels during surgery,
demand regions receive increased DO2, whereas avoiding a progression toward values that clearly
low-demand regions receive decreased delivery. correlate with significant cellular hypoxia from
Typically, a DO2 of approximately 1000 mL/m2/min hypoperfusion.
84 H.F.G. Araque et al.

The oxygen delivered to an organ is equal to increased flow in the setting of increased demand
the QB to the organ, indexed to the weight of the to maintain oxygen consumption constant (sup-
organ or body times the arterial oxygen content ply dependent) as opposed to the kidney that at
(CaO2) times a factor of 10 used to transform the baseline extract only 7 % of the oxygen deliv-
units in mL/m2/min where ered, therefore, can maintain its oxygen con-
sumption constant by increasing extraction in
DO2 = QB × CaO2 × 10 (mL / min) (8.1)
the setting of decreased flow. Since CI plays a
The arterial oxygen content is depicted by the dominant role in the DO2I equation, the major
following equation: efforts to maintain or increase tissue perfusion
must be directed at optimizing the four variables
CaO2 = (Hg × 1.34 × SaO2 ) + PaO2 × 0.003 (8.2)
that affect CO, namely, heart rate, preload, after-
where Hg is the hemoglobin concentration (g/ load, and contractility taking into consideration
dL), 1.34 is the oxygen-binding capacity of Hg, the more recent understanding of ventriculo-
SaO2 is the arterial oxygen saturation (%), and arterial coupling.
PaO2 is the partial pressure of oxygen (mmHg) in Since the heart rate affects the modulus of
arterial blood. chamber stiffness of the left ventricle, it must be
Total DO2 indexed to the body weight is the optimized (should be kept below 120 bpm) in
product of cardiac index (CI) times CaO2 times order to allow the preload recruitment of stroke
10: volume without incurring an increase in pulmo-
nary artery occlusion pressure (left ventricular
DO2 I = Cl × CaO2 × 10 (mL / m 2 / min)
end-diastolic pressure) with the potential of
Venous oxygen content is defined by the follow- increased extravascular lung water. Preload
ing equation: recruitment with incremental volume loading
(250 mL of crystalloids every 10–15 min or more
CvO2 = (Hg × 1.34 × SvO2 ) + (PvO2 × 0.003)
rapidly, if required) of SV is the ideal strategy to
where Hg is the hemoglobin concentration (g/ increase CO without incurring an increase in
dL), SvO2 is the venous oxygen saturation (%), myocardial oxygen consumption. Of note, since
and PvO2 is the partial pressure of oxygen two data points will always yield a straight line,
(mmHg) in venous blood. one must acquire at least three data points, while
Oxygen consumption by the Fick principle is volume loading the ventricle, in order to evaluate
the product of QB times the arteriovenous oxygen the slope of the pressure–volume relationship
difference: and in order to make sound clinical decisions
regarding the approach to preload, afterload, and
(VO2 ) = QB × (CaO2 − CvO2 )
cardiac contractility. We advise against the use of
In normal conditions, VO2 is 250 mL/min, a high-molecular-weight hydroxyethyl starch solu-
small portion of the oxygen delivered to the tions (>150 kD) as plasma expanders during sur-
body. The increases in capillary density of per- gery because of the increased risk of renal
fused capillaries within tissues resulting from dysfunction associated with these solutions, as
the release of intracytosolic adenosine in the set- well as because of their effect on the microcircu-
ting of decreased redox potential secondary lation including experimental evidence of upreg-
either to hypoxia and/or disoxia is a compensa- ulation of the pro-inflammatory response and
tory response aimed at optimizing the transit negative effects on the ability of the cells to
time and the diffusion distance, therefore pre- extract oxygen [8, 9].
venting molecular diffusion limitations in the With respect to the use of blood transfusion to
unloading of oxygen. The ability to extract oxy- increase DO2 and VO2 at the cellular level, one
gen differs significantly among organs in the must be familiar with the effects of storage and
body, with one organ, the heart, always working the age of the transfused red blood cells on their
at maximum extraction (60 %), therefore, requiring ability to unload oxygen and to negotiate the
8 Intraoperative Endpoints of Resuscitation 85

microcirculation following the storage related during surgical procedures on the gastrointestinal
changes that occur and due to the documented tract involving the performance of gastrointesti-
increase in nosocomial infections and adult respi- nal anastomoses because of its negative effect on
ratory distress syndrome associated with the splanchnic blood flow and mucosal oxygen ten-
transfusion of non-leukodepleted stored red sion [12]. An individualized goal-directed ther-
blood cells. While the transfusion of stored blood apy aimed at optimizing the balance of DO2 and
will increase DO2 by increasing the hemoglobin VO2 with a restrictive fluid therapy using flow-­
level, it may not yield a corresponding increase in based hemodynamic parameters should be used
oxygen utilization due to the depletion of 2,3 in high-risk surgical patients. The ideal monitor-
diphosphoglycerate (2,3-DPG) and the morpho- ing methodologies include arterial waveform
logic changes in the red cells associated with analysis with either stroke volume or pulse pres-
storage, which increase the hemoglobin oxygen sure variations and the intraoperative use of
affinity and compromise the unloading of oxygen esophageal Doppler monitoring with disposable
at cellular level. The normal P50 of 27 mmHg of probes in order to assess the functional status of
non-stored red blood cells decreases to a P50 of 7 the left ventricle and to optimize ventriculo-­
mmHg after prolonged storage (>14 days) arterial coupling. The preemptive use of hemody-
decreasing the unloading of oxygen to approxi- namically guided perioperative therapy has been
mately 7 %. The administration of old blood, shown to decrease morbidity and mortality in
defined as blood older than 14 days, has been high-risk surgical patients [13].
shown to compromise oxygen availability and
utilization in the splanchnic circulation as mea-
sured by monitoring of the intragastric mucosal Arterial Base Deficit
pH, as well as an increased morbidity and mor-
tality in patients undergoing cardiac surgery The measurement of arterial blood gases is a
[10, 11]. The detrimental effect of the transfusion daily practice in many operating rooms. The arte-
of old stored blood is more evident in the low rial base deficit obtained from the gas analysis of
shear rate districts of the body where the effect of the arterial blood is a very useful tool widely
the depletion of 2,3-DPG leads to a more com- used to help monitoring surgical patients in order
promised unloading of oxygen. It takes between to determine the global balance between DO2 and
16 and 24 h to have the complete restoration of VO2. It is a superior marker of adequacy of tissue
the 2,3-DPG and the normalization of the oxygen perfusion because it alerts the physician to the
hemoglobin dissociation curve. Therefore, to presence of occult hypoperfusion because it
increase oxygen utilization at cellular level dur- increases even when arterial blood pressure is
ing surgery one must consider using fresh or normal. Its use to predict the need for blood
ultra-fresh blood, namely, blood stored for 5 days transfusion in trauma patients, to consider imple-
or less. menting damage control surgery, as well as its
The use of pure alpha agonist agents such as prognostic value in trauma patients is supported
phenylephrine or strong alpha agonists with min- by level I and II evidence [14–16].
imal beta agonist activity such as norepinephrine Base deficit is defined as the amount of base
should be avoided because it increases systolic required to raise the serum pH of 1 L of whole
blood pressure by increasing the afterload at the blood to 7.40 at a temperature of 37 °C and a
expense of SV. An increase in afterload will PCO2 of 40 mmHg. Zakrison et al. have shown
increase the end-systolic pressure point without a that there is not a significant, clinically important
corresponding increase in SV; therefore, it will difference between arterial and venous base defi-
increase thermodynamic waste (increased pres- cit, even in the presence of shock and in the
sure in mmHg for displacement of 1 mL SV) ­elderly [17]. Venous sampling for measurement
(Fig. 8.1). We advise against the use of vasopres- of base deficit is easier to do in the perioperative
sin to maintain or raise mean blood pressure setting, in the emergency department, and in the
86 H.F.G. Araque et al.

ESP1
150 C1
B1

Left ventricular pressure (mmHg)

ESP
100
C

A
D D1

Vo 50 75 150
Left ventricular volume (ml)
Fig. 8.1 Effect of increasing afterload with vasopressors ume of 50 mL, is generating an aortic root end-systolic
on the P–V loop. Illustrated is the pressure–volume rela- pressure of 100 mmHg. Therefore, the effective elastance
tion for the left ventricle over an entire cardiac cycle. The of the aortic root, namely, the end-systolic pressure
area ABCD represents the energy added to the aortic root divided by the stroke volume, is 1.0 mmHg/mL, an opti-
by the ventricular contraction. The heat dissipated in the mal ventricular-arterial coupling with optimal efficiency.
ventricular wall during isovolumic relaxation is repre- Following the administration of a vasopressor, such as
sented by the area contained within the triangle C, V0, D. norepinephrine and/or phenylephrine, there is an increase
The end-systolic volume is 50 mL at the end-systolic pres- in the afterload (impedance) facing the left ventricle. The
sure of 100 mmHg. Of note, no work is done on the aortic pressure has increased from the ESP to ESP1; however,
root during isovolumic contraction from point A to B the result is more energy wasted as heat dissipation during
because the volume of the ventricle is unchanged. Work, isovolumic relaxation as depicted by the C1, V0, D1 trian-
however, is done on the aortic root from the opening of the gle and decreased efficiency of ventricular-arterial cou-
aortic valve to end-systole, from point B to C. The stroke pling as shown by an end-systolic pressure 150 mmHg
volume of 100 mL, the difference between the end-­ divided by a stroke volume of 75 mL, yielding a 2
diastolic volume of 150 mL minus the end-systolic vol- mmHg/1 mL ratio

intensive care unit. It is also associated with less intraoperative resuscitation. An attempt should
pain as compared to arterial sampling. be made to improve the base deficit throughout
As it has been mentioned before, inadequate the operative procedure with an attempt at nor-
tissue DO2 causes anaerobic metabolism, which malization, which would indicate that the patient
is proportional to the depth, duration, and com- does not have ongoing cellular hypoperfusion
plexity of the procedure being performed, which potentially priming the patient to the develop-
typically is reflected in the base deficit and lac- ment of MODS. Initial base deficit levels and
tate level. Due to the impaired oxygen utilization time to its normalization have been shown to
by patients undergoing general anesthesia, it is correlate with the need for transfusion and the
unlikely that normalization of the base deficit risk of MODS and death in trauma patients [18].
may occur at the end of the surgical procedure. However, there are no data on the impact of
We suggest that changes in base deficit over monitoring intraoperative base deficit on sur-
time, which are more predictive than absolute vival. While there is a physiological basis to do
values from the standpoint of outcome, should so, there is no evidence supporting its utility
be monitored and minimization of an increase in from the standpoint of postoperative morbidity
base deficit should be one of the endpoints of and mortality.
8 Intraoperative Endpoints of Resuscitation 87

With respect to the use of the intraoperative tion of the phosphofructokinase enzyme, the
base deficit as a surrogate marker for serum lac- pacemaker of the anaerobic glycolysis, the anaer-
tate, we must point out that the base deficit can obic glycolysis favors the formation of lactate
mislead the surgeon as to the actual measurement from the pyruvate acting as the proton acceptor
of serum lactate. The reported ROC area under from NADH2. In this setting, the lactate pyruvate
the curve for base deficit to predict increased lac- ratio is 10:1, typically associated with a normal
tate level is 0.58, just above the guessing value of NADH/NAD ratio, which in turn is associated
0.50 [19]. Therefore, the intraoperative resuscita- with a normal cytosolic ATP/ADP ratio and no
tion should not be guided by base deficit with or net increase in cytosolic H+ concentration (no
without anion gap as the sole criterion, but it acidosis). Conversely, in the setting of cellular
should be guided by a combination of both in hypoxia, mitochondrial oxidative phosphoryla-
conjunction with the measurement of serum lac- tion is blocked with a consequent inhibition of
tate concentration. Of note, elevation of base def- synthesis of ATP and the reoxidation of NADH.
icit without a corresponding increase in serum This causes an increase in the NADH/NAD ratio
lactate level can be observed in patients with and a decrease in the cytosolic ATP/ADP ratio
hyperchloremia from successful resuscitation and the degradation of ATP to adenosine, inor-
with normal saline. ganic phosphate and an increased concentration
of H+ (acidosis). The decreased redox potential
prevents the utilization of the pyruvate via its
Lactate conversion into oxaloacetate by the pyruvate car-
boxylase. Therefore, the increase in lactate pro-
During the past years, there has been an increas- duction from cellular hypoxia is the result of the
ing acceptance to use lactate as a marker to guide increase in pyruvate and its conversion to lactate
the perioperative resuscitation of trauma, sepsis, stemming from the decreased redox potential;
and cardiac surgery patients, as well as to use lac- this is responsible for the increased lactate/pyru-
tate levels to identify unexpected major bleeding vate ratio and the increased concentration of
and to identify patients with severe sepsis. cytosolic H+ (acidosis). The hypoxic release of
Lactate-based goal-directed therapy has been adenosine is aimed at decreasing the tone of the
shown to minimize the incidence of ongoing precapillary sphincters which regulate the num-
occult hypoperfusion and to improve outcomes in ber of open capillaries with red cells transit (cap-
surgical and trauma patients by decreasing the illary density) improving the conditions for gas
development of the intraoperative oxygen debt diffusion and ultimately, restoration of the redox
[20]. However, lactate clearance, namely, the rate potential (Fig. 8.2). Of note, accelerated glycoly-
of decline in lactate concentration, as a target of sis from a major stress response and/or the release
goal-directed therapy in septic patients who do of endogenous catecholamines or the administra-
not have an oxygen debt may be actually associ- tion of exogenous catecholamines exceeding the
ated with worse outcome [21]. capability of the pyruvate dehydrogenase com-
plex to metabolize the pyruvate to acetyl-CoA in
order to allow it to enter the Krebs Cycle will
Lactate Metabolism cause an increase in lactate proportional to the
pyruvate due to the conversion of pyruvate to
Lactate produced by glycolysis from the skin (25 lactate.
%), muscles (25 %), red cells (20 %), brain (20 Prolongation of lactate clearance in critically
%), and intestine (10 %) is metabolized by the ill surgical patients has been shown to correlate
liver (60 %) and to a much lesser degree by the with outcome. In a study by McNelis and associ-
cortex of the kidney (30 %). In normal physio- ates, mortality increased from 3.9 % in surgical
logic normoxic conditions and in the absence of patients who were able to normalize their lactate
cytosolic pH mediated, sepsis and/or gene inhibi- levels within 24 h to 13.3 % in those who had
88 H.F.G. Araque et al.

Vasodilatation

Adenosine AMP pH pH No ∆

L/P > 20 ATP ADP + Pi + H+ +

L/P < 20 ADP + Pi + H = ATP

Lactate/Pyruvate

NADH/NAD+

L/P =K x [NADH/NAD] x H+

Fig. 8.2 Lactate excess with and without acidosis. The change in pH. In contrast, when the L/P ratio is greater
lactate/pyruvate ratio is the mirror image of the NADH/ than 20, the energy state of the cell is compromised, there-
NAD ratio. In normal conditions when the energy state of fore, there is hydrolysis of ATP in ADP, Pi, with an
the cell is within normal range, the NADH/NAD ratio is increase in the hydrogen ions concentration, hence, cellu-
normal, and the L/P ratio is less than 20. In the setting of lar acidosis. The subsequent hydrolysis of ADP to AMP
an increase in lactate proportional to pyruvate with a ratio and then adenosine is aimed at inducing a relaxation of the
less than 20, there is adequate energy to provide synthesis precapillary sphincters in order to increase local blood
of ATP from ADP and Pi and hydrogen ions, therefore flow and hence oxygen availability at cellular level to
there is no net increase in cytosolic hydrogen ions and no restore the redox potential and cellular pH

normal levels of lactate within 48 h to 100 % in development of MODS via upregulated oxygen
patients who were unable to reach normal lactate sensing pathways. At this time, there is support-
levels within 72 h of the septic insult [22]. Further ing evidence for the utility of normalization of
evidence supporting the utility of lactate clear- the lactate level as one of the endpoints of intra-
ance as a prognostic tool in trauma patients has operative resuscitation. Of note, while there is
been provided by Regnier et al. [23]. We suggest good evidence that shows that intraoperative
the serial measurement of intraoperative lactate goal-directed therapy reduces morbidity and
levels every 2 h in high- and very high-risk surgi- mortality in very high-risk surgical patients, it
cal patients (10–19 % and >20 % predicted mor- has not been shown to have the same efficacy in
tality) in order to guide fluid and inotropic intermediate- and low-risk surgical patients.
therapy using flow-based monitoring tools fol-
lowed by postoperative measurement every 8 h
until normalization of two values. The addition of Venous Oxygen Saturation (SvO2)
continuous or intermittent mixed SvO2 measure-
ments to the serial monitoring of lactate levels The global oxygen extraction can be estimated
can provide additional information regarding from the measure of SvO2. Pulmonary artery
whether an abnormally elevated lactate level and/or superior vena cava ScvO2 is considered a
reflects an imbalance between oxygen transport surrogate marker of the balance between oxygen
and oxygen demand. One of the intraoperative demand and supply in tissues. In normal condi-
endpoints of goal-directed resuscitation includes tions, SvO2 is 75 % consistent with an oxygen
minimizing the increase in serum lactate level extraction ratio of 25 %, typically associated
that may be associated with a degree of oxygen with a normal base deficit and lactate level. In
debt, which may in turn prime the patient to the the setting of decreasing oxygen delivery as a
8 Intraoperative Endpoints of Resuscitation 89

60% 45% 35% 25%

Oxygen consumption

8.2
Oxygen delivery in ml/kg/min

Fig. 8.3 Relationship between DO2, VO2, O2Ex, and early dependent, therefore the patient is now in a state of
anaerobic threshold. In normal conditions, VO2 remains supply dependent VO2. Any further increase or decrease in
supply independent as DO2 decreases due to increased DO2 will be accompanied by a corresponding increase or
extraction. However, when the extraction ratio approaches decrease in VO2. The level of critical DO2 documented by
60 %, the anaerobic threshold, DO2, and VO2 become lin- Shibutani et al. is 8.2 mL kg/min [24]

result of either decreased flow or oxygen carrying because it identifies at an earlier stage occult
capacity, oxygen extraction increases in order to hypoperfusion compared with increases in lactate
maintain tissue oxygen consumption constant levels, its value is limited by the fact that while
(Fig. 8.3). The increased extraction is repre- decreasing SvO2 reflects an unbalance between
sented by a decreasing SvO2 with a supply inde- oxygen delivery and consumption, a higher SvO2
pendent lactate production until the point of does not assure the absence of an ongoing oxy-
critical oxygen delivery, associated with an gen debt. As previously mentioned, during gen-
extraction ratio of 60 % (SvO2 40 %) at which eral anesthesia it is not uncommon to observe
point oxygen consumption and lactate produc- SvO2 values higher than 80 % in patients with
tion are both supply dependent. As shown by preserved myocardial function, normal Hg con-
Shibutani et al., the critical level of oxygen centration, and SaO2 > 98 % [3]. Therefore, mixed
delivery in patients undergoing general anesthe- SvO2 cannot be used in isolation as an endpoint
sia is 8.2 mL/kg/min; at this level of oxygen of resuscitation. Its trend must be correlated with
delivery, lactate production becomes supply other biomarkers such as base deficit and lactate
dependent implying that a further decrease in levels in order to guide intraoperative therapy and
oxygen delivery will cause a decreased oxygen minimize the risk of under-resuscitation during
consumption and a consequent increase in lac- complex procedures in high-risk patients.
tate level [24]. A decreasing SvO2 in the absence While Rivers et al. have reported improved
of acutely decreasing hemoglobin indicates outcome in septic patients treated with an early
decreasing flow as a result of decreasing CO. goal-directed therapy targeted to a ScvO2 ≥ 70 %,
One of the issues regarding the use of a spe- two recent multicenter randomized control trials
cific value or range of values of either SvO2 or (ProCESS and ARISE) have failed to reproduce
ScvO2 as one of the endpoints of intraoperative similar results [25–27]. However, it is important
resuscitation involves the effect of anesthesia on to underline two crucial differences between the
mixed SvO2 and with respect to ScvO2 the loca- more recent trials and the trial by Rivers: the first
tion of the tip of the central venous catheter, involves a ScvO2 of 48 % in Rivers’ experimental
whether it is in the superior vena cava as opposed group in contrast to significantly higher values in
to the right atrium. While there is evidence that the two recent trials (71 % for the ProCESS and
targeting intraoperative resuscitation to mixed 73 % for the ARISE); the second involves the
SvO2 in high-risk surgical patients is beneficial evolution of treatment of septic patients over the
90 H.F.G. Araque et al.

past 14 years with respect to the early implemen- of intraoperative resuscitation in order to avoid
tation of antibiotic administration, fluid resusci- an upregulated inflammatory response at cellu-
tation, and source control which has now become lar level from the activation of the oxygen sens-
the standard of care. We continue to believe that ing pathways [30, 31].
current recommendations should include target- Habicher et al. in a retrospective study
ing hemodynamic resuscitation to an ScvO2 of 70 described the PCO2 gap as a marker to detect
% or to an SvO2 of 65 %. The last consensus on global and microcirculatory hypoperfusion in
circulatory shock and hemodynamic monitoring postoperative cardiac surgical patients. They
suggest that a low ScvO2 indicates inadequate observed increased lactate levels, increased
oxygen transport, especially in the context of duration of mechanical ventilation, and longer
hyperlactatemia; therefore, in patients with a cen- intensive care unit stay in patients with an
tral venous catheter, measurements of ScvO2 may ScvO2 > 70 % but with a PCO2 gap >8 mmHg [32].
help assess flow related abnormalities requiring Further evidence supporting the utility of the
further hemodynamic monitoring and targeted central venous-to-arterial carbon dioxide pres-
therapy [28]. sure difference [P(cv−a)CO2] in the periopera-
Based on recently published data demonstrat- tive settings during high-risk surgery has been
ing that low ScvO2 is associated with an increased provided by Futier et al. [31]. In his study
risk of postoperative complications in patients involving 70 patients undergoing high-risk sur-
undergoing major abdominal surgery, we sug- gery, the 24 patients suffering complications
gest that one of the intraoperative endpoints of had a significantly lower mean and minimum
resuscitation should be the achievement of ScvO2 compared to patients without complica-
ScvO2 > 70 % [29]. However, it is important to tions, 78 ± 4 versus 81 ± 4 % and 67 ± 6 versus
underline that a high ScvO2 in isolation does not 72 ± 6 %, respectively, p < 0.05. The P(cv−a)
necessarily preclude the development of postop- CO2 was significantly larger in patients with
erative complications. complications as opposed to those who were
complications free, 7.8 ± 2 versus 5.6 ± 2 mmHg,
respectively, p < 0.05.
Venous-to-Arterial CO2 Difference A P(cv−a)O2 < 5 mmHg may be used as a
complementary target to ScvO2 during goal-­
Tissue CO2 represents the balance between its directed therapy in high-risk surgical patients to
production from the local metabolic processes identify persistent inadequacy of the circulatory
and its removal from the perfused capillaries. A response, in the subset of patients who appear to
rising value is caused by decreased local blood have been optimized based on the achievement of
flow and not by increased production. The ScvO2 ≥ 70 %.
venous arterial carbon dioxide difference (PCO2
gap) is the difference in the partial pressure of
carbon dioxide (PCO2) between central venous Conclusions
blood and arterial blood. The PCO2 gap is
inversely proportional to the number of perfused Based on the review of the best available evi-
capillaries. A difference of ≥6 mmHg may be dence regarding intraoperative goal-­ directed
used to identify tissue hypoperfusion, even therapy and the endpoints of intraoperative
when the ScvO2 is ≥70 %. It may be a particu- resuscitation, we conclude the following: (1)
larly useful added marker to identify under- High- and very high-risk surgical patients under-
resuscitated patients during complex surgical going major surgical procedures should be
procedures, particularly in high-risk patients. It treated with an individualized goal-directed
reflects regional microcirculatory perfusion; approach titrated to dynamic indices of flow uti-
therefore, it may be a useful adjunctive endpoint lizing Doppler-derived peak aortic flow velocity
8 Intraoperative Endpoints of Resuscitation 91

(deltaPV) aimed at maintaining a deltaPV < 13 8. Brunkhorst FM, Engel C, Bloos F, et al. Intensive
insulin therapy and pentastarch resuscitation in severe
%; (2) Hourly ScvO2 monitoring should be com-
sepsis. N Engl J Med. 2008;358:125–39.
plemented with measurement of P(cv-a)CO2 and 9. Sossdorf M, Marx S, Schaarschmidt B, et al. HES
directed at the achievement of values >70 % and 130/0.4 impairs haemostasis and stimulates pro-­
< 5 mmHg, respectively with the optimization of inflammatory blood platelet function. Crit Care.
2009;13:R208.
flow indices using a combination of preload
10. Marik PE, Sibbald WJ. Effect of stored-blood transfu-
recruitment of stroke volume with volume load- sion on oxygen delivery in patients with sepsis.
ing and appropriate use of inotropes as directed JAMA. 1993;269(23):3024–9.
by the measurement of stroke volume and ejec- 11. Koch CG, Li L, Sessler DI, et al. Duration of red-cell
storage and complications after cardiac surgery. N
tion fraction; (3) Base deficit and lactate levels
Engl J Med. 2008;358:1229–39.
should be measured serially every 2 h intraoper- 12. Knotzer H, Pajk W, Maier S, et al. Arginine vasopres-
atively and every 8 h postoperatively until the sin reduces intestinal oxygen supply and mucosal tis-
achievement of two normal values at 8 h inter- sue oxygen tension. Am J Physiol Heart Circ Physiol.
2005;289:H168–73.
vals with the understanding that even when
13. Hamilton MA, Cecconi M, Rhodes A. A systematic
treated optimally intraoperatively patients may review and meta-analysis on the use of preemptive
develop a significant oxygen debt manifested by hemodynamic intervention to improve postoperative
increased base deficit and lactate levels; (4) outcomes in moderate and high-risk surgical patients.
Anesth Analg. 2011;112(6):1392–402.
Early detection and correction of hypoperfusion
14. Davis JW, Parks SN, Kaups KL, et al. Admission base
identified by increasing base deficit and lactate deficit predicts transfusion requirements and risk of
levels associated with either a low ScvO2 < 70 % complications. J Trauma. 1996;41(5):769–74.
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 Part II
Difficult Clinical-Based Surgical Decisions
 Surgical Decision-Making Process
and Damage Control: Current 9
Principles and Practice

Ruben Peralta, Gaby Jabbour, and Rifat Latifi

Introduction World War II described the use of open abdomen

technique in severely injured patients [2]. Lucas and
Traditionally, the common surgical practice Ledgerwood reported the management of liver
included the completion of the operation regard- injuries with temporary perihepatic packings in
less of the physiologic condition of the patient. 1976 [3]. Stone described the modern concept of
However, in trauma patients this can be challeng- abbreviated laparotomy in 1983 [4]: hemorrhage
ing. Therefore, multiple strategies were devel- was controlled by tamponade; bowel injuries were
oped to avoid this dilemma. resected; noncritical injured vessels were ligated;
While the damage control (DC) has become and biliopancreatic injuries were drained. Later,
popular in the last few decades, this is not a new these patients underwent definitive repairs. The
concept. Historically, the management of devastat- term “damage control” was popularized by Rotondo
ing abdominal injuries has been documented by in the 1990s [5], and has become a powerful tool in
the work of others, but the most well-known sur- the management of severely injured patients.
geon is Pringle, who described the use of packs and
digital compression of the portal triad in large liver
injuries more than a century ago [1]. Ogilvie during Indications and Timing of Damage
Control
R. Peralta, M.D., F.A.C.S. (*)
Department of Surgery, Division of Trauma Surgery, Damage control includes the termination of the
Hamad General Hospital and Hamad Medical surgery after controlling bleeding and contami-
Corporation, Al Rayyan Rd, nation, and before the patient physiological
PO Box 3050, Doha, Qatar
e-mail: rperaltamd@gmail.com reserve is exhausted and frequently manifested
by the developing of the lethal triad of acidosis,
G. Jabbour, M.D.
Division of Trauma Surgery, Department of Surgery, coagulopathy, and hypothermia. Definitive repair
Hamad Medical Corporation, is delayed until the patient is stabilized.
Al Rayyan Rd, PO Box 3050, Doha, Qatar When a surgeon is operating in a patient with
e-mail: Jabbourgaby9@hotmail.com hemodynamic instability, hypothermia (<35 °C),
R. Latifi, M.D., F.A.C.S. coagulopathy, severe metabolic acidosis (pH < 7.2
Department of Surgery, Westchester Medical Center, or base deficit >8), multiple injuries, massive
New York Medical College, 100 Woods Road,
Valhalla, NY 10595, USA transfusion requirements (>10 units packed red
blood cells), and long operative time (>90 min)
Department of Surgery, University of Arizona,
Tucson, AZ, USA for trauma or emergency, he or she should think
e-mail: Rifat.latifi@gmail.com of abbreviating the procedure [6, 7].

© Springer International Publishing Switzerland 2016 95

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_9
96 R. Peralta et al.

The Damage Control Operation Hemostatic Resuscitation

for Trauma
During the initial evaluation and management,
While DC may be performed in any part of the intraoperatively and following termination or
body from craniotomies to orthopedic injuries, abbreviated surgery, resuscitation continues.
most commonly it is done in abdominal trauma, This includes resuscitation with intravenous flu-
both penetrating and blunt. In general, most fre- ids and early administration of blood products
quently it is done in liver injuries and vascular and prevention of and correction of the lethal
injuries [4, 5]. Initial hemorrhagic control is triad. Warm room and airway circuit should be
achieved by packing of the liver, and most vascu- instituted in the ICU, and warmer device should
lar injuries can be treated by packing, simple be applied to the patient. A level I rewarmer
ligation, or temporary intraluminal shunts [6, 7]. device is useful at this time where all fluids and
Hollow viscus injuries are treated by resection of blood products should be infused warmed into
affected areas, and anastomosis is postponed the patient. In rare cases, described continuous
until the patient is stabilized. The majority of bil- arteriovenous rewarming can be used, a tech-
iopancreatic injuries can be treated with closed nique that permits rapid rewarming of hypother-
suction drainage [8]. Pre-peritoneal packing has mic patients without requiring cardiopulmonary
gained popularity in recent years and is per- bypass or heparinization in severely hypothermic
formed when there is significant pelvic fracture patients as described by Gentilello et al. [13, 14].
with hemodynamic instability requiring an oper- Damage control resuscitation (DCR) in brief
ation and embolization [9]. One other historical consists of the following: (1) Avoiding or minimiz-
indication of DC use is the inability to close the ing crystalloid resuscitation; (2) Treatment of aci-
abdomen, in order to avoid abdominal compart- dosis requires optimization of oxygen delivery by
ment syndrome due to massive fluid providing optimizing cardiac output, hemoglobin,
resuscitation. and oxygen saturation. Acute traumatic coagulopa-
By using hemostatic resuscitation instead of thy is a frequent occurrence in severely injured
massive crystalloid resuscitation, the need for patients [15]. It is corrected by aggressive blood
leaving the abdomen open has decreased sig- product replacement with fresh frozen plasma,
nificantly, and, thus, DC, once overused, is platelets, and cryoprecipitate. A hemostatic adju-
being used less. Another new technique in the vant that has been shown effective in the correction
management of trauma patients that has become of acquired coagulopathy of trauma is tranexamic
more popular is permissive hypotension when- acid (TXA) [16]. We recommend the use of TXA
ever clinical conditions permit. in bleeding trauma patients, and it is part of our
Significantly less frequently, DC is done in MTPs. Regarding prothrombin complex concen-
isolated chest injuries, with exception for a trates (PCCs), clinical data are still lacking for use
short period of DC during emergency resusci- in massively bleeding trauma patients [17].
tative thoracotomy, clamping the pulmonary Recombinant factor VIIa has been shown to reduce
hilum, or twisting the lung along its hilar axis the transfusion requirement [18, 19].
to stop bleeding from the pulmonary paren-
chyma [10–12]. Occasionally, one has to pack
the chest wall temporarily due to massive rib Definitive (Injury Repair) Operation
fractures associated with chest wall soft tissue
destruction. Other compartments where DC After stabilization and the restoration of the physi-
may be done are extremity soft tissue injuries, ological reserve, the patient is returned to the oper-
particularly associated with vascular injuries, ating room for definitive management. Studies
requiring revascularization. have shown that when patients are returned earlier
9 Surgical Decision-Making Process and Damage Control: Current Principles and Practice 97

than 72 h, they have a lower rate of morbidity and

mortality compared with patients who return later
[20]. In our practice, we return the patient to the
operating room within 12–24 h. One cannot, how-
ever, wait for complete normalization of all resus-
citative indicators before returning to the OR, as
there may be a missed injury that is causing the
patient not to have normal physiology.
During the definitive procedure, a complete
exploration is performed, packs are removed, and
bleeding sites are controlled. This procedure in
fact can be called a tertiary operative survey. Small
bowel continuity is restored, and patients with
colonic injuries are treated with stoma or repair.
Closing the abdominal fascia is considered at this
time if the patient’s clinical condition allows.
Other important elements that need to be consid-
ered at this stage are long-term nutritional access,
completing orthopedic repairs and even potential
for tracheostomies, if one suspects long hospital-
ization or long ICU stay.
Fig. 9.1 Intestines are covered with sterile plastic bag

Management of Open Abdominal

Wound and Definitive Abdominal
Closure

Staged abdominal reconstruction has three main

functions: washout to reduce contamination,
debridement of devitalized tissue, and appropri-
ate reconstruction. This is usually done after
correction of the physiological derangement or
within 36 h, and helps improve the outcomes in
severe injuries. Preoperative patient optimiza-
tion is conducted in order to create an ideal set-
ting for reconstruction (optimal nutritional
status, resolution of sepsis, correction of acido-
Fig. 9.2 Additional cuts may be required on the plastic
sis, hypothermia, and coagulopathy). Delaying bag to allow better drainage of fluid
primary fascial closure is considered according
to abdomen condition (edema, viability) [21,
22]. The surgical decision-making process on the poor man technique. On occasion, the intes-
abdominal wall reconstruction has been tines are so swollen or there is continuation of
addressed in more details in Chap. 11. In this intra-abdominal pathology (such as pancreati-
section, we will describe temporal abdominal tis); thus, we are unable to close the fascia at all.
closure (TAC). Most commonly, the so-called In these cases, we have adopted the technique
“poor man VAC” is used (Figs. 9.1, 9.2, 9.3, that uses temporary vicryl mesh, followed by
and 9.4). In our practice, if we expect to bring wound VAC (Fig. 9.5) and eventually skin graft, with
the patient back to the operating room within 12 delayed reconstruction. Often, as in Fig. 9.6, the
to 24 h, we do not use VAC; instead, we use abdomen is covered with skin only.
98 R. Peralta et al.

Fig. 9.3 Most Kerlix™ (Covidien, Dublin, Ireland) Fig. 9.5 Wound VAC, used even for smaller wounds
gauze is placed over the plastic bag, and two drains are that are left open
placed between gauzes

Fig. 9.6 Closure of the skin only in a patient who had

Fig. 9.4 Finally the gauze and the drains are covered abdominal catastrophe managed with open abdomen
with sticky plastic for weeks
9 Surgical Decision-Making Process and Damage Control: Current Principles and Practice 99

Postoperatively, patients should have good of the aorta (REBOA) has emerged as a promis-
pain control (epidural anesthesia or patient con- ing alternative to packing in the setting of severe
trolled analgesia), antibiotic treatment until ongoing noncompressible major torso hemor-
packs are removed, appropriate nutrition, and rhage [27–31].
deep venous thrombosis prophylaxis. The
wound should be inspected daily, and the drains
left in place until there is minimum drainage. Orthopedic Interventions

The damage control orthopedics (DCO) concepts

Damage Control for Abdominal Sepsis refer to the initial rapid skeletal stabilization with
external fixation, followed by intramedullary
Patients with a septic abdomen have similar man- nailing after the systemic inflammatory response
agement focuses as the damage control trauma has subsided [32–36]. External fixation is also
patient; however, the sequence differs. A longer used in open book pelvic fractures and helps limit
initial resuscitation phase is used in the septic venous bleeding (Fig. 9.7). Arterial bleeding is
abdomen. The operative goal at the initial laparot- treated by angiographic embolization. External
omy is control of the infectious source. In general, fixation and temporary soft tissue coverage in
a temporary abdominal closure is used at the end open fractures are the standard of treatment in
of the initial laparotomy. A second resuscitative critically ill trauma patients. Fasciotomy is per-
phase is then performed in the ICU in preparation formed in vascular injuries and in ischemia reper-
for further surgery. If control of the septic source fusion injuries [37].
is not done, then subsequent interventions are
required. Common complications include entero-
cutaneous fistula and intra-abdominal infections
(tertiary peritonitis) [23].
Complications associated with damage con-
trol can be classified as local (abscess, fistula, and
intestinal necrosis) or systemic complications
(ARDS and MOF). They are also divided into
early (missed injuries, infections, and compart-
ment syndrome) and late (fistula, dehiscence).
Several studies have shown improved out-
comes since the widespread institution of dam-
age control techniques [24, 25].

Vascular Interventions

The most commonly used damage control inter-

ventions in major vascular injuries are the follow-
ing: TIVS (temporary intravascular shunt), where
the operating surgeon can place shunts in patients
with complex vascular injuries in the neck, abdo-
men and extremities, and proceed with the vascu-
lar anastomosis or reconstruction procedure
Fig. 9.7 External fixation for severe pelvic fractures, as
when the patient has reached a more reasonable
part of damage control, in a patient with hemodynamic
hemodynamic stability [26]. Most recently, the use instability, bleeding perineal injury, and large sigmoid
of resuscitative endovascular balloon occlusion colon devascularization, requiring diversion
100 R. Peralta et al.

Summary thoracic trauma. Ann R Coll Surg Engl.

2013;95(1):20–5.
12. Rizzo AG, Sample GA. Thoracic compartment syn-
In summary, damage control is a staged approach drome secondary to a thoracic procedure: a case
to severely injured patients. Initially, life- report. Chest. 2003;124(3):1164–8.
threatening injuries are managed rapidly with 13. Gentilello LM, Rifley WJ. Continuous arteriovenous
rewarming: report of a new technique for treating
appropriate abbreviated procedures. The patient is
hypothermia. J Trauma. 1991;31:1151–4.
then stabilized in the ICU. Later, definitive surgi- 14. Gentilello LM, Cobean RA, Offner PJ, et al.
cal management is performed. This strategy is Continuous arteriovenous rewarming: rapid reversal
beneficial and results in improved outcomes. This of hypothermia in critically ill patients. J Trauma.
1992;32(3):316–27.
approach is still evolving, and many studies are
15. Brohi K, Singh J, Heron M, et al. Acute traumatic
done to implement it as a standard management coagulopathy. J Trauma. 2003;54(6):1127–30.
approach to trauma patients. It requires a multidis- 16. CRASH-2 trial collaborators. Effect of tranexamic
ciplinary team to achieve better outcomes. acid on death, vascular occlusive events, and blood
transfusion in trauma patients with significant haem-
orrhage (CRASH-2): a randomized, placebo-
controlled trial. Lancet. 2010;376(9734):22–32.
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analysis and expert appropriateness rating study. Lottenburg L, Mowery N, Riordan Jr WP, Martin N,
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 Reoperative Surgery in Acute
Setting: When To Go Back? 10
Elizabeth M. Windell and Rifat Latifi

Introduction surgical and anesthesia team is paramount. If the

situation is clearly emergent, this conversation
Most surgical procedures done either electively or may not happen preoperatively, but needs to
emergently go well, and, postoperatively, patients occur after the procedure. Other times, the clues
recover nicely. However, despite our best efforts are subtle, and the decision to return early to the
and highest levels of preparation, complications operating room needs to be taken in a timely
can and do occur. These complications can be fashion, rather than procrastinating the inevita-
simple and easily remedied, but they can also be ble, and is a matter of combination of art and sci-
serious and life threatening, and at times patients entific evidence. Unplanned trips to the operating
need to be returned to the operating room at once room are not very common, some sources in the
or acutely, or in less urgent basis in a semi-planned literature describe a rate of <3.5 % [1–3], but we
fashion, but still need reoperation. The profiles of will all encounter this at some point in our careers
these patients or these procedures that are likely to and knowing when and how best to perform these
undergo reoperation, that is, unplanned operation, operations can make the difference in the survival
have not been clearly defined. and outcomes of our patients.
When the unplanned return to the operating The purpose of this chapter is to describe the
room becomes necessary, such as in the case of times when a repeat operation is necessary and
early hemorrhage or profound abdominal sepsis, when the best time is for performing these opera-
there are a number of issues that surgeons need to tions. As there is a lack of paucity of good evi-
address. Discussing the plan with a patient and dence behind this question in the literature, this
his/her family as well as other members of the chapter will focus more on this decision-making
process from an anecdotal standpoint rather than
from a standpoint of level one evidence.
E.M. Windell, D.O.
Department of Trauma, Surgical Critical Care, and
General Surgery, Legacy Emanuel Medical Center,
Portland, OR, USA Reasons for Reoperative Surgery
e-mail: ewindell@lhs.org
in the Early Postoperative Period
R. Latifi, M.D., F.A.C.S. (*)
Department of Surgery, Westchester Medical Center,
The need to return to the operating room in the
New York Medical College, Valhalla, NY, USA
early postoperative period can be for a variety of
Department of Surgery, University of Arizona,
reasons and it also depends on the surgical
Tucson, AZ, USA
e-mail: latifi@surgery.arizona.edu; Rifat.latifi@ discipline. We will divide these reasons into
gmail.com the acute phase unplanned and planned return to

© Springer International Publishing Switzerland 2016 103

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_10
104 E.M. Windell and R. Latifi

the operating room. While we will concentrate on Depending on the severity of the injury or
the unplanned return, the planned return to the infection, most of these issues start improving
operating such as continuous management (dam- within 12–48 h of the initial operation. The best
age control, burn, multiple reconstruction) will times for considering a second operation tend to
be discussed as well. Later on, the unplanned be in the 24–48 h window. Prior to the 24 h win-
return to the operating room can also happen, dow, patients may still be too unstable for an
such as hernia recurrence, need for revision of operation, and subjecting them to prolonged sur-
grafts in vascular surgery or tumor resection, but geries or anesthesia is not advisable. At the same
this is not a subject of this chapter. As a rule, the time, waiting longer than 48 h may increase fur-
more common causes for reoperative surgery are ther morbidity and mortality as it can lead to
ongoing management after initial damage control organ failures, prolonged need for ventilatory
laparotomy, infectious complications, hemor- support, nutritional deficits, open abdomens
rhage, early bowel obstructions from both adhe- which are a source of fluid loses, and it puts
sions and hernias, and positive margins on the patients at higher risk for serosal injuries, EC
initial field of resection. We will explore each of fistulas and anastomotic leaks. Loss of domain is
these topics in more detail. also a concern with an open abdomen, and delay-
ing closure of the abdominal wall past 48 h may
lead to large hernias and need for future surgeries
Damage Control Laparotomy for abdominal wall reconstruction [5, 6].
One caveat to the 24–48 h window is when
Occasionally in trauma and emergency general source control has not been established, such as
surgery, performing a definitive operation may with profound contamination or necrotizing soft
not be safe at the initial procedure. This is often tissue infections or in the case of ongoing hemor-
due to physiologic instability in the patient mani- rhage. Often in these cases, patients continue to
fested grossly as the lethal triad of coagulopathy, do poorly or worsen in the first 12 h after the
hypothermia, and acidosis. Damage control sur- initial operation, and they may need a second
gery can be used as a temporizing measure to procedure sooner to establish better source con-
control hemorrhage, prevent ongoing contamina- trol or complete disruption of infectious cascade.
tion, and to prevent further issues from profound In these cases, the risk of a second surgery is less
systemic inflammatory response. When damage than the risk of death from ongoing septic shock
control laparotomy is utilized though, one must and a second operation should be performed
consider at the initial operation at what point you before 12 h.
plan to go back for your definitive repair. While
the “norm” is normalization of end point resusci-
tations, one cannot and should wait more than 36 Infection Complications: Source
h to bring back the patient for another exploration Control
or definitive surgery [4, 5].
The major tenant of a damage control lapa- Unfortunately, despite having perioperative opti-
rotomy is that the underlying problems that are mization, infectious complications such as
leading to the lethal triad need to be corrected. wound infection and other intra-abdominal catas-
The coagulopathy, acidosis, and hypothermia trophes do occur. Anastomotic leaks range any-
need to be resolving if not already corrected where from 3–15 % of all bowel anastomoses
before a definitive operation is safe. In the [7–10], and the morbidity and mortality associ-
instance of a damage control laparotomy, tempo- ated with this complication make appropriate
rizing measures are applied to the abdomen, and management crucial. Management of this
the patient is taken to the ICU for rewarming, dreaded complication can range anywhere from
ongoing fluid and blood product resuscitation, observation to IR drainage to need for repeat
and shock management [6]. surgery, and it can be difficult sometimes to
10 Reoperative Surgery in Acute Setting: When To Go Back? 105

determine how best to approach this. You also Rarely, but definitely occurring, these complica-
must take into consideration what resources you tions can occur weeks out [11]. As is well known
have available to you in your institution to deter- in the literature, adhesions and inflammation
mine how to approach management. after surgery are at their worst 10 days to 3
Other situations where patient needs to be months after the initial operation. If a serious
taken back are missed enterotomies or intestinal complication occurs within the first week to 10
perforation manifested clinically and/or demon- days from the original surgery, most of the times
strated by imaging techniques (CT scan images the re-operation is safe. Occasionally, infectious
and intraoperative picture os Picotte). complications occur after this period, and the
Most anastomotic failures occur around day management depends on clinical presentation.
3–7 after initial resection and anastomosis. There We recommend attempting conservative, obser-
have been cases reported though, of late anasto- vant management if patient is hemodynamically
motic failures occurring weeks after the primary stable and responds to conservative management.
operation [11]. Missed enterotomies typically At times, however, the most conservative man-
declare themselves within 24–48 h from surgery, agement in fact is taking the patient back to the
and intra-abdominal abscesses typically present operating room, for what we call “an eye scan.” If
about 5–7 days from surgery. The approach to the patient, though, is hemodynamically unstable
these complications depends on the severity of the one needs to proceed with an operation.
leak and the clinical presentation of the patient. Depending on the clinical situation, one can
In the case of patients who are hemodynami- approach reoperative surgery in the acute set-
cally stable and who have small, contained leaks ting laparoscopically or open. This question is
or easily accessible abscesses, there may be a greatly up for debate, and has a lot of bearing
place for observant management. This type of on each individual surgeon’s technical skills
management typically requires antibiotics to be and the approach at the original operation. If
administered, serial abdominal exams to be per- your original operation was done using mini-
formed and consideration of drain placement by mally invasive technique (bariatric surgery, for
interventional radiologists to help provide source example), there could be consideration of man-
control, but this depends on available resources aging the complications with a laparoscopic
[12]. If you decide that your patient is a candidate approach. A takedown of an anastomosis,
for observant management, you need to be vigi- abdominal washout, and reconstruction of a
lant to continually reassess for any clinical wors- new anastomosis can feasibly be done using
ening or instability. If at any point your patient minimally invasive techniques. At the same
clinically worsens, he or she has worsening sep- time, drainage of a large intra-abdominal
sis, and/or has failure to thrive, an operative abscess or identification of a source of enter-
intervention should be strongly considered. otomy can be done laparoscopically as well.
Anastomotic leaks, intra-abdominal infec- The threshold to convert to an open technique
tions, and missed enterotomies can be life threat- should be very small. Identifying a small enter-
ening and if the initial presentation of the patient otomy or source of leak can be difficult laparo-
in the postoperative period is that of hemody- scopically, so a low threshold for opening
namic instability, severe acidosis, or shock, the should be maintained if you are unable to find
best way to proceed would be for a re-exploration the source of infection. If you started your
as soon as possible. Immediate source control is original operation open, it would be advised to
necessary, with or without temporary diverting reuse those previous incisions for your re-
ostomy as needed. exploration. This will provide you with maxi-
Most of these life-threatening leaks or infections mal visualization and ability to address the
occur within the first week of initial operation. complications before you.
106 E.M. Windell and R. Latifi

Postoperative Hemorrhage: Need may not identify the source of bleeding and
to Stop the Bleeding patients need to be packed and his or her coagu-
lopathy reversed.
Bleeding can and does occur in the perioperative There may be a role of nonselective angio-
period. Typically, bleeding will present or recur embolization for management of venous bleed-
within the first few hours to days from surgery. ing, especially in the setting of pelvic injury or
The mainstay of treatment really depends on a surgery with ongoing hemorrhage. Access to the
number of factors: hemodynamic stability of the region can be difficult and identification of the
patient, resources available in your institution, source of bleeding can often be near impossible
and location and cause of the bleeding. with an open procedure. This technique has gar-
Postoperative hemorrhage can be from a num- nered a lot of attention in the literature in recent
ber of sources, and identifying the source can years and involves nonselective embolization of
often help determine which management will be the feeding artery with a temporary substance,
appropriate [13–15]. In the instance of arterial typically Gelfoam® (Pfizer, New York, NY).
bleeding, these patients are often acutely unstable, The site of where the operative bleeding is
showing evidence of hemorrhagic shock (tachy- occurring from can also be a guide to manage-
cardia, hypotension, altered mental status, oligu- ment. In the case that the bleeding is coming
ria, palor), and they are often non-responders vs. from the pelvis, a strong consideration should be
transient responders to blood transfusions. In for IR intervention to address this. As previously
these cases, patient needs to be brought back for discussed, access and visibility within the pelvis
an immediate reoperation. Depending on the situ- can often be difficult, even in the situation of an
ation (pelvic trauma, solid organ injuries), embo- open laparotomy. Pre-peritoneal packing may be
lization therapy can be considered. If you do required as well.
decide to proceed with IR intervention, you need If the bleeding occurs from the intestines or a
to be constantly monitoring your patient and pro- staple line from a bowel resection, reoperation is
viding aggressive resuscitation. If at any point required. The use of embolization for manage-
your patient is no longer responding to blood ment of bleeding after an anastomosis would be
transfusions or medical management in the prepa- ill-advised. Embolization, either selective or non-
ration of doing an IR intervention, then the patient selective, can compromise blood flow to the area
should be taken immediately for surgery [13]. of the healing anastomosis. If this occurs, an
Occasionally, postoperative hemorrhage can anastomotic leak or breakdown can occur and
be due to venous bleeding or oozing from raw would lead to life-threatening complications.
operative surfaces. Typically, patients with this Also, expanding hematomas in and around the
type of bleeding will be more responsive to fluid intestines could lead to compression of the lumen
resuscitation and overall tend to be more hemo- and bowel obstructions. In this instance, we
dynamically stable, although not always. This would recommend re-exploration.
type of bleeding is not amenable to direct inter-
ventional radiology interventions; therefore, the
options for management are observation vs. re- Early Bowel Obstruction: When
exploration. Most of this bleeding tends to be Waiting Is No Longer an Option
self-limiting, unless there is an injury to large
veins, and will often resolve with appropriate The most common unplanned reason for reopera-
fluid resuscitation with balanced transfusions, tion after abdominal surgery is adhesive small
utilizing clotting factors, allowing for mild per- bowel disease. Just the opening of the peritoneal
missive hypotension, and correction of coagu- cavity leads to adhesions forming in 95 % of
lopathies. If the patient responds to resuscitation, patients. Of this, approximately 4 % of all patients
we would consider observation and correction who undergo abdominal surgery will go on to
of coagulation factors. A repeat operation often have a clinically significant bowel obstruction.
10 Reoperative Surgery in Acute Setting: When To Go Back? 107

These obstructions often occur months to years mended to proceed with watchful waiting and
after an operation. Occasionally, these obstruc- conservative management which includes NG
tions occur within the first few days to weeks tube decompression, limitation of narcotics, TPN
after initial surgery. It has been reported that 30 and serial abdominal exams, as the majority of
% of all bowel obstructions occur within the first these will resolve with this treatment [19]. Again,
30 days of surgery, but the way to manage this is very rarely, these obstructions will show no
heavily debated [16]. improvement at the 10–14 day point. When this
Adhesion formation occurs from a local occurs, reoperation needs to be heavily consid-
response of the peritoneum and serosa to isch- ered as again, >90 % of these will not resolve
emia, desiccation, and trauma that can originate without an operation. Delaying beyond this point
from the primary disease process or surgery itself leaves the patient at high risk or complications
(contact with instruments, gloves, sponges, due to dense adhesions and increased difficulty
suture, or other irritants). When this occurs, the with surgery. We recommend conservative man-
normally fluid bowel can become twisted or agement for 7–10 days post-op. If the patient still
kinked leading to a bowel obstruction. Adhesions shows no improvement or resolution, and imag-
and inflammation tend to be at their worst at 14 ing suggests a bowel obstruction, we recommend
days to one month post-op, and then slowly re-exploration at this point. One point that is
improve over months. extremely important to remember, though, is if at
Post-op ileus is unfortunately a frequently any point the patient shows evidence of bowel
encountered condition after intra-abdominal sur- ischemia (increasing abdominal pain, elevated
gery. The symptoms of ileus (distention, lack of WBC, increasing lactate, evidence of sepsis),
flatus, belching, abdominal pain, nausea, and immediate operative intervention should be
vomiting) mimic that of bowel obstruction, often undertaken to prevent irreversible bowel death
leading to some confusion on practitioner’s part and or perforation.
as how best to proceed with management. It is If a patient is over 14 days out from his or her
recommended that to start, NG tube decompres- initial operation and develops a bowel obstruc-
sion and bowel rest should be utilized. If symp- tion at that point, unless there is evidence of
toms persist, consideration should be given to GI bowel ischemia or abdominal sepsis, it would be
imaging, starting first with abdominal x-ray and advised to consider conservative management.
then a CT scan with oral contrast versus small Conservative management would consist of NG
bowel follow through, looking for potential tube decompression, bowel rest, and initiation of
sources of obstruction. If a diagnosis of ileus is TPN. If partial obstruction does not resolve
decided, watchful waiting is recommended. entirely, we recommend re-exploration. Studies
Typically, this will resolve within 3 days to 7 have shown that early postoperative bowel
days. obstructions that persist beyond 10 days post-op
In the setting of an early small bowel obstruc- typically will not resolve without operative inter-
tion, the majority of these will also resolve within vention. Operating before 6 weeks again puts a
7–14 days after initial surgery. A study by patient at high risk for complications due to dense
Chessin et al. showed that the need for reopera- adhesions.
tion on early small bowel obstruction was only With the advancements in surgeon’s skills
0.8 % [17]. With that being said, though, if a with performing primary operations laparoscopi-
bowel obstruction persists beyond 14 days post- cally, the incidence of postoperative bowel
op, the likelihood it will resolve without a reop- obstructions has greatly decreased, thought to be
eration is extremely low, <10 % [18], and due to less adhesion formation. One must be
reoperation should be strongly considered. With aware though, that bowel obstructions do occur
these statistics in mind, if imaging reveals that a after laparoscopic surgery, and the causes of
patient has a bowel obstruction, especially within these are often very different from open surgery.
the first 10 days of surgery, it would be recom- In open laparotomy, adhesions occur due to the
108 E.M. Windell and R. Latifi

trauma from a large open incision with significant regional control? Will not doing the operation
exposure of both the bowel and peritoneum [20]. delay the patient’s ongoing cancer therapy? Will
In a study from the French Association for performing a second operation delay medical
Surgical Research, only 50 % of postoperative management of the cancer further? Will the risk
bowel obstructions after laparoscopic surgery of adhesions and the possibility of a fistula or
were due to adhesions, significantly less than the enteric leakage occurring delay ongoing treat-
75 % from open procedures [21]. New opportuni- ment for the patient? You should address these
ties for problems occur with laparoscopic sur- questions prior to considering an early second
gery, problems such as internal hernias and operation. It may also be well advised to discuss
hernias from trocar port sites. These types of the case with the oncologist or surgical oncolo-
obstructions are of immediate concern as they gist to best answer this.
often lead to bowel ischemia if not addressed
early. In the setting of an early postoperative
bowel obstruction after a laparoscopic surgery, it Summary
would be recommended for immediate re-
exploration. One could consider doing this reop- The need for early reoperation after primary
eration laparoscopically, but if the bowel is intra-abdominal surgery is rare, but can be due to
markedly distended, visualization may be diffi- multiple different etiologies. We have discussed
cult and an adequate pneumoperitoneum may not the situations of damage control laparotomy,
be possible. In this case, an open exploration infectious complications, postoperative hemor-
should be performed. Another reason to avoid a rhage, early bowel obstruction, and positive mar-
laparoscopic approach is the fact that the intes- gins. Determination of the specific etiology will
tines may be injured during manipulation with help to guide appropriate management, and we
instruments as they are filled with fluids. If you hope that our insights into these various compli-
do proceed laparoscopically, one has to carefully cations will help in management of your patients.
examine all surfaces of bowel as partial ischemia With damage control laparotomy, reoperation
of the bowel wall may be present from a port-site is always necessary to finalize definitive repairs
Richter’s hernia. and to assess for ongoing bleeding. In these
cases, a surgeon should plan for the second look
and if able definitive repair 24–48 h after the ini-
Reoperation: Positive Margins tial operation. Again, if initial source control has
of Resection not been obtained and the patient continues to
show signs of instability and non-progression
You operate on a patient. You notice a large with medical management, it may be necessary
mass. You perform the appropriate en bloc resec- for re-exploration prior to 24 h.
tion, but your final pathology comes back 7 days In the instance of infectious complications or
after your initial operation: you have positive postoperative hemorrhage, surgery is always a
margins. You thought you had it all, but the recommended approach. Occasionally, if the
microscopic disease is telling you otherwise. patient is stable and not overtly toxic, consider-
What should your approach be in this situation? ation can and should be placed on medical man-
Ultimately, the answer to this can be very differ- agement with or without the assistance of
ent depending on the clinical pathology that you interventional radiology. If at any point, though,
are addressing, something that is beyond the your patient worsens or does not improve, then
scope of this text. Questions that you can ask to heavy consideration to reoperate is necessary.
help guide your therapy though are: Will doing a Management of early postoperative bowel
second operation improve the outcomes of the obstruction has a lot to do with initial operative
cancer, or is systemic therapy the way to go? Can approach. With an open laparotomy, unless the
radiation be utilized for treatment for local patient has evidence of bowel ischemia, watchful
10 Reoperative Surgery in Acute Setting: When To Go Back? 109

waiting with decompression and TPN should be 8. Catena F, La Donna M, Gagliardi S, Avanzolini A,
Taffurelli M. Stapled versus hand-sewn anastomosis
initiated, but if it persists beyond 10–14 days then
in emergency intestinal surgery: results of a prospec-
reoperation should be considered. In the setting tive randomized study. Surg Today. 2004;34:123–6.
of laparoscopic surgery at the initial operation, 9. Farrah JP, Lauer CW, Bray MS, McCartt JM, Chang
immediate re-exploration would be recom- MC, Meredith JW, Miller PR, Mowery NT. Stapled
versus hand-sewn anastomosis in emergency general
mended by these authors due to the high potential
surgery: a restrospective review of outcomes in a
of closed loop obstructions or port-site hernias. unique patient population. J Trauma Acute Care Surg.
Lastly, in the event of positive margins in the 2013;74(5):1187–94.
setting of cancer, reoperation depends on the ini- 10. Shekarriz H, Eigenwald J, Shekarriz B, Upadhyay J,
Shekarriz J, Zoubie D, Wedel T, Wittenburg
tial pathology and it would be advised to discuss
H. Anastomotic leak in colorectal surgery: are 75%
management as a multidisciplinary approach. preventable? Int J Colorectal Dis. 2015;30(11):
If you do find yourself in the situation of 1523–31.
needing to reoperate, we hope this will be a 11. Hyman N, Manchester TL, Osler T, et al. Anastomotic
leaks after intestinal anastomosis: it’s later than you
guide for you, and remember to be meticulous
think. Ann Surg. 2007;245(2):254–8.
and slow in your dissections to prevent 12. Nicksa GA, Dring RV, Johnson KH, et al. Anastomotic
additional injury. leaks: what is the best diagnostic imaging study? Dis
Colon Rectum. 2007;50(2):197–203.
13. Young JL, Lachance JA, Rice LW, Foley
EF. Reoperation and management of postoperative
pelvic hemorrhage and copagulopathy. In: Billingham
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bypass. Obes Surg. 2016;26(2):345–9. JM. Adhesive postoperative small bowel obstruction:
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 Surgical Decision-Making Process
and Definitive Abdominal Wall 11
Reconstruction

Rifat Latifi, Ruben Peralta, and John A. Stroster

Introduction decisions that are often considered “outside sur-

gical dogma,” long-term follow-up, and ensuring
Reconstruction of complex abdominal wall full recovery of the patient to normal functional
defects and recreating functional abdominal wall status are all basic requirements. One very impor-
represent major challenges, often requiring surgi- tant factor is the dedication of the surgeon to
cal creativity, and a strategy that involves differ- these patients and to their surgical problems, and
ent aspects of care along the various stages of these operations are not to be performed by an
treatment [1]. These challenges need to be under- “itinerary surgeon.”
stood primarily by the surgeon, but by the patient The management of these patients should be
as well. The issues range from defining the approached in a step-wise fashion, ensuring that
pathology to understanding the impact of the each phase is truly understood by the surgeon, as
clinical condition, physiology, nutritional status, well as by the patient and their family. While
and wound care. Redefining the anatomy and there is always room for a discretionary surgical
physiology, timing the definitive surgery, execut- approach, disciplined protocols and a well-
ing the operative plan, making intraoperative planned surgical strategy, particularly in patients
with abdominal wall defects complicated by fis-
tulas or stomas, make the intraoperative manage-
R. Latifi, M.D., F.A.C.S. ment process easier and may improve
Department of Surgery, Westchester Medical Center, postoperative outcomes. Such a strategy has been
New York Medical College, 100 Woods Road, described in a six-step strategy for management
Valhalla, NY 10595, USA of enterocutaneous fistulas (ECFs), known as
Department of Surgery, University of Arizona, “SOWATS” (S = Sepsis Control, O = Nutrition
Tucson, AZ, USA Optimization, W = Wound Care, T = Timing,
e-mail: Rifat.latifi@gmail.com
A = Anatomy, and S = Surgery) [2]. Use of this
R. Peralta, M.D., F.A.C.S. (*) approach on 79 patients led to spontaneous clo-
Department of Surgery, Division of Trauma Surgery,
Hamad General Hospital and Hamad Medical sure in 23 (29 %) patients after a median period
Corporation, Al Rayyan Rd, PO Box 3050, of 39 (range 7–163) days. Forty-nine patients
Doha 3050, Qatar required operative repair after median period of
e-mail: rperaltamd@gmail.com 101 (range 7–374) days; closure was achieved in
J.A. Stroster, Ph.D. 47 (96 %) patients. The reported mortality was
Department of Surgery, Banner University Medical 10 % during the study period, although in a sepa-
Center, 172 S. Bonanza Ave.,
Tucson, AZ 85748, USA rate publication, the authors reported that 44/135
e-mail: stroster@surgery.arizona.edu or 32.5 % of patients died [3]. While this strategy

© Springer International Publishing Switzerland 2016 111

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_11
112 R. Latifi et al.

is applicable in the acute setting, it does not ate the decision of whether to operate, except in
address important aspects of the management of situations involving intestinal obstruction not
these patients as part of the continuum of care. responding to conservative treatment. While not
Initial diagnosis, the immediate postoperative all surgeons agree, at times the strategy for these
period, postoperative care following definitive patients should be “more is less,” and often the
surgery, and finally long-term follow-up are all definitive surgery is the only choice and should
equally important to consider. To address these be performed. We prefer to operate earlier rather
aspects, our surgical practice group has expanded than later, assuming that the patient is not pro-
the six-step strategy to nine steps, and call it hibitively at high risk for major complications.
“ISOWATS PL” [4] where I = Identification and While timing when to repair large abdominal
diagnosis of the postoperative fistula; S = Sepsis wall hernias is less debatable [5–7], operating on
and Source Control; O = Optimization of Nutrition; fistulas and knowing how long a surgeon should
W = Providing and Ensuring Wound Care; wait until takedown are more contentious.
A = Redefining the anatomy and understanding Delaying surgery anywhere from 12 to 36 months
the pathology at hand; T = Timing of definitive to improve the outcomes in patients with ECF
surgery and/or takedown of fistulas; S = Definitive has been suggested [8], although prolonging sur-
surgery and surgical creativity; P = Postoperative gery for longer than 1 year following ECF diag-
care; and L = Long-term follow-up. We adhere to nosis doubles the risk of postoperative
the “ISOWATS PL” strategy as much as possible, refistulization [9], and waiting longer than 36
although we sometimes cannot strictly follow all weeks increases the reported risk for fistula recur-
nine steps in certain patients, as some often require rence by five times [10]. There are no solid data
emergency surgery. In this chapter, we will dis- to inform such decisions, and thus the individual
cuss the decision-making process for parts of our patient’s condition is the main factor that should
nine-step approach, which deal with timing of the be used as a guide.
surgery, and the methods and techniques used to
reconstruct the complex abdominal wall defects.
Surgical Approach

Timing to Definitive Repair Once the decision to operate has been made
jointly by both the patient and the surgeon, decid-
We have previously described that the decision if ing on the definitive reconstruction technique is
and when to reoperate on patients with complex the next challenge faced. Most patients who have
abdominal wall defects should be individualized, previously undergone large abdominal surgeries
and represents one of the most important steps in have a midline abdominal incision, so their lat-
the surgical management of these patients [4]. eral abdominal wall is usually free of scars and
We base this decision on many factors, but par- defects, thereby providing a well-vascularized
ticularly on the comorbid diseases and on the soft tissue donor site. There are a number of
anatomy of the surgical problem. In addition to exceptions, however, especially when the patient
considering the clinical status and physiology of has had any lateral incision or stomas. Unless the
the patient, one has to remember that these large patient has a giant hernia with loss of abdominal
defects can be functionally devastating and lead domain, the abdominal wall can be anatomically
to further weight gain and more problems, and restored with minimal tension and without com-
potentially may lead to major morbidity. If promising the integrity of the abdominal muscles,
patients have serious comorbid diseases such as vessels, and nerves. The surgical goals are to
extreme obesity, severe heart disease, high-grade establish gastrointestinal (GI) tract continuity,
liver cirrhosis or lung disease (dependent upon obtain full closure of the abdominal wall, avoid
oxygen therapy at home), and do not have symp- the postoperative abdominal compartment
toms of obstructions, one should carefully evalu- syndrome, minimize the formation or recurrence
11 Surgical Decision-Making Process and Definitive Abdominal Wall Reconstruction 113

of fistulas, hernias, wound infections, and strive of the abdominal wall surface by separating and
to restore the patient’s functionality. In patients advancing the muscular layers. Some form of
with frozen abdomen, or when a split-thickness component separation, alone or in combination
skin graft (STSG) exists, dealing with adhesions, with other adjunct procedures, has become com-
resecting fistulas, and performing the anastomo- mon practice.
sis require experience, and even entering the Other methods can be used to reconstruct the
abdomen may prove challenging. abdominal wall complex defects such as local
advancement or regional flaps, distant flaps, or
combined flap and mesh; however, which tech-
Definitive Abdominal Wall nique is used will depend on the pathology at
Reconstruction hand. In Type I defects with stable skin coverage,
bridging the fascial gap with prosthetic mate-
Creating a new abdominal wall may represent a rial or autologous tissue is sufficient, whereas in
serious surgical challenge, and both the surgeon Type II defects with absent or unstable skin cov-
and the patient should be prepared for a lengthy erage, fascial repair alone is inadequate, and the
procedure (i.e., entering the abdomen, lysis of repair must be done with skin utilizing more
adhesions, resecting the fistulas, and performing complex reconstruction techniques (e.g., regional
the anastomosis). Some authors have suggested or distant flaps, either alone or in combination
that reconstruction should be performed by another with mesh). Vascularized flaps provide healthy
team, such as plastic surgeons [11]. On occasion, autologous tissue coverage and usually do not
the primary author (R.L.) has used the principle require any implantation of foreign material at
of damage control on demand, returning the next the closure site. Small and midsize defects can be
day or so to completely inspect the anastomosis repaired with pedicle flaps within the arch of the
again, ensuring that there are no missed enteroto- rotation of the flap. In extensive upper midline
mies before performing the final closure. abdominal wall and thoraco-abdominal defects, a
If native tissue can be used without undue ten- free flap that offers a completely autologous,
sion, then it should be utilized. If that is not pos- single-stage reconstructive solution is the best
sible, a synthetic or biologic prosthesis can be option available.
used instead. In most patients, some sort of com- Timing of the procedure depends on the pre-
bination of reconstruction techniques will be operative evaluation, the physiological condition
needed. If the midline tissue cannot be easily of the patient, and the anatomical condition of the
approximated, or if mesh reinforcement is needed tissues. The presence of the so-called “pinch
(as it is in almost all abdominal wall defects sign” (i.e., easy retraction of the skin or skin graft
larger than 6 cm), then other techniques must be over the defect) is a good indicator that the adhe-
considered. For example, if midline tissue cannot sions are subsiding, and that it is appropriate to
be easily approximated, in order to avoid undue schedule the abdominal reconstruction. In our
tension on the tissue and postoperative compart- experience, the optimal time for abdominal wall
ment syndrome, the lateral components, bilater- reconstruction is 6–12 months after the first pro-
ally, need to be released and a neo-abdominal cedure (when adhesions are less prominent).
wall created. Tissue transposition of myocutane-
ous flaps through lateral component separation is
the procedure of choice [12, 13]. Component The Component Separation
separation results in medial advancement of Technique
intact rectus myofascial units bilaterally, enabling
the closure of defects of up to 10 cm in the upper During the component separation technique
abdomen, 20 cm in the mid-abdomen, and (CST) for abdominal wall reconstruction, the
6–8 cm in the lower abdomen. The component anterior abdominal skin flaps are developed and
separation technique is based on an enlargement dissected out laterally from the chest wall to the
114 R. Latifi et al.

anterior superior spine, then the aponeurosis of

the external oblique muscle is divided longitudi-
nally 2 cm laterally to the lateral edge of the rec-
tus sheath, which will allow the mobilized rectus
myofascial component to be mobilized medially
and facilitate the approximation of the midline
with sutures (Figs. 11.1, 11.2, 11.3, and 11.4).
There are various modifications of the compo-
nent separation procedures. A popular modifica-
tion was described by a Memphis group as the
“separation of parts.” Another variation is the
“open book” technique described by a group at
the University of Virginia: in addition to the lat-
eral release of the external oblique, the rectus fas-
cia is flipped into the midline using the linea alba
as the fulcrum to extend the midline [14–22];
when a minimally invasive surgical technique is
employed, the rates of recurrence are similar
[23]. Other tissue transfer techniques have been
utilized and described as well. Vascularized flaps
provide autologous tissue coverage and help
avoid the use of foreign material. In general, ped- Fig. 11.2 Drains are placed under the skin and subcuta-
neous tissue to reduce seromas

Fig. 11.1 Completed closure of the abdominal defect

after underlay mesh placement and bilateral component Fig. 11.3 Underlay mesh placement, before the newly
release created abdominal wall is closed
11 Surgical Decision-Making Process and Definitive Abdominal Wall Reconstruction 115

are not solid. Each of these techniques has their

own pros and cons, and should be used based on
one’s surgical expertise and patient selection.

Onlay Placement

From a technique standpoint, onlay placement is

the easiest way to situate the mesh. When the
abdominal wall edges are easily approximated,
free of defects and contamination, there is no
contraindication to using synthetic mesh. In
these situations with synthetic mesh, preference
should be given to the onlay placement tech-
nique, although there is concern for higher risk
of seroma formation. There is always a small
risk of wound infection, and one needs to remove
the mesh if it gets infected, but currently this is a
standard of care. The key element of this
approach is fixing the mesh both laterally and
over the edge of midline. We prefer fixing the
mesh to fascia using absorbable sutures (Vicryl®
Fig. 11.4 Underlay mesh needs to feel like a drum when
all sutures are placed under some tension and pulled
(Ethicon, Edinburgh, UK) 2.0 or 3.0), either
laterally interrupted or continuous. The main objective is
to reestablish closure, and the primary author
uses 3 or 4 large, closed-suction drains (19
icle flaps are an alternative option for small defect French) under the subcutaneous tissue, and
repair. Free flaps cover large thoraco-abdominal keeps the drains in until the individual drain out-
wall defects in a single stage reconstructive pro- put is less than 25 mL over 24 h.
cedure; however, they are complex procedures
and require institutional expertise [24–35].
The placement of some sort of synthetic or Underlay Placement
biologic graft, that is a mesh, is recommended
even if you perform lateral component release Underlay graft placement (Figs. 11.3 and 11.4)
[36]. The question of whether the mesh should be has now become the main technique in all high-
biologic or synthetic mesh depends mostly on its risk and complex ventral hernia defect recon-
availability and patient’s clinical profile, although structions. It is more involved, but once it is
deciding how to place the mesh should be given mastered and perfected, it does not add signifi-
special consideration. Deciding between the cant operative time. Although it is believed that
three most common techniques used to place a that underlay graft placement is associated with
mesh during abdominal wall reconstruction (i.e., lower incidence of seroma, in our practice the
onlay, underlay, and interposition or bridge determining factor is the thickness of the pan-
placement) depends on the surgeon’s expertise nus over the fascia. The decision to perform
and the clinical status of the patient. For most of underlay technique is an important one, and
our patients who experienced major abdominal should be done after freeing the abdominal wall
wound contamination in the past or at the time of entirely from any adhesions, as far laterally as
reconstruction, we prefer biologic mesh, although possible both on the posterior and anterior
the data to support this decision, while intuitive, aspect.
116 R. Latifi et al.

Placement of the interrupted sutures should Bridge Mesh Placement

ensure complete stretching of the mesh once
sutures are tight. Sutures are placed using the In patients with a major loss of abdominal wall
“parachuting” technique under direct vision at all domain, approximating the medial edges of the
times. The direct-vision parachuting technique abdominal wall may be impossible, despite per-
minimizes the potential for bowel injury during forming bilateral anterior or posterior compart-
fixing of graft on the abdominal wall. When lat- ment release. In this situation, the only remaining
eral component release is used, sutures in the option is to use mesh as a bridge (Fig. 11.3), but
anterior abdominal wall are placed as far laterally patients should be advised that there is high
as possible, and must include the medial edge of chance of hernia recurrence and/or wall laxity
the external oblique fascia. Doing so prevents that will mimic hernia (Fig. 11.5). The suture
bulging laterally at the release component site, bites are placed at least 2 or 3 cm into the muscles
which the patient might think the bulging is a and fascia. One should avoid tacking the mesh on
new hernia. It is important to ensure that sutures the edge of the fascia, given the risk of herniation
are close enough to each other to prevent intesti- or suture failure. If at all possible, the “bridge”
nal herniation between the sutures. A number of should be covered with native skin and subcuta-
techniques of “underlay” placement have been neous tissue. However, when mesh is used as a
described, including retro-rectus and sublay, as bridge and there is no skin or subcutaneous tissue
well as release of posterior aspect of the rectus. If to cover the mesh, then the use of a wound
the peritoneum is intact and not violated from Vacuum-Assisted Closure (VAC) with continu-
stoma placement of other reason, retro-rectus and ous irrigation is very useful to keep the mesh
preperitoneum mesh placement may have advan- moist and to speed up the process of granulation
tages [37]. for later skin grafting. Based on the extent of the
While retromuscular mesh repair has gained operation and dissection, the postoperative
popularity, a number of associated complications course can be quite complicated. Wound infec-
have been reported, including surgical site infec- tion, necrosis of mucocutaneous flaps, seroma,
tions (SSI) in 19.6 % of cases, and the overall and long-term open wounds are common and the
recurrence rate was 16.9 %. In one study, the patient should be prepared for these possibilities
highest rate of recurrence (25 %) occurred when in advance.
hernia was repaired with biologic mesh, followed
by synthetic mesh (16.2 %), and bio-absorbable
mesh (17.1 %). The lightweight mesh use was
associated with 22.9 % vs. mid-weight mesh
(10.6 %) (p = 0.045). The only predictor of recur-
rence was the presence of an SSI (OR 3.1, 95 %
CI 1.5–6.3; p < 0.01). Similarly, after multivari-
ate analysis, diabetes, hernia width >20 cm, and
use of biologic mesh were statistically associated
with the development of a surgical-site occur-
rence (SSO) (P < 0.05). Notably, the mere pres-
ence of contamination was not independently
associated with wound morbidity (P = 0.11). SSO
and SSI rates anticipated by a recent risk predic-
tion model were 50–80 % and 17–83 %, respec-
tively, compared with our actual rates of 20–46 % Fig. 11.5 Laxed abdominal wall after AlloDerm®
and 7–32 % [38]. (LifeCell, Bridgewater, NJ) reconstruction
11 Surgical Decision-Making Process and Definitive Abdominal Wall Reconstruction 117

Summary 11. Leppäniemi A, Tukiainen E. Reconstruction of com-

plex abdominal wall defects. Scand J Surg.
2013;102(1):14–9.
The management of complex abdominal wall 12. Albanese A. Eventracion mediana xifoumbilical
defects continues to evolve and still poses a gigante: metodo para su tratamiento. Rev Asoc Med
major challenge for the clinical surgeon. Argent. 1951;65(709–710):376–8.
13. Ramirez OM, Ruas E, Dellon AL. “Components sep-
Successful abdominal wall reconstruction relies
aration” method for closure of abdominal-wall
primarily on good judgment, careful periopera- defects: an anatomic and clinical study. Plast Reconstr
tive preparation, expertise on performing the sur- Surg. 1990;86(3):519–26.
gical technique, and close follow-up. Physiology 14. de Vries Reilingh TS et al. Repair of giant midline
abdominal wall hernias: “components separation
of the patient, defect size, its location, and level
technique” versus prosthetic repair. World J Surg.
of contamination are considerations that influ- 2007;31(4):756–63.
ence the management of abdominal wall defects. 15. Diaz Jr JJ et al. Eastern Association for the Surgery of
Trauma: a review of the management of the open abdo-
men—part 2 “management of the open abdomen”.
Acknowledgements There are no identifiable conflicts
J Trauma Acute Care Surg. 2011;71(2):502–12.
of interests to report.
16. Latifi R, Turégano F. Current management of entero-
The authors have no financial or proprietary interest
cutaneous fistulas. Eur J Trauma Emerg Surg.
in the subject matter or materials discussed in the
2011;37(3):207–8.
chapter.
17. Leppäniemi A. The hostile abdomen—a systematic
approach to a complex problem. Scand J Surg.
2008;97(3):218–9.
18. Vargo D. Component separation in the management
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 Dealing with the Most Difficult
Situations in Abdominal Surgery 12
Rifat Latifi and John A. Stroster

Epigraph collections filled with air, too many to be drained

percutaneously. The situation is made even worse
You get a phone call from your resident that the if you are at a conference or perhaps on vacation
patient on whom you performed an abdominal with your family. Your rule is to never do a “big
exploration 7 days earlier for mechanical intesti- case” before leaving town, but this happened to be
nal obstruction and severe adhesive disease now an emergency when you were last on-call.
has some murky fluid coming out of the lower In this chapter, we will address a few difficult
portion of the incision. The resident adds “do not situations with which a general surgeon must
worry, he is looking good, although his body tem- deal with increasing frequency.
perature is slightly up, and the WBC count is
17,000 this morning.” You know exactly what will
happen next, or at least you fear you know what Introduction
will happen next: fascial dehiscence, a missed
intestinal injury, which you caused while dissect- Other chapters in this text dealt with the most dif-
ing those severe adhesions. What else it could be? ficult situations in trauma and oncological sur-
How many times you have taught your resi- gery, respectively and therefore this chapter will
dents that wound dehiscence is almost always refrain from most of the cross-over between
from the intra-abdominal infection and not simply abdominal surgery and oncologic or trauma
from the superficial wound infection? But, those causes. Instead, this chapter will emphasize some
infections have always happened in the patients of of the most complicated situations faced by gen-
your partners. Now it may be your turn. The next eral surgeons including enterocutaneous fistulas,
phone call confirms all your fears: multiple fluid necrotizing soft tissue infections, postoperative
anastomotic leaks, and delayed recognition of
R. Latifi, M.D., F.A.C.S. (*) intestinal ischemia in order to shed light on how
Department of Surgery, Westchester Medical Center, we surgeons handle serious situations.
New York Medical College, 100 Woods Road,
Valhalla, New York, NY 10595, USA
Department of Surgery, University of Arizona, Enterocutaneous Fistulas
Tucson, AZ, USA
e-mail: Rifat.latifi@gmail.com
Enterocutaneous fistulas (ECF) are arguably one
J.A. Stroster, Ph.D. of the most complex issues a surgeon can treat
Department of Surgery, Banner University Medical
Center, 172 S. Bonanza Ave., Tucson, AZ 85748, USA and given that more than three-quarters of fistulas
e-mail: stroster@surgery.arizona.edu are postoperative complications, surgeons also

© Springer International Publishing Switzerland 2016 119

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_12
120 R. Latifi and J.A. Stroster

play a role in their origin [1]. Since the overall abdominal dehiscence is not straightforward, and
incidence of ECF is low [2], and their etiology one has to fear intra-abdominal catastrophe
varies, there is a lack of randomized trials in the before “blaming” technical reasons for suture
literature, and therefore management guidelines failure of the closure. The first cause of abdomi-
tend to be based upon expert opinion rather than nal wound dehiscence, after the creation of a
evidence-based, grade-A recommendations. A single or multiple anastomoses, with or without
15-year study reviewing the application of the lysis of adhesions, should be sought in some
SOWATS treatment guideline (comprised of: other sort of abdominal catastrophe, such as
Sepsis, Optimization of nutritional state, Wound severe infection (abscess), or a fistula due to
care, Anatomy [of the fistula], Timing of surgery, missed injury or anastomotic leak.
and Surgical strategy) in 135 patients treated for The choices of action are: some sort of imag-
ECFs demonstrated an overall closure rate of ing such as computerized tomography (CT) scan;
87.4 % (n = 118) [3]. Spontaneous closure upper gastrointestinal (UGI) series with small
occurred in 21 patients which was usually those bowel follow-through; a fistulogram; enemas; or
with an intact abdominal wall and on total paren- an “eye-scan” that is intraoperatively performed.
teral nutrition (TPN), while surgical closure was We prefer that would exploration should be done
achieved in the remaining 97 individuals [3]. Our in the operating room in fresh postoperative
surgical group has expanded the SOWATS patients in order to completely assess the wound
guideline to nine steps and we call it “ISOWATS as well as the subfascial collections and intes-
PL,” where the additional components are tines lying under the sutures, which could easily
I = Identification and diagnosis of postoperative erode into the lumen and cause new fistulas. Most
fistula, P = Postoperative care, and L = Long-term of these patients in practice receive a CT scan as
follow-up [4]. well, although magnetic resonance imaging
While the reported mortality rate resulting (MRI) is being increasingly used as well [10].
from treating ECFs has dropped from 44 % in The CT scan or MRI will identify any deep peri-
1960 [5] to around than 10 % presently [6], toneal or pelvic collections that could be drained
patients with ECFs still present the most difficult or guided by CT, MRI, or ultrasound. In the first
and complex challenge to any general surgeon, few postoperative days (and in my experience,
not to mention the patient. Despite the develop- the first 10–14 days), one should not hesitate to
ments in surgical techniques, wound care, nutri- take the patient back to the operating room for an
tional support, and overall intensive and surgical exploration and direct assessment, if clinically
care, patients with high-output fistulas (>500 warranted.
mL/day) are still at risk of severe malnutrition, Over the years, the senior author (RL) has
blood stream catheter-related sepsis, intra- observed an interesting phenomenon in surgeons’
abdominal sepsis, and death [2, 7]. Dealing with behavior. As surgeons, we not only behave differ-
ECF or enteroatmospheric (EAF) is considerably ently in novel situations, but we also vary our
complex and will test the skills of even most behavior in the same scenarios with different
experienced surgeon [8]. patients. The best examples are among acute care
surgeons or trauma surgeons. When a trauma
patient is not doing well postoperatively, we the
Identification and Diagnosis trauma surgeons immediately think that we have
of Fistulas missed an injury or there is something new hap-
pening, and taking the patient back to the operat-
The diagnosis, which is the early identification of ing room for an “eye-scan exploration” is almost
the fistulas, needs to be established in a timely the first thought in our minds. And we do that
fashion and without much delay, while the pre- exact thing, most of the time. Yet, when we per-
sentation depends on the clinical situation [9]. form an elective surgery, such as the patient with
The cause of postoperative wound infections and elective colostomy take down described at the
12 Dealing with the Most Difficult Situations in Abdominal Surgery 121

onset of this chapter, and they develop a severe in a very busy practice, it is easily forgotten that a
complication like a wound infection, even with patient who underwent a major surgical operation
questionable fascial integrity, we use any possible needs aggressive nutrition support.
imaging technique to avoid returning to the oper-
ating room, often causing significant delays in
dealing with the problem at hand. I cannot entirely Management for Fistulas
explain such a change in a surgeon’s behavior.
The basic treatment strategy for patients with One of the most important elements in the man-
acute postoperative wound dehiscence, severe agement of complex open wounds, with or with-
soft tissue infections, or simple wound infections, out fistula and/or stomas, is continuous wound
as well as of those with ECFs (and/or EAFs) care and reduction of the overall infectious bio-
include source control; proper antibiotic therapy; burden. Therefore, avoiding skin excoriations
electrolyte and fluid normalization; correction of from the bile salts, intestinal fluids, or stool is
coagulation factors and hemoglobin levels; essential. The vacuum-assisted closure (VAC)
achievement of hemodynamic stability; and pro- and proper stoma equipment have revolutionized
vision of nutritional support while patient under- wound care. However, collecting all the fluids
goes diagnostic or therapeutic interventions or from patients with large open abdominal wall
simply being observed for any reason. In the last defects (which we have termed “fistula city”)
few decades, the achievement of sepsis and source may prove extremely difficult. Controlling sep-
control has undergone significant changes [8]. sis, providing adequate wound care and tissue
coverage (native or biologic) of the abdominal
wall, and maintaining nutritional support will
Provision and Optimization result in patient improvement. They may eventu-
of Nutrition ally develop a major hernia that also needs to be
fixed at a later time, but at least they will be alive.
Initiating, maintaining, and optimizing the nutri- One major aspect of this surgical decision-
tion for patients with fistulas or other postopera- making process is the involvement of the patient
tive complications are not easy matters. Let us and their families in every aspect of care.
consider our patient with take down colostomy Remember, the patient is the main decision
again. Most of us have changed the practice when maker in this triangle consisting of the disease
we do straightforward colon surgery, and we no process, the patient and their family, and the sur-
longer leave a nasogastric (NG) tube in for 7 geon. We need to make sure that all work together
days, starving the patient until the gastrointesti- to both inform and empower the patient, while
nal function is returned postoperatively before we the surgeons are merely the advisers and
initiating oral or enteral nutrition. Yet, when we implementers of such decisions.
lyse adhesions, which seem to be almost 90 % of Factors that favor surgical treatment of a fis-
the time, we take down stomas and even if we do tula include high output and the presence of mul-
not leave an NG tube, we often will not advance tiple fistulas [1]. To reestablish intestinal
the feeding for days. continuity, the bowel segment giving rise to the
The patient from our example was barely fistula is resected, and some have recommended
started on a clear liquid diet by day 5. On the sixth long intestinal tube stenting of the entire small
postoperative day, she was not feeling well and bowel afterward [11]. The surgery for ECFs
now you receive the call on day 7. By this point, should be timed after sepsis has been addressed
the patient has developed complications and this and nutritional status has been improved. In order
process of starvation will be prolonged ever fur- to protect the surrounding skin from the caustic
ther. One has to remember that we should initiate effects of intestinal contents, the output of the fis-
and maintain nutritional therapy enterally or par- tula needs to be controlled [12]. For patients with
enterally throughout the hospitalization. However, an abdominal wound that cannot immediately be
122 R. Latifi and J.A. Stroster

closed and are at high risk for complications, a take her uterus out, but decided not to. I packed
vacuum-assisted closure (VAC) device can be the stoma site with gauze soaked in betadine and
utilized both pre- and postoperatively, and main- normal saline and put in four sutures for a delayed
tained on a continuous mode with a negative closure on day 5 or 6.
pressure from −75 to −125 mmHg. Dressings are She did well until postoperative day 4, when
to be changed every 2 days, and the use of such she developed a fever and a foul smelling wound.
devices reduces the number of required dressing The first thought that came to my mind was that
changes [7, 12]. For high-output ECFs, a 10-year the anastomosis has fallen apart. I ordered and
review of vacuum-compaction devices demon- arranged an emergency rectal contrast study and
strated that the treatment was effective in con- repacked the wound. About 1 h later, the contrast
trolling output among 89 out of 91 (97.8 %) study was normal and there was no leak from the
patients, with output being entirely suppressed recto-sigmoid anastomosis. I concluded it is just
within a week for 37 patients (40.7 %), and spon- a wound infection that can be treated nonopera-
taneous closure being achieved in 42 patients tively. The fascia at the stoma site felt good, and
(46.2 %) [2]. Knowing the anatomy of the fistula the sutures were still in place. But the smell: it
is also important to the surgeon as visualization was an awful smell.
of the complete bowel tract informs both the Later that evening, my partner called to tell
complexity of the fistula and also the length and that the patient has coughed vigorously, as her
quality of the remaining bowel [3]. The incidence tracheostomy was clogged—she had a tracheos-
of spontaneous closure for a fistula is greater tomy for many years due to some unclear immune
when there is a greater distance between the disease—with a mucus plug and she eviscerated
bowel and the skin; therefore, estimating the most of her intestines through midline incision.
length of the fistula is important when determin- He took her to the operating room, but was really
ing the course of treatment [7]. surprised when he found a necrotizing soft tissue
In summary, when one is dealing with diffi- infection of her stoma site and had to resect a
cult situations such as postoperative fistulas, the large portion of her left abdominal wall. I used
priorities are management of sepsis, nutritional the antibiotics perioperatively as recommended
optimization (including rehydration and electro- and packed the stoma site with betadine and
lyte correction), and wound care, while you pre- saline. I did not get any sleep that night. The
pare the patient for the definitive surgery. Sources patient underwent multiple debridements, skin
of sepsis should be identified and treated quickly coverage of the defect, wound VAC, and now is
by using appropriate radiological investigation awaiting repair of large abdominal defect, for
and culture of all potential sites of infection [7]. which she will need complex abdominal
reconstruction.

Necrotizing Soft Tissue Infections

The Disease
The Patient
Necrotizing soft tissue infections (NSTIs) are
I performed a take down colostomy on a 51-year- rapidly progressing conditions with high mortal-
old female in whom one of my partners did an ity, which include fasciitis, gas gangrene,
end colostomy for perforated diverticulitis. (I Fournier gangrene, or anaerobic myositis [13].
took over her care because she no longer wanted These life-threatening emergencies are usually
to deal with him after he advised her to stop caused by gas-forming bacteria that often spare
smoking and stop taking drugs!) This was a very the skin and underlying muscle and instead
low handsewn two layers anastomosis, but there involve the superficial fascia and subcutaneous
was a large uterus lying right on top of the anas- tissue [14]. Patients often first perceive a trivial
tomosis. I considered inviting the gynecologist to lesion (e.g., insect bite, boil, injection site) that
12 Dealing with the Most Difficult Situations in Abdominal Surgery 123

becomes a blue or purple spot and then melts that is produced by clostridial or polymicrobic
within a day, leaving a nearly black area that infections, they are of no value for other causes
spreads rapidly in expanding circles. They classi- of necrotizing infections [16]. Instead, computed
cally present with fever, signs of systemic toxic- tomography (CT) and more often magnetic reso-
ity, and severe pain that is disproportionate to the nance imaging (MRI) is being used [14, 18].
clinical findings [14–16]. Common risk factors
include diabetes mellitus, obesity, peripheral vas-
cular disease, chronic renal failure, intravenous The Management
drug use (particularly black tar heroin), alcohol-
ism, immunosuppression, and old age (>50 The aforementioned case example and data from
years) [15–17]. While the overall pathophysiol- our own clinical practice demonstrate that surgi-
ogy is common among all necrotizing infections, cal intervention within the first 6 h after diagnosis
the rate at which clinical symptoms develop is of NSTIs improves hospital outcomes in terms of
dependent upon the particular pathogen [15]. shortening both the hospital length of stay (LOS)
The U.S. Food and Drug Administration and intensive care unit (ICU) LOS [22]. In our
(FDA) excludes necrotizing soft tissue infections study, the overall mortality was 12.5 % (or
from therapeutic trials, and therefore current rec- 11/87), which is less than has been reported in
ommendations have been inferred from compli- many previous studies [13, 23–25]. Although
cated skin and soft tissue infections (cSSTIs) there was a clinically significant difference in the
[18]. Complicated SSTIs are generally classified mortality between the groups based on the timing
either by their anatomical site, microbial etiol- of surgical intervention (17.5 % in late vs. 7.5 %
ogy, or severity, with complicated cases being in early intervention group), this did not reach
those requiring surgery [14]. The management of statistical significance.
necrotizing infections normally involves a com- NSTIs, in particular necrotizing fasciitis,
bination of wound drainage, aggressive surgical remain the most deadly surgical infections if not
debridement, and antibiotic management adher- treated aggressively with resuscitation and surgi-
ing to empirical guidelines [14, 19, 20]. The cal debridement. Early diagnosis, early antibiotic
prompt recognition of NSTIs is essential, but in treatment, and early surgical debridement remain
their early stages they can be mistaken for cellu- the cornerstone of care for these patients. While
litis. However, a delay in treatment often means “early” has not been clearly defined, we believe
the difference between life and death for this that surgery in these patients should be performed
patient group [13, 16]. The patient can rapidly within the first few hours and no longer than 6 h
develop sepsis and/or multiple organ failure, [22]. In a study by McHenry et al., the mean time
which needs to be intensively corrected before from admission to operation was 45 h (range:
surgery can be performed, but if essential surgery 1.7–312 h), while average time from admission
is postponed for too long, there is a significant to operation was 90 h for non-survivors versus 25
increase in both morbidity and mortality [13, 18]. h in the survivors group (p = 0.0002) [26]. In our
Antibiotic therapy should initially be broad, as study, we found that patients with NSTIs required
the necrotizing infection may be the result of an operation as soon as possible and certainly no
multiple organisms, and targeted at the most later than 6 h after their arrival or presentation to
likely pathogen, but should then be quickly the emergency department. In fact, most of our
adjusted after culture and sensitivity laboratory early group patients underwent an operation even
results become available [20, 21]. earlier, within a mean time of 2.95 ± 1.1 h.
When attempting to diagnose the condition, In patients with NSTIs, the most common rea-
the presence of gas in the soft tissues is specific son for a delay in surgery is difficulty in making
for necrotizing infections and is more sensitive the correct diagnosis. Erythema, tenderness, and
than physical examination alone [18]. While swelling are all common. The clinical presenta-
plain radiographs may detect the presence of gas tion can be deceiving, particularly in immuno-
124 R. Latifi and J.A. Stroster

compromised patients, ranging from indolent Despite numerous scoring systems and mod-
wound infections to severe gangrene with septic els introduced to discriminate between NSTIs
shock, as defined with end organ failure requiring and non-necrotizing soft tissue infections, mak-
vasopressors despite adequate fluid resuscitation ing the diagnosis, predicting mortality and limb
[27]. Often patients seem too sick to be immedi- loss in NSTIs is still difficult [29, 30] and the
ately operated on, so clinicians will attempt to most important element remains early clinical
resuscitate them first, resulting in significantly recognition (Fig. 12.1a–d). Yet, there can be con-
delayed surgery or the clinical presentation is siderable diagnostic challenges when one is faced
deceiving, particularly in immunocompromised with “bad-looking” cellulitis and trying to distin-
patients [28]. However, one has to keep in mind guish it from NSTs. While we do not have a set
that source control of the infection is the priority protocol managing these patients, most patients
in the management of any critically ill patients. will get a CT scan or more commonly an MRI if
These patients should be treated with the same no clear clinical indication for surgery exists. As
urgency as a gunshot wound or any other major mentioned previously, on occasion, the patient
insult to the body. may get a plain film radiograph to rule out gas in

Fig. 12.1 (a) Neglected Fournier’s gangrene believed to patient in (a) and (b) proved to be not enough to save his
have been a “coffee burn.” (b) Aggressive debridement in life. (d) Incisional skin necrosis on an obese patient,
search for health tissue. (c) Right hip disarticulation on requiring major debridement
12 Dealing with the Most Difficult Situations in Abdominal Surgery 125

the tissue, but this is rare and it is useless for the there is still lack of a clear definition concerning
most part. As a rule, we use imaging techniques the exact definition of “early.” Therefore, together
more often to assure ourselves and the patient with future studies, our work may contribute to
that there is no immediate indication for an oper- the definition of early intervention. McHenry
ation. However, clinical exam remains the most et al. reported that early surgical intervention is
important (Fig. 12.1d) diagnostic method. associated with survival [26]. The mean time of
Laboratory test results in patients with NSTIs surgical intervention (interval between diagnosis
have been well studied by a number of authors. and surgical treatment) was 25 h in survivors. In
The Laboratory Risk Indicator for Necrotizing their study, other risk factors previously associ-
Fasciitis (LRINEC) scoring system has been ated with the development of NF did not affect
advocated to be helpful in distinguishing between mortality. Kobayashi et al. showed significantly
NSTIs and non-necrotizing soft tissue infections lower mortality in early intervention group [34].
[31], as well as in differentiating between severe In summary, early and aggressive emergency
and not severe NSTIs. However, in our study, we debridement of necrotic tissue is a life-saving
found that no single laboratory value indepen- treatment [15–17]. Enteral nutritional feedings
dently predicted early diagnosis of NSTIs. should be initiated as soon as possible to offset
Furthermore, a study of a small group of patients malnutrition, but parenteral nutrition support
strongly suggested that the LRINEC system is should be undertaken if more aggressive therapy
too insensitive for diagnosis of NSTIs [32]. is warranted after multiple debridements. If
Although hypoalbuminemia (<2 g/dL) is a known available, hyperbaric oxygen may be of benefit to
factor for postoperative complications, in our a hemodynamically stable patient with certain
study, the albumin level did not significantly dif- infections, particularly Clostridium species;
fer between our two groups (2.1 ± 0.7 vs. 1.9 ± 0.5; however, the evidence regarding the benefit for
P = 0.579). Our microbiologic findings were sim- its use in non-clostridial infections is weak [15].
ilar to those of other reported series and reflected
a wide spectrum of bacteria (data not published).
We believe that our rapid surgical treatment of Postoperative Anastomotic Leaks
our patients, once the diagnosis was estab-
lished—especially our relatively short time to One of the most dreaded complications of gen-
surgery—was the main reason for our low mor- eral surgery is the anastomotic leak following
tality rate. The overall reported mortality rate has small or large bowl resection. These postopera-
been reported to be very high (up to 72 %) if the tive anastomotic leaks are serious complications
patient does not undergo surgical debridement as of colorectal surgery, and, while their incidence
soon as possible. A median time to surgery of 8.4 is reported to be below 20 %, their associated
h had a relatively low mortality rate of 16.4 % mortality can be as high as 39 % [35, 36].
[23], while an interval >14 h from diagnosis to Advanced tumor stage, distal site (particularly
surgery in patients with septic shock was inde- with rectal tumors), and need for postoperative
pendently associated with in-hospital death [13]. blood transfusion have been independently asso-
Hyperbaric oxygen therapy for NSTI, despite ciated with increased rates of anastomotic disrup-
all its commercial activities, continues to be con- tion [35], and the rates of anastomotic dehiscence
troversial [33]. Our center does not have a hyper- are similar between open versus laparoscopic
baric oxygen chamber; so none of our patients techniques [36]. Those leaks that are diagnosed
with NSTI undergoes such treatment. Although through radiography, without any patient signs or
we have no experience with such treatment, we symptoms, are usually considered subclinical
believe that hyperbaric therapy may actually whereas clinical leaks present with signs of peri-
delay treatment of patients with NSTI. tonitis or septicemia [37]. While the periopera-
Evidence suggests that early surgical interven- tive management of anastomotic disruptions has
tion is crucial in reducing morbidity and mortal- improved in recent years, they are still a major
ity in necrotizing fasciitis (NF) patients. However, surgical challenge often resulting in sepsis,
126 R. Latifi and J.A. Stroster

reoperation, and increased length of hospital stay Hartmann’s procedure may minimize the possibil-
[35, 36]. The manner in which the patient presents ity of further abdominal catastrophe. Some sur-
will be determined by whether the anastomotic geons may instead opt to perform a re-anastomosis
leak is either intraperitoneal or extraperitoneal with a proximal section of bowel, but this should
[37]. An anastomotic leak may present early and only be attempted in those patients who are asep-
dramatically, or more subtly and later in the post- tic, well-nourished, and do not suffer from inflam-
operative period, making them difficult to distin- matory bowel disease. In this situation, our
guish from other infectious complications [38]. preference is to divert the patient, either totally or
The decision of how to approach this poten- using some sort of loop diversion. Regardless of
tially catastrophic complication is not entirely the technique, a tension-free anastomosis is a
straightforward. For patients with previous surger- must. While others suggest the use of drains [37],
ies and intestinal resection and/or obese patients, this is not our practice.
an anastomotic leak may be lethal if not recog- If the intraperitoneal leakage is instead accom-
nized immediately. Patients with intraperitoneal panied with localized peritonitis or abscess, a
leaks with clinical generalized peritonitis or high- diagnostic imaging workup using computerized
grade sepsis require immediate surgical interven- tomography (CT) scan of the abdomen and pelvis
tion after receiving appropriate resuscitation [37]. should be performed (Figs. 12.3 and 12.4); CT
If there is evidence of ischemia at the site of anas- scanning appears to be far more helpful than con-
tomosis recognized following the anastomosis, it trast enema in diagnosing a leak [38]. If a large
should be redone immediately (Fig. 12.2), other- abscess or multiple abscesses are noted, then the
wise it will leak and cause significant morbidity patient should be managed surgically as described
and mortality if not corrected before the abdomen before if the site of the abscess is inaccessible for
is closed. When there is significant peritoneal con- draining. However, if the abscess is small (<3
tamination or if the anastomotic defect is large, cm), broad spectrum intravenous antibiotics are
the patient should undergo a resection of the anas- recommended instead [37]. Distinguishing an
tomosis with the formation of an end stoma [37]. anastomotic leak from a postoperative abscess
If the leak is at the sigmoid colon or rectum, a can be difficult [38]. Occasionally, following
Hartman’s procedure, closure of the rectal rem-
nant may prove challenging.
The basic principles of patient management
are similar to fistulas management for the most
part. At times, surgeon may get “too close” to the
patient and family over the long course of their
care and it may be really beneficial to have a
partner look after the patient for a while. This is
not an abandonment of the patient, but simply
taking a “break” to gain some perspective, and
later approach the case more objectively to pre-
vent a potentially catastrophic event.

Intestinal Ischemia

Fig. 12.2 An 84-year-old female underwent proximal Every general surgeon has had a memorable case
small bowel resection for spontaneous perforation due to of intestinal ischemia, either because s/he missed
severe hemorrhagic necrotizing pancreatitis. Ischemia of
the diagnosis altogether or simply intervened too
the one side of the anastomosis was recognized intraop-
eratively and resected. Ischemic segment lies superiorly late (Fig. 12.1a–d). Intestinal ischemia, particularly
to the anastomosis for illustration acute mesenteric ischemia (AMI), is a complex
12 Dealing with the Most Difficult Situations in Abdominal Surgery 127

Fig. 12.3 Post operative leak

following sigmoid resection and
primary stapler anastomosis in a
patient with gunshot wound to the
pelvis

Fig. 12.4 Abdominal catastrophe

following total colectomy with
spontaneous perforation of small
intestines

problem still commonly faced by general sur- systemic coagulation disorders). All these etiolo-
geons. Despite decades of treatment advance- gies can lead to intestinal hypoxia, irreversible
ments, AMI still has a high risk for complications bowel damage, and potentially death [39].
and a mortality rate upward of 60 % [39]. Patients The blood supply to the intestines is mainly pro-
are typically elderly, with clinical histories con- vided by three large vascular systems stemming
sisting of atrial fibrillation, recent myocardial from the abdominal aorta: the superior mesenteric
infarction, congestive heart failure, or other risks artery (SMA), the inferior mesenteric artery (IMA),
for superior mesenteric artery (SMA) embolism and the celiac axis. Arterial emboli are more com-
[40]. There are a number of underlying causes for monly localized in the SMA due to its wider angle of
AMI, but arterial thrombosis is the most common origin compared with the celiac artery and parallel
pathophysiology, accounting for about half of the course to the abdominal aorta [39]. The SMA and
cases [40]; other causes include arterial or venous celiac axis systems communicate via the gastrodu-
thrombosis, and non-obstructive causes (such as odenal artery and pancreaticoduodenal arcades at
128 R. Latifi and J.A. Stroster

the pancreatic head region, and, since routine pan- sions as well as the consequences of the intestinal
creaticoduodenectomy (PD) involves resection of hypoxia; in situations where it is not available,
these branches, ischemic complications may also mesenteric angiography or duplex ultrasonogra-
arise in this patient group [41]. phy can be utilized [39, 40].
Timely diagnosis is critical to prevent isch- Particularly difficult is the situation of a
emic complications and improve odds of sur- patient with multiple abdominal surgeries, requir-
vival; however, the diagnosis of patients with ing significant amounts of pain medication.
AMI can be difficult, as the abdominal pain is When these patients develop ischemia, it is diffi-
often accompanied by nonspecific symptoms cult to discern pain associated with ischemia
such as fever, vomiting, diarrhea, and loss of from their “usual pain.” Such an example is an
bowel sounds. Therefore, the patient’s history is obese patient with multiple previous abdominal
important to consider, particularly if he or she is operations and large ventral hernia, who pre-
elderly and has cardiovascular or peripheral vas- sented with the exacerbation of the abdominal
cular disease [39]. Computerized tomography pain, which turned out to be intestinal ischemia
(CT) scan is both highly sensitive and specific for due to thrombosis of SMA (Fig. 12.5a–c).
diagnosing AMI and can visualize both the occlu-

Fig. 12.5 (a) CT scan demonstrating a large thrombus in superior mesenteric artery. (b) Same patients as in (a). Giant
hernia and “frozen” abdomen from multiple operations. (c) Intraoperative view of intestines of patient in (a) and (b)
12 Dealing with the Most Difficult Situations in Abdominal Surgery 129

Fig. 12.6 Super obese patient with

giant hernia undergoing emergency
surgery from Fig. 12.1d

Surgical exploration is warranted for all we are expected to deal with situations that often
patients who have any evidence of threatened are very difficult. However, when we face a com-
bowel, such as suspected mesenteric ischemia plicated patient, either during reoperative surgery
and signs of peritonitis, regardless of its cause. (when others have operated beforehand) or for
These patients are at high risk for irreversible when your patient’s postoperative course gets
bowel infarction and abdominal sepsis and bowel truly complicated, then things get difficult on
that is approaching irreparable necrosis can more than one level. They are personal failures.
seem normal in appearance. In contrast, bowel These personal complications sometimes make it
that may appear necrotic may be viable after difficult to return to the operating room, but one
revascularization. For these reasons, the priority has to do it and start the fight again. One thing is
of the surgeon should be to reestablish vascular- very certain: we are operating more and more on
ization and then reassess the viability of the super obese patients that have ignored clinical
bowel (after perhaps 20–30 min) before making problems (Fig. 12.6) or have been passed from
decisions about intestinal resection. one surgeon to another surgeon until it becomes
an emergency situation. These patients represent
some of the most difficult cases that we deal with
Conclusion in general surgery. Furthermore, as patients are
kept alive in various ways, such as complex heart
Dealing with really difficult situations in general and lung machines, they will develop decubitus
surgery is challenging and requires a thoughtful that, if not treated early and appropriately, may
and meticulous approach, yet expeditious action. develop into necrotizing soft tissue infections
The worst thing that we can do is rush into a deci- that goes beyond any possibility to salvage such
sion that we cannot come back from yet it is also patients (Fig. 12.7a–c).
critical, not to become paralyzed with the fear of
failing or having complication. Fistulas, necrotiz-
Acknowledgments There are no identifiable conflicts of
ing soft tissue infections and intestinal failure are interests to report.
all dramatic and can have significant mortality if The authors have no financial or proprietary interest in
not addressed appropriately. As general surgeons, the subject matter or materials discussed in the manuscript.
130 R. Latifi and J.A. Stroster

Fig. 12.7 (a) Decubitus over the upper back in a patient on an artificial heart. (b) Postoperative view at the completion
of aggressive debridement on patient in (a). (c) Neglected sacral decubitus on the same patient

4. Latifi R, Peralta R, Al Thani H. Surgery of complex

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 Trauma Surgeon Decision-Making:
Surviving Outside the Realm 13
of the Evidence Based

Samir M. Fakhry

Epigraph and found to have several areas of sub-arachnoid

hemorrhage (SAH) without midline shift. He was
A 65-year-old male is involved in a single-vehicle admitted to the ICU for management.
high-speed motor vehicle crash approximately
45 min before he was brought to trauma center.
He was an unrestrained driver and went off the Introduction
road striking a tree head-on. He was found unre-
sponsive with a GCS of 5 and shallow respira- Trauma surgery is inherently a decision intense
tions. The EMS team immobilized him, assisted specialty. In caring for injured patients, trauma
his breathing with bag-valve mask, and brought surgeons make impactful decisions on a nearly
him promptly to the trauma center as high-level constant basis. Decision-making is not a homo-
trauma activation. On arrival, the trauma team geneous process with a single pathway that is
performed rapid sequence intubation and initi- universally recognized as optimal. By its
ated ATLS resuscitation. His initial BP was 85 nature, surgical disease, and especially injury,
systolic and he initially responded to initial resus- requires a broad repertoire of decision-making
citation. A CXR showed a 30 % left-sided pneu- skills as differing clinical situations require
mothorax and a chest tube was inserted with differing approaches (temporally and in terms
return of air and 150 mL of blood. He became of process).
hypotensive again 10 min later. FAST exam Rarely are all the “necessary” data and “ade-
showed free fluid in the abdomen and because his quate” time available to weigh options. Trauma
BP was improving slowly he was taken to CT surgeons are thus subjected to high-stakes
scan where a ruptured spleen was identified. The decision-making throughout their careers and
rest of the body was not scanned and he was probably self-select for a certain comfort with
taken to the OR for exploration. A splenectomy uncertainty and “pattern recognition” as opposed
was rapidly performed and his BP stabilized with to the more traditional scientist phenotype. In
three additional units of pRBCs. Postoperatively, some ways, this is similar to the difference
he was taken for CT scan of his head and neck between a fine restaurant’s head chef (who relies
on experience, palate, and the learned taste of
particular combinations of ingredients) and its
S.M. Fakhry, M.D., F.A.C.S. (*) pastry specialist (who is committed to precision
Department of Surgery, Medical University of South recipes and exact formulations).
Carolina, 96 Jonathan Lucas St, CSB 426 MCS 613,
Charleston, SC 29425, USA There has been little if any research into how
e-mail: fakhry@musc.edu trauma surgeons make decisions and deal with the

© Springer International Publishing Switzerland 2016 133

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_13
134 S.M. Fakhry

dual pressures of incomplete data and pressing application of the ill-defined skill set of rapid
timelines. It is also unclear whether recent decision-making without adequate data.
advances in diagnostic technology have resulted The example of ATLS is only one of many
in fundamental changes in how trauma surgeons applicable to decision-making in trauma care. This
make care decisions. Although there are increas- chapter will attempt to provide an overview of
ing calls to apply evidence-based practice to clini- some of the theoretical constructs proposed for
cal care, the relative paucity of methodologically modeling decision-making, incorporate a brief
robust and statistically valid studies to guide sur- review of the evolution of modern trauma decision-
gical care makes it unlikely that the majority of making, and incorporate personal viewpoints of
decisions in trauma care can be guided by high the author as a practicing trauma surgeon.
quality data [1–6]. At least one published study
goes further and suggests that due to inherent
bias, most study results are in fact false [7]. As a Decision-Making as a Science?
result, the care of the trauma patient is often
guided by consensus guidelines and widely In addition to drawing on the literature and their
accepted (if not well supported) algorithms and accumulated experience, trauma surgeons may
protocols. This is especially apparent in the early refer to “pattern recognition,” “fuzzy logic,” and
care of the acutely injured patient where the other techniques that they utilize to make clinical
Advanced Trauma Life Support (ATLS) course of decisions often under difficult conditions while
the American College of Surgeons is the de facto caring for the acutely injured and/or critically ill.
standard not only in the United States but also In some areas of clinical care, a deliberate, step-
around the world. Although ATLS has had a major by-step process may be successfully employed
impact on trauma care by standardizing early care (Fig. 13.1): identify the decision to be made,
of the injured patient, evidence of improved out- gather relevant information, identify alternatives,
comes remains elusive [8–10], leaving significant weigh evidence, choose among alternatives, take
opportunity for the exercise of judgment and the action, review decision and consequences. Such

Review the Decision

7
Take Action
6
Choose
From Alt
ernative
s 5
Weigh
the Ev
idence
Iden
tify t
4
he A
ltern
ative
s
Gat
her
Info
3
rma
tion
Ide
ntif
y
To the D
Be e
2
Ma cision
de
1

Fig. 13.1 Decision-making model. (Used with permission from the University of Massachusetts Dartmouth at http://
www.umassd.edu/fycm/decisionmaking/process/)
13 Trauma Surgeon Decision-Making: Surviving Outside the Realm of the Evidence Based 135

a deliberate process is not usually possible in the Formalized Pattern Matching

care of the acutely ill and injured, and a variety of
methods to shorten the cycle of deliberation and Formalized Pattern Matching (FMP) is a com-
action are needed. monly utilized decision-making technique in
Although most trauma clinicians are not well clinical medicine. It consists of grouping data
versed in the theoretical constructs of decision- and observations into recognizable subsets (e.g.,
making and more than a few regard their work as hypotension, lactic acidosis, tachycardia suggest-
much an art as a science, there is a substantial ing shock). Pattern matching is then used to
body of clinical research in this area. In a very select particular characteristics (called “pivots”)
approachable review of decision-making, Stiegler of the case in question that seem important, are
and Tung [9] describe commonly accepted theo- unique, or do not fit the pattern. The clinician
ries of decision-making and comment on the uses “pivots” to ignore or amplify particular
impact of heuristics, bias, and nonrational factors diagnostic choices thus narrowing the options
that influence decision-making. being considered. The process proceeds as addi-
tional data or new observations are added until a
final option is selected. When using FMP, “cog-
Expected Utility nitive shortcuts” are used preferentially over sta-
tistical probability as in EU or BP. Clinicians
The Expected Utility (EU) model suggests that a who are more experienced are thus more likely
decision maker considers the expected benefit of to employ and benefit from FMP as they are more
each choice (its probability x its payoff) and likely to have encountered the “patterns” and rec-
selects the one with the superior expected value ognize the “pivots.” These experienced clinicians
(EV = probability × payoff). This model assumes will thus have a “mental library” of recognizable
knowledge of the probabilities and payoffs of all patterns to draw on and they can accelerate
choices and is rarely applicable in its purest sense decision-making through these “cognitive short-
in the real world. The 1978 Economics Nobel cuts.” Although generally quite effective, this
Laureate, Herbert Simon, proposed a variation technique can lead to erroneous diagnostic deci-
wherein “good enough” solutions replaced ideal sions because of inherent biases and minimal
ones if the effort of obtaining the needed infor- reliance on statistical probability.
mation was significant, and measurable “sub-
goals” took the place of goals that were more
difficult or impossible to determine [11]. Heuristics

Heuristics are cognitive shortcuts (also referred

Bayesian Probability to as “decisional shortcuts”) utilized to decrease
the cost of decision-making even though they
Bayesian Probability (BP) begins with a similar may violate logical concepts and objective data
setup as EU, calculating the expected outcome of [12, 13]. Stiegler and Tung [1] illustrate the use
each of the choices. It then allows new informa- of heuristics with a classic example: a group of
tion from diagnostic testing, treatment, and dis- college students are asked whether a meek, tidy
ease progression to influence the decision-making man who loves books was a librarian or a sales-
process. By making frequent course adjustments man. Most choose “librarian” despite the fact that
in response to incoming information, the quality there are statistically few male librarians and
of the decision-making process is improved. many male salesmen. Occam’s Razor and the
Although favored in many domains, BP suffers idiom “If it looks like a duck and walks/quack/
from the same limitations that plague EU in clini- flies etc. like a duck, it is a duck” are examples of
cal settings: both assume some knowledge of all heuristics and inductive reasoning where effi-
relevant outcomes and their individual merits. ciency in making a decision is chosen over actual
136 S.M. Fakhry

data. Heuristics are useful when dealing with diagnostic information but was associated with
complex clinical scenarios with incomplete data- many nontherapeutic laparotomies. Current
sets, but may not always lead to correct choices approaches, on the other hand, involve procuring
because of the inherent biases they may be based maximal amounts of data on patients before ther-
on. apeutic decisions are made and has resulted in
Stiegler and Tung also describe more recent new problems of missed injuries such as blunt
theoretical models such as dual process reason- small bowel perforation [21]. In addition, some
ing which is a hybrid of EU and heuristic models centers have extended the concept of increasing
[1]. In addition, they review other cognitive, baseline diagnostic data to the point of advocat-
emotional, cultural, and environmental factors ing CT scan even for some unstable patients [22].
that affect decision-making (Table 13.1). One possible explanation for this change in
approach is the routine availability of advanced
diagnostic tools, primarily CT scan. Another
Evolution of Trauma Surgical plausible hypothesis is that the decision-making
Decision-Making approach employed in the 1980s and early 1990s
of necessity more closely approximated the con-
Over the past three decades, there has been sig- cepts of “pattern recognition” inherent in FPM
nificant evolution in the way trauma care is deliv- and required the use of heuristics and associated
ered. The broad introduction of computerized “shortcuts” given the relative paucity of baseline
tomography (CT) technology in the 1980s pro- data and urgent/emergent timelines. With the
moted the transition to nonoperative care [14], explosion in diagnostic medical technology over
evidence-based medicine began to replace expert the past half-century, most specialties have
opinion and apprenticeship models, previously become highly reliant on these technologies to
irrefutable standards such as colostomy for all improve diagnostic accuracy and perhaps out-
gunshot wounds of the colon [15] and the 10/30 comes. The perceived availability of extensive
rule for transfusion were toppled [16, 17]. The baseline data may have the effect of changing the
management of liver injury is a good example of manner in which physicians are making deci-
how decision-making in trauma care evolved sions, making techniques such as the step-by-step
over the years. As a surgical intern in the early approach, EU and BP more feasible. Although
1980s, I was taught that all patients with blunt or trauma care still requires more rapid decisions
penetrating liver injuries had to undergo explor- than other specialties, the CT scanners on which
atory laparotomy. As a university trauma surgeon we rely have become exceedingly fast and nearly
at a busy level 1 trauma center nearly 30 years universally available. It may be that the tempta-
later, I have not performed a major liver repair in tion to “know more” and the perception that the
the past academic year and our graduating chief time delay is relatively minor is changing the
residents have performed many more Whipple’s way trauma surgeons approach decision-making
procedures than they have major liver repairs for and narrowing the difference between decision-
trauma. This is in keeping with trends in nonop- making in the acute/emergent setting and that of
erative management at nearly all centers [18] but the elective setting.
also reflects the dramatic change in trauma surgi- As we review various decision-making
cal decision-making that has occurred in my approaches and the utility of increasing baseline
career. Perhaps most interesting is the paradigm data through diagnostic technology, the question
shift from operating on large numbers of injured, of error rates in decision-making should be con-
frequently stable patients to a near reluctance to sidered. Since the Institute of Medicine report
operate on patients without completing a diag- “To Err Is Human: Building a Safer Health
nostic work-up that includes “pan CT scan.” [19, System” was published, increased attention has
20] The former approach may have been neces- been focused on medical errors [23]. The Harvard
sary in an era of limited availability of specific Medical Practice Study identified adverse events
13 Trauma Surgeon Decision-Making: Surviving Outside the Realm of the Evidence Based 137

Table 13.1 Nonrational cognitive factors that influence decision-makinga

Cognitive influence Explanation
Representative Diagnosing or identifying by the degree of resemblance to preexisting or “classic” mental
heuristic models
Availability Diagnosing or identifying by resemblance to previous, highly memorable, events, “memorableness”
heuristic May be induced by an emotionally charged past experience (usually negative), media
attention, legal action, peer review “morbidity and mortality” conference, or other novelty
Anchoring/ 1. Insufficient adjustment from an initial assessment of a value or a state. “Anchoring” on
fixation/“tunnel the starting point can bias subsequent estimates
vision” 2. Focus on a single feature of a case or event exclusively, at the expense of considering
other aspects of the case. This may include task fixation, such as troubleshooting of an alarm
at the expense of maintaining situation awareness
Retrospective Tendency to view events that have already occurred differently once the outcome is known
biases 1. Hindsight bias: Tendency to view events as having been more predictable, and thus
actions more correct or incorrect, than was apparent as the situation was unfolding
2. Outcome bias: Favorable (if the outcome is good) or unfavorable (if the outcome is bad)
assessments of judgments, regardless of actual decision quality. (Example: drunk driver who
arrives home safely rationalized that he made a “good choice”—which is obviously incorrect)
Confirmation bias A tendency toward only seeking (or only “seeing”) information that supports a diagnosis or
hypothesis, rather than information that refutes it
Visceral Visceral bias describes the tendency to allow feelings about a patient to affect care decisions,
(transference) bias as with a “VIP patient,” a victim of trauma, or a “high-maintenance” patient
Omission bias Tendency toward inaction rather than action, out of fear of causing harm (to patient, if action
failed; to self, by damaging professional reputation if wrong). May be especially likely when
a significant authority gradient is perceived or real
Bias blind spot A flawed sense of invulnerability to bias; may be more prominent among cognitively
sophisticated and highly intelligent
Overconfidence Inaccurately high self-assessment with regard to positive traits. Can refer to medical
knowledge, certainly regarding diagnosis, technical abilities, and situational assessment
Memory shifting/ Failure to accurately recall information. Occurs due to meaning and verbatim information
reconstruction being coded differently, and results in “filling in” details (sometimes misinformation) when
memories are recalled. Also called “memory reconstruction error”
Preference for Human preference for certainty over risk, even at the expense of sacrificing a greater expected
certainty value (i.e., calculated via expected utility theory)
Framing A schema of interpretation that changes perception without altering facts. Equivalence
framing refers to the interpretation of the same set of data as either a gain or a loss. Emphasis
framing focuses on a subset of selected data to match an event or explanation
Loss aversion Tendency for humans to view a loss as significantly more psychologically powerful than a
gain of the same amount
Affect (emotion) Emotional influences on decision behavior
Anger Anger describes the tendency for angry or disruptive behavior to influence the decisions of
oneself or others
Regret Regret describes the tendency to allow regret for previous decisions to affect future ones. Anticipated
regret is the desire to avoid regret from future consequences or outcomes of decision choices
Feedback bias Significant time elapses between actions and consequences; lack of outcome data reporting.
Absence of feedback is subconsciously processed as positive feedback
Commission bias Tendency toward action rather than inaction, even when those actions are unindicated or
founded on desperation. This is the “better safe than sorry” mentality of adding additional
invasive monitors, central venous access, or liberal blood transfusion. Backfires when those
actions have untoward effects
VIP: very important person as with a celebrity, personal friend, or high-level executive
Used with permission from Stiegler MP, Tung A. Cognitive processes in anesthesiology decision making.
Anesthesiology. 2014;120:204–17
a
Table is not intended to be exhaustive
138 S.M. Fakhry

in 3.7 % of 1984 hospitalizations in New York with severe injury requiring high-level trauma
State using standardized chart review. The most care. Although this is not always true and some
common adverse events were drug complications of these patients are “over-triaged,” the lack of
(19 %), wound infections (14 %), and technical complete baseline data and the time constraints
complications (13 %) [24]. Diagnostic mishaps are best dealt with by adopting the “cognitive
and events in the emergency department (ED) shortcut” of transporting all such patients to a
were among adverse events due to negligence level 1 trauma center. On arrival, the patient
[25]. More recently, an expanded definition has undergoes ATLS-based resuscitation and is
yielded an error rate as high as 11.2 % [26]. intubated almost immediately. Waiting to
Error rates in trauma care have been studied secure the airway until comprehensive data are
and provide some insights. Introduction of available would likely be detrimental so once
trauma centers and trauma systems has been again a heuristic is employed: standardized
associated with a decrease in mortality especially management without adequate data sacrificing
preventable mortality [27–29]. It is less clear diagnostic precision for decreased mortality.
what aspects of the systematic application of Although the patient may be intoxicated with-
trauma care provide the improvements in out- out major injury and may not necessarily
comes detected in such studies. A report from the require intubation, it is unlikely that a trauma
San Diego trauma system pointed out an addi- team employing ATLS principles would choose
tional interesting observation: complication rates not to intubate him under these circumstances.
in a mature trauma system leveled off at a low but A chest radiograph is routinely performed
finite level and further improvements would because of historical data suggesting that pneu-
require novel enhancements to process and qual- mothorax is one of the lethal situations in
ity methodology [30]. The role physician injured patients. The patient is a “transient
decision-making plays is not clear and may rep- responder” and in most cases would be taken to
resent opportunity for additional investigation. A surgery for the combination of the positive
novel analysis of trauma resuscitation process FAST exam and hypotension. The lack of an
errors using a computer-base system validated by exact anatomic diagnosis in this setting would
trauma experts found that process errors were be of no great import because of the hemody-
ubiquitous in the 97 cases of penetrating trauma namic instability. This is in contrast to the elec-
studied [31]. Errors of commission were twice as tive surgery scenario where much more time is
common as errors of omission and of greater spent on diagnostic work-up and considering
severity. Interestingly, the greatest number of the pros and cons of various options. Finally, it
errors was related to the failure to record and per- has generally been the case that the trauma
haps observe relevant bedside information. patient is not involved in care decisions under
Although the errors were not usually related to these circumstances.
adverse outcomes, this analysis points out that As this case illustrates, the current state of
errors of reasoning may be more common than is decision-making in trauma surgery consists of
generally appreciated. making do without either comprehensive baseline
data or the luxury of enough time to gather needed
information. In addition, the quality of the evi-
Conclusion dence supporting much of what trauma teams do
is moderate at best and comprehensive follow-up/
In the case study presented at the beginning of loop closure is not always available to guide
this chapter, trauma decision-making is accom- improvement efforts. Although consensus guide-
plished in a variety of ways. Triage of the lines and algorithms are helpful, trauma surgeons
patient to a Level 1 trauma center occurs based must still make decisions on a regular basis with-
on pattern recognition: high-speed crash, coma, out the benefit of a full dataset and under time
and respiratory distress are generally associated pressures. It is likely that we will continue to see
13 Trauma Surgeon Decision-Making: Surviving Outside the Realm of the Evidence Based 139

further changes in how trauma surgeons make 16. Hebert PC, Wells G, Blajchman MA, et al. A multi-
center, randomized, controlled clinical trial of trans-
decisions and in the care protocols they utilize.
fusion requirements in critical care. Transfusion
There is an important opportunity to study not requirements in critical care investigators, Canadian
only injuries and proposed treatments but also the Critical Care Trials Group. N Engl J Med.
ways in which trauma surgeons make decisions 1999;340:409–17.
17. Vaziri K, Roland JC, Robinson LL, Reines HD,
and the consequences of those decisions.
Fakhry SM. Extreme anemia in an injured Jehovah’s
witness: a test of our understanding of the physiology
of severe anemia and the threshold for blood transfu-
sion. J Trauma. 2008;67:E11–3.
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 Management of the Most Difficult
Perioperative and Technical 14
Challenges in Abdominal
Transplantation

Chirag S. Desai, Yong Kyong Kwon, Mark R. Laftavi,

Vaughn Whittaker, and Rainer W.G. Gruessner

types of surgical challenges in the operating room:

Introduction expected and unexpected encounters. Expected
challenges include typical technical complications
Transplant surgery is one of the most challenging such as bleeding, graft vascular thrombosis,
surgical subspecialties because it requires a com- anastomotic leaks, or anastomotic strictures.
prehensive clinical knowledge about the patient’s Unexpected challenges include unforeseen condi-
underlying disease and comorbidities, a detailed tions that were not present on previous imaging
understanding of the indications to surgery in studies (e.g., recent portal or iliac vein thrombosis)
transplant recipients and superb technical skills or unknown anatomical variants that prevent the
to successfully perform even the most complex execution of a standard procedure. This chapter
transplant procedures with the highest level of focuses on exactly these types of unusual or
efficiency and accuracy. Because of this com- unforeseen conditions and technical challenges:
plexity, most multiorgan transplant surgeons are they can occur not only intraoperatively but also
well trained in a wide array of general, vascular, immediately pre- and posttransplant.
gastrointestinal, hepato-pancreatico-biliary, and
pediatric surgery as well as urologic procedures.
Technically extremely difficult situations can
arise during transplant procedures that not only
Pretransplant Challenges
require technical mastery but also a high degree of
The first challenging situation can arise when the
flexibility and adaptation. In general, there are two
potential recipient gets admitted to the hospital
after the transplant team members are already left
C.S. Desai, M.D. • Y.K. Kwon, M.D. for the organ procurement. It is not unusual that
Medstar Georgetown University Hospital, Medstar the potential recipient is admitted in the middle of
Georgetown Transplant Institute, the night when there is not a senior house staff
3800 Reservoir Road NW, 2 PHC Building,
Washington, DC 20007, USA available to evaluate the transplant candidate.
e-mail: Chirag.s.desai@gunet.georgeown.edu; Thus, once the surgical team has left for the pro-
Yong.k.kwon@gunet.georgetown.edu curement of the donor organs, there may not be a
M.R. Laftavi, M.D. • V. Whittaker, M.D., F.A.C.S. team member available with appropriate experi-
R.W.G. Gruessner, M.D. (*) ence to evaluate the potential recipient. Most
Transplant Center and Department of Surgery, transplant candidates often times have been eval-
Upstate Medical University, 750 E. Adam Str.,
Syracuse, NY 13210, USA uated long back regarding, for example, their car-
e-mail: whittakv@upstate.edu; gruessnr@upstate.edu diovascular status. Upon arrival to the hospital,

© Springer International Publishing Switzerland 2016 141

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_14
142 C.S. Desai et al.

the particular candidate may present with a new taken to the operating room and the organ does
set of cardiac problems or outdated previous stud- not go to waste.
ies to safely take the patient to the operating room Other pretransplant challenges can arise during
in light of the candidate’s most current condition. the induction of anesthesia. For example, after
Aside from new cardiovascular issues, transplant placing a Swan-Ganz catheter in a liver transplant
candidates may also have developed recent infec- candidate with pulmonary hypertension, the
tions. To avoid these kinds of situations that may patient’s pulmonary pressure can be so high that
result in the delay or even cancellation of the despite all efforts to lower it, the candidate is con-
transplant procedure only after the potential can- sidered unsuitable for transplant at this time [1–3].
didate has been admitted to the hospital, the trans- Although in such cases the transplant procedure
plant coordinator should call up a potential has to be cancelled after the patient has been under
candidate early in the process and go over his/her general anesthesia (but still before the incision is
medical history before the candidate is asked to made), it emphasizes the need to admit a backup
come in and gets admitted. The availability of candidate until the actual transplant procedure is
modern electronic medical record systems and started. In case a high-risk candidate is scheduled
integrated health data from multiple visits at mul- to undergo the transplant, it may also be prudent, if
tiple places allows the transplant coordinator to possible, to have a second operating room ready
review all pertinent and current information with and available in order to continue with backup
the physician team members, specifically with the candidate swiftly without wasting OR turnover
recipient surgeon regarding the potential candi- time. The former approach clearly decreases cold
date’s medical and surgical suitability for trans- ischemia time and improves outcome.
plantation. All this should be completed before Liver transplant candidates with a high MELD
the potential candidate walks into the hospital. score can go into sudden cardiovascular instabil-
Despite these preadmission precautions, the ity under anesthesia. Based on the patient’s con-
admitting physician(s) may still diagnose medi- dition, it is up to the attending anesthesiologist
cal conditions that may make the potential candi- and the lead surgeon to determine if the proce-
date unsuitable for the transplant procedure based dure should continue, cancelled, or be aborted.
on H&P, chest X-ray, EKG, lab results, imaging It is not uncommon for high MELD score
studies, etc. Although most potential candidates patients to have concurrent renal failure.
have been on the waiting list for a long time and Specifically liver transplant candidates that are
are very anxious to undergo the transplant proce- already on dialysis may require a simultaneous
dure, it is in their best interest as well as in the liver and kidney transplant [4, 5]. These patients
best interest of optimal donor organ usage and are at a higher risk for intraoperative volume fluc-
recipient outcome to cancel the transplant for a tuations and imbalances, hyperkalemia, the devel-
particular candidate due to new and serious medi- opment of cerebral edema, etc. All these
cal conditions that would not allow safe perfor- complications increase in turn the risk for cardiac
mance of the transplant procedure. Under such events such as atrial fibrillation, ventricular arrhyth-
circumstances it is best to contact and, following mias, etc. Patients with hepato-renal syndrome
an appropriate health evaluation on the phone, to should therefore undergo dialysis pretransplant or
bring in the next candidate on the waiting list. If be placed on controlled continuous veno-venous
serious health conditions are only diagnosed dur- hemodialysis (CVVH) during surgery to better
ing the actual transplant procedure, the conse- regulate their fluid status and balance.
quences can be disastrous for both patient and In kidney and pancreas transplant candidates,
surgeon. However, if recent and serious medical diabetes and hypertension are not only the most
conditions preclude the primary candidate from common causes of end-stage renal disease, but
undergoing the transplant procedure, the backup also the reasons for unexpected perioperative
candidate without losing precious time can be cardiac events. In case of a high-risk kidney
14 Management of the Most Difficult Perioperative and Technical Challenges… 143

transplant candidate it is prudent to also do a (SBP) and extrahepatic metastases or tumors.

crossmatch in a backup candidate so that several Imaging studies may not reveal the true extent of
suitable transplant candidates are identified so the inflammatory changes in SBP patients or may
that the transplant can be done safely and the not be recent in patients with liver or intrahepatic
donor organ does not go to waste. bile duct malignancies.
A very unusual situation arises when the trans- In patients with a history of multiple episodes
plant candidate is put under anesthesia and the of SBP, the whole visceral peritoneum is usually
donor team recognizes major issues with the donor thickened and cocooned, making it extremely
graft that makes a transplant for technical or qual- difficult to identify the proper planes. In general,
ity reasons impossible or increases the risk of graft there are only two options under these circum-
failure substantially. In that case, the transplant stances. The first one, in patients without exces-
candidate who underwent anesthesia without sub- sive portal hypertension, is to identify the hilum
sequent surgery needs to be counseled frankly on after careful surgical dissection, to clamp the
all the issues, specifically on the ramifications of whole hilum en-mass and to then transect the
undergoing a transplant with a suboptimal donor whole hilum as close to the liver as possible. The
organ. Such situations should be included in the longer the main structures (portal vein, hepatic
consenting process that there is always a chance artery, bile duct) are behind the vascular clamp,
that they may undergo anesthesia without a subse- the better for the following dissection and con-
quent transplant if the donor or the donor organ struction of the anastomoses. Because of the
turn out to be bad. This emphasizes the importance “frozen” abdomen and liver in SBP patients, the
of obtaining the patient’s consent directly by a cava also needs to be resected en-mass along with
transplant surgeon rather than a resident surgeon the liver and an orthotopic transplant should be
who is not aware of all the transplants intricacies. performed. The piggyback technique (leaving the
Finally, in preparation for transplantation, it is native cava in place) can rarely be employed in
recommended in all liver and some multivisceral patients with recurrent bouts of SBP. The second
transplant candidates, to prep the patient’s axilla option is to abort the transplant before vital struc-
and groin areas as well in case unexpected veno- tures are transected, wait for several weeks for
veno bypass is required or recipient vein grafts are the sclerosis to abate and ensure that the patient
needed. remains infection-free until another transplant
attempt is started.
In patients with a known history of liver or
Intraoperative Challenges intrahepatic bile duct cancer, a meticulous explo-
ration of all abdominal organs is paramount
Intraoperative challenges are best addressed in an before the liver dissection is started. Suspicious
organ-specific manner although some challenges lymph nodes and tissues need to be biopsied and
are similar in nature and the same basic princi- send for frozen section. Only after extrahepatic
ples apply. metastasis and tumor spread are ruled out, can the
native liver be dissected and removed. Alerting
the pathologist beforehand of obtaining frozen
Liver Transplantation sections reduces cold ischemia time and decreases
graft dysfunction and patient morbidity.
Intraoperative Inoperability Rarely, but with dire consequences, the sur-
geon may only realize after complete dissection
There are instances in which only after the of the porta hepatis and ligation of the hepatic
patient’s abdomen has been opened, the surgeon artery that the patient is not transplantable due to
realizes that the transplant cannot be done. Such extrahepatic metastases involving the hilum or
scenarios are most often encountered in patients retroperitoneum. The only option that remains is
with recurrent spontaneous bacterial peritonitis to close the patient’s abdomen, to inform the
144 C.S. Desai et al.

patient’s family about the intraoperative findings, cardiovascular shock and acute renal failure with
and to transfer the patient to the regular floor or to or without respiratory failure. However, this
the intensive care unit. Most patients with end- approach is planned and the anhepatic patients are
stage liver disease die within hours after ligation kept on CVVH until they get transplanted [7, 8].
of the hepatic artery.
Another dire situation arises if the recipient
surgeon ligates the hepatic artery before getting Congenital Agenesis of the Cava
word from the procurement team that the donor
liver is in fact unsuitable for transplantation. If it Congenital agenesis of the cava, retrohepatic
turns out that the donor organ is not usable for caval interruption, or complete thrombosis should
transplantation and the recipient hepatic artery be diagnosed as part of the patient’s transplant
(and/or the portal vein) is already ligated, chances work-up which includes imaging studies. The
for the recipient to receive another donor liver in venous reconstruction during the transplant pro-
time, even if relisted as status 1A, are very small. cedure can then be planned in advance. These
Reanastomosis of the severed artery—even if conditions usually allow performance of a liver
possible—or creation of a porto-caval shunt do transplant can be managed by using the standard
not substantially increase patient survival. orthotopic bicaval replacement technique. In
Therefore, the hepatic artery or portal vein should recipients of a living donor graft or a split liver
only be divided after the procurement team deter- graft without the cava, venous reconstruction via
mines that the donor liver is transplantable and the systemic circulation is more difficult. Options
the recipient surgeon has been informed. include the use of (parts of) the deceased donor
Tragically, there have been also a few instances cava or the donor iliac or superficial femoral
in which the donor surgeon(s) on the way from veins; cryopreserved or prosthetic grafts [9–12].
the procurement have been involved in car acci- In pediatric recipients, the donor saphenous
dents or even plane or helicopter crashes. In fact, vein(s) can also be used. In contrast to congenital
surgeons have lost their lives in accidents after caval agenesis, duplication of the inferior vena
the procurement and the donor organ(s) were lost cava allows liver transplantation both in ortho-
as well [6]. If the donor liver is lost in such an topic and piggyback technique.
accident, and the recipient hepatic artery and/or
the portal vein have already been divided, chances
for the recipient, as mentioned above, to receive Uncontrollable Caval/Hepatic Vein
another donor liver in time, even if relisted as sta- Bleeding
tus 1A, are very small. As stated, reanastomosis
of the severed artery, even if possible, or creation Careful dissection of the suprahepatic cava and the
of a porto-caval shunt do not substantially hepatic veins with subsequent placement of a ves-
increase patient survival unless another donor sel loop that encircles the cava and its confluence
liver becomes quickly available. The outlook is makes uncontrollable caval/hepatic vein bleeding
even grimmer if the recipient liver has already a relatively rare event. The Achilles heel is the pos-
been removed. The window for undergoing a terior wall of the suprahepatic vena cava anasto-
successful transplant in an anhepatic patient with mosis, and it has to be done very meticulously
porto-caval shunt is usually only several hours. since adequate exposure after unclamping is
In contrast, in patients with fulminant hepatic impossible. However, if there is major bleeding
failure a planned total hepatectomy with tempo- from the back wall anastomosis and it cannot be
rary porto-caval shunt has been successfully controlled by suture ligation or infradiaphragmatic
employed as a bridging procedure before liver vein clamping, a thoracotomy/sternotomy should
transplantation. This approach has been applied to be performed to gain control over the inferior cava
avoid the effects of the “toxic liver syndrome” in just below its entrance into the right atrium. To
which extensive liver necrosis is associated with increase the chances of successfully stopping the
14 Management of the Most Difficult Perioperative and Technical Challenges… 145

(life-threatening) bleeding, a Pringle maneuver artery that needs to be used for size matching. If
and clamping of the infrahepatic cava for total vas- insufficient hepatic artery flow is confirmed intra-
cular exclusion should be performed as well. operatively by flow studies, ligation of the recipi-
ent’s splenic artery is most commonly performed
to improve arterial inflow [20–22].
Absence or Agenesis of the Portal In recipients of a deceased donor liver graft
Vein several options to correct insufficient hepatic
artery flow can be considered. Less commonly,
Like caval agenesis, absence or agenesis of the an end-to-side anastomosis between donor
portal vein is usually noted on imaging studies as hepatic artery and the hump of the recipient
part of the pretransplant work-up. The venous splenic artery can be constructed, followed by
reconstruction during the transplant procedure ligation of the splenic artery distal to the anasto-
can then be planned in advance. mosis to further improve arterial inflow and to
If the portal vein is absent or completely avoid the splenic steal syndrome [23–25]. More
thrombosed but parts of the superior mesenteric commonly, a donor artery jump graft is used from
vein (SMV) are present and patent, a jump graft the supraceliac or infrarenal aorta or the right
such as the donor portal, iliac, or superficial fem- common iliac artery [26, 27]. Other potential
oral vein can be used for reconstruction [13]. sources for jump graft anastomosis such as the
If a proper distal SMV is not present, a large renal artery are hardly ever used, but remain
extrahepatic portosystemic collateral, jump grafts options in case of complete aortic and iliac artery
as described above from the collateral or the calcification.
patient’s renal vein are options for portal vein
inflow and reconstruction. Sometimes only
caval hemitransposition might achieve sufficient Instrument Failure
inflow [14–16]. However, if reconstruction is not During the Transplant
feasible, a multivisceral rather than a liver trans-
plant remains the last resort in these patients One of the most dreaded complications for any
[17–19]. surgeons is an instrument failure during surgery.
Portal vein thrombosis should be addressed Most commonly, vascular clamps come off acci-
first by standard thrombectomy. If thrombectomy dentally during transplant surgery. In order to
is not possible, but the confluence of SMV and avoid such hazardous occurrences, the surgeon
splenic vein is open, a jump graft as described must make sure before applying any clamp that
above can be used for reconstruction of portal all the jaws are perfectly aligned and the clamp
vein continuity. can be closed properly.
Portal vein arterialization is a salvage proce- In liver transplantation, the most important
dure for insufficient hepatic artery or portal vein clamp is the one placed on the suprahepatic infe-
vascularization as a result of absence or agenesis rior vena cava. If that clamp malfunctions and
of portal and mesenteric veins, intraoperative low comes off completely, the patient can immedi-
portal flow, hepatic artery thrombosis (HAT) and ately die from sudden and extreme blood loss, air
pre- or post-liver transplant extended splanchnic embolism, or a combination of both. For that rea-
vein thrombosis. son and as a measure of precaution, most liver
transplant surgeons tie the rings of the suprahe-
patic caval clamp together. If the clamp were still
Insufficient Hepatic Artery Flow to slide or come off partially, another clamp can
be immediately applied behind or above the
Insufficient hepatic artery flow is most com- original clamp. Other rescue efforts such as an
monly seen in recipients of living donor or split immediate thoracotomy to gain control from
liver grafts due to the small size of the recipient above are rarely successful. Prevention of this
146 C.S. Desai et al.

life-threatening complication by taking the above- lemia and bleeding is the most common cause of
described measure(s) is the best way of avoiding intraoperative cardiac arrest. If treated accord-
it altogether. ingly, most patients survive the event.
If clamps on the infra-hepatic cava, portal In contrast to common belief, pulmonary throm-
vein, or hepatic artery come off, the consequences boembolism is a very rare cause of intraoperative
are not as dire. In such circumstances it is best to cardiac arrest. Of note, mortality is higher in
put a finger on the vessel opening to prevent patients with an isolated pulmonary embolism
excess bleeding, improve visibility through opti- compared to patients with a combination of pulmo-
mal suction, compress the distal vessel manually, nary embolism and intracardiac thrombosis [28].
and reapply a (different) clamp. If the portal vein Despite emergent thrombectomy or thromboly-
clamp comes off a very short stump, compression sis intraoperative mortality of pulmonary embolism
of the base of the mesentery and the SMV helps and intracardiac thrombosis is about 80 % [28].
to reduce the bleeding. Intracardiac thromboemboli also occur most
frequently during the neo-hepatic phase and are
associated with treated or untreated portal hyperten-
Bile Duct Challenges sion and intraoperative hemodialysis/hemofiltration.
Inadvertent hypothermia is not uncommon in
In contrast to intraoperative vascular complica- liver transplantation and causes many undesired
tions, bile duct issues during the transplant proce- effects such as hypotension, arrhythmias, and
dure are not life-threatening and much easier to hypocoagulability. Hypothermia can be avoided
handle. There are two options for the bile duct by commencing active warming preoperatively,
anastomosis in liver transplantation: end-to-end use of warmed fluids and transfusions intraopera-
or hepaticojejunostomy. The construction of the tively, forced-air warming and intraoperative
bile duct anastomosis can be challenging if the monitoring.
patient develops massive intestinal distention Acute intraoperative renal failure is usually
intraoperatively secondary to massive blood loss, the result of pronounced hypotension and all
extreme portal hypertension and or long portal potential causes, primarily major bleeding, need
vein clamping time especially in the absence of a to be prevented. Administration of high-doses of
portosystemic bypass machine. In such cases the catecholamines can also contribute to acute renal
bile duct should routinely be stented or the stent failure.
can be externalized to do the bilio-enteric anasto- Massive intestinal swelling is multi-factorial.
mosis at a later time. If it occurs, it is best to leave the abdomen open
In living donor liver transplants, construction upon completion of the transplant procedure and
of the bile duct anastomosis is usually tedious close it over the following days in order to not
and stricture-prone. Meticulous placement of the compromise flow to and from the liver graft.
sutures, knot tying in a parachuting manner, and
internal stent placement are all keys to reduce the
rates of leakage and strictures. The Suboptimal Graft

Precarious situations can arise intraoperatively

Other Unexpected Intraoperative from the graft itself mainly as a result of techni-
Complications and Challenges cal complications or poor graft function.
Technical mistakes during the procurement
Intraoperative cardiac arrest occurs most fre- can result in damage not only to the blood vessels
quently during the neo-hepatic phase, less so dur- but also to the bile ducts and parenchyma.
ing the anhepatic phase, and rarely during the Although most technical injuries of the donor
pre-anhepatic phase. During the neo-hepatic liver can be successfully corrected and repaired on
phase, post-reperfusion syndrome with hyperka- the back table during benching, some complications
14 Management of the Most Difficult Perioperative and Technical Challenges… 147

may only become apparent after unclamping and early retransplant is to use as much length of the
reperfusion. This includes, for example, injuries original donor vessels as possible [29].
to the hepatic artery intima with subsequent If the previous transplant was done in piggy-
thrombosis and need for re-anastomosis using an back technique, the new superior caval anasto-
interposition graft for reconstruction. If the donor mosis should be constructed just below the old
portal vein is extremely short, an interposition anastomosis, i.e., towards the liver, to make the
graft may also become necessary to avoid any anastomotic opening as wide as possible. If the
unnecessary tension on the anastomosis. In gen- previous transplant was done in standard ortho-
eral, “air”-knotting of the portal vein anastomosis topic fashion, as much length of the original
as a growth factor is recommended to avoid donor vessels should be preserved especially for
strictures. the suprahepatic caval anastomosis. Severe ste-
Of great concern is a liver graft with immedi- nosis of the suprahepatic caval anastomosis is not
ate dysfunction. Diffuse bleeding after unclamp- uncommon if the previous anastomosis is
ing can be life-threatening and may warrant tight reopened and only completed under extremely
packing of the abdomen and transfer to the surgi- difficult sewing conditions because of the short
cal ICU with an open abdomen for further stabi- recipient vessel stump. It may also predispose to
lization. Once the recipient’s condition is stable, immediate and severe bleeding complications
a second look and re-exploration is performed right after unclamping.
that includes removal of all laps and towels, evac- Much more difficult than early retransplants
uation of hematomas, and control of any remain- are retransplants months or years after the origi-
ing bleeding. nal liver transplant due to the presence of severe
Subcapsular hematomas as a result of liver adhesions or even sclerosis. The keys to success-
damage during the procurement can also cause ful late retransplants are dissection on the surface
ongoing and massive bleeding after unclamping of the liver by always respecting the integrity of
particularly in a nonfunctioning graft. Packing of the liver capsule and the parenchyma, ligation of
the graft and administration of platelets, fresh the hepatic artery as early as possible, complete
frozen plasma, and clotting factors are useful control of the cava and portal vein and use of as
tools to minimize the diffuse bleeding as a result much length of the original donor vessels as pos-
of hypocoagulability. sible. For arterial reanastomosis, it is frequently
preferable to use an interposition graft to avoid
any possibility of thrombosis or stenosis.
Retransplant Challenges

Liver retransplants are among the most challeng- Intestinal Transplantation

ing surgical procedures. There is a major differ- and Multivisceral Transplantation
ence in technical complexity between early and
late retransplants. Difficult intraoperative situations in combined
If the donor organ is chosen appropriately in intestinal/liver and multivisceral transplants are
size and quality and the recipient is stable, techni- very similar to those of solitary liver transplants.
cally the least challenging type of a retransplant is Challenges different from liver transplantation
the very early retransplant secondary to primary- are highlighted below. Intestinal and, more so,
nonfunction of the graft or hepatic artery throm- multivisceral recipients usually have a very
bosis. Under these circumstances, the patient is small abdominal domain. Closure of the abdo-
immediately relisted as a status 1A and most men after perfusion of the new intestinal or mul-
retransplants take place within 7 days. Depending tivisceral graft can be very difficult or impossible.
on the recipient’s hemodynamic stability, fluid It is, therefore, to use in most cases a donor
status, etc., tissue edema and swelling may com- smaller in size and height (<30 %) than the
plicate the procedure, but the key to a successful recipient.
148 C.S. Desai et al.

In case of a difficult closure, several options are most common and warrant abortion of the
exist. First, a plastic surgeon working in close planned transplant. If the graft implantation is
collaboration with the intestinal/multivisceral already completed when the MI occurs, the
transplant team can be of great help in closing the patient needs to be stabilized and after skin clo-
abdomen primarily. Second, the donor abdominal sure transferred to the intensive care unit with the
wall on a vascular pedicle can be used as a com- goal to keep the systolic blood pressure
posite graft to close the abdomen. The third >120 mmHg and to avoid any hypotensive
option, using a mesh graft or leaving the abdo- episodes.
men (partly) open is less favorable. If due to previous transplants, technical diffi-
Another challenging situation arises when culties, or anatomical variants the kidney trans-
during the recipient enterectomy or exposure of plant cannot be placed retroperitoneally, the
the vessels, the recipient ureter(s) is (are) injured. surgeon can always place it intraabdominally.
To avoid this complication, some transplant sur-
geons prefer to place bilateral ureteral stents
using a cystoscope immediately prior to the Arterial Challenges
enterectomy or transplant surgery.
Not infrequently the primary conduit vessels The number of kidney transplants in elderly
are insufficient in length and/or number because patients continues to increase. As a result, athero-
other organs requiring their own vessel supply sclerotic aorto-iliac disease secondary to hyper-
are procured from the same donor. Most trans- tension, diabetes, or a combination thereof is
plant centers, for that reason, maintain their own common. If the recipient external iliac artery is
vessel bank. completely atherosclerotic, the common iliac
The results of intestinal transplants alone have artery or the internal iliac artery after appropriate
significantly improved over the past two decades. endarterectomy may be used. A meticulous
Patient survival remains high even after intestinal suture sewing technique is key to achieving a low
graft failure. Outcome is different for recipients arterial thrombosis and stenosis rate. Tacking
of combined intestinal/liver or multivisceral sutures may be required if atherosclerotic plaques
transplants with a relatively high mortality within are only partly wall-adherent. Patients with
the first year posttransplant due to a magnitude of advanced atherosclerotic disease or known
technical issues [30, 31]. Some of the most pre- peripheral vascular disease should receive intra-
dictive factors for poor outcome, aside from tech- operative systemic heparin before cross clamping
nical complications, are ICU hospitalization of the artery. The placement of vascular clamps
immediately before the transplant, severe portal has to be done in such a way that atherosclerotic
hypertension, advanced liver disease, and severe plaques are not cracked and dislodge distally,
adhesions from previous surgeries. causing an embolic event downstream.
Anastomosing more than two renal arteries with-
out a Carrel patch (or an aortic cuff) or vessels
Kidney Transplantation <2 mm in diameter can be equally challenging.
In case of intraoperative thrombosis at the
Intraoperative Inoperability anastomotic site or apparent stenosis, the anasto-
mosis has to be redone at the same site or, prefer-
Intraoperative inoperability is a rare occurrence ably, at a different site after the original site has
in kidney transplant candidates. If it occurs, it is been patched with a venous or prosthetic graft. If
most frequently observed in patients with consid- the thrombus extends into the graft renal artery, a
erable comorbidities such as cardiac disease, thrombectomy needs to be performed and the
hypertension, and/or diabetes. In this patient kidney graft re-flushed. If in preparation of the
cohort, hypotension and/or sudden arrhythmias anastomosis the recipient artery is already opened
as a result of an acute myocardial infarction (MI) but a portion of the external or common iliac
14 Management of the Most Difficult Perioperative and Technical Challenges… 149

artery is so damaged that flow to the leg would be they are routinely used). For retransplants, the
compromised, the segment in question should be same veins as well as the renal vein of the previ-
resected and an end-to-end interposition graft be ous transplant can be considered.
placed and anastomosed end-to-side to the graft The most feared intraoperative complication
renal artery. arises when a clamp comes suddenly off the
Retransplants can also provide arterial chal- recipient vein, especially if a side-biding clamp is
lenges. Usually, the same retroperitoneal site can used and the recipient vein has not been circum-
be used for a second transplant. The dissection of ferentially dissected out. In contrast to portal vein
the iliac vessels is usually performed distally as stump bleeding as noted above, bleeding of the
this area is less scarred [32]. Another option is to iliac vein occurs from both proximal and distal.
remove the previous kidney graft and use the Good visibility, effective suction, and manual
original donor vessels for anastomosis [33]. compression on both sides of the vessel can help
In patients with more than four previous kid- to decrease the bleeding until a clamp has been
ney transplants, the kidney graft is usually re-applied and the bleeding is stopped. Use of
implanted intraabdominally via a lower midline balloon catheters both proximally and distally is
laparotomy incision. The bowels are mobilized a last resort to gain control in case of uncontrol-
cranially to expose the iliac vessels in order to lable bleeding.
find the most suitable place for construction of
the arterial anastomosis.
In the rare case that the iliac arteries on both Ureteral Challenges
sides cannot be used, the recipient aorta, the renal
arteries [34, 35], and the splenic or inferior mes- Similar to bile duct challenges in liver transplan-
enteric artery [36] can be all used as inflow ves- tation, intraoperative ureteral complications in
sels. Likewise, in patients with aorto-iliac/ kidney transplantation are not life-threatening
femoral or axillofemoral bypass grafting, the and much easier to handle. There are several
prosthesis can be used for inflow [37]. options for the construction of ureteral anastomo-
In small children (<30 kg BW) the kidney is ses: the most common anatomical anastomoses
routinely placed intraabdominally and anasto- are the Lich-Gregoir and Leadbetter-Politano
mosed to the infrarenal aorta and cava or the techniques, the most common non-anatomical
common iliac vessels. It is crucial to fluid-load anastomosis is the one- or single-stitch tech-
pediatric recipients well before unclamping to nique. Upon completion, a difficult ureteral anas-
achieve good graft perfusion. Inadequate graft tomosis should be tested for leakage and, if
perfusion is the most common complication in necessary, repaired. In the presence of a large
pediatric recipients predisposing them to acute leak, the non-anatomical anastomosis can be
tubular necrosis (ATN) and subsequent graft immediately converted to an anatomical anasto-
rejection. mosis. Like with the bile duct anastomosis, stent-
ing of the ureteral anastomosis has been at the
center of discussions for decades. Our personal
Venous Challenges recommendation is to stent the difficult and small
ureteral anastomosis.
As with setting up the renal artery anastomosis,
identification of the most suitable spot for the
venous anastomosis is key to avoiding throm- The Suboptimal Graft
botic or stenotic events. In uncomplicated cases,
the external iliac vein is most commonly used The suboptimal kidney graft may have been dam-
and the common iliac vein and the cava are back- aged at the time of procurement or it may become
up options (except for small children in whom apparent only after unclamping in the recipient.
150 C.S. Desai et al.

Many technical injuries can be repaired on the plants are performed in the SPK category, are
back table where the bench work is performed. placed through a midline incision intraabdomi-
Serious graft injuries that may warrant abortion nally (including the simultaneously transplanted
of the transplant include extremely short vessels kidney), are anastomosed to the right common
that were cut mistakenly way inside the renal iliac vessels (the simultaneously transplanted kid-
hilum, shortened and ligated accessory arteries of ney is anastomosed to the left external iliac ves-
large caliber in the presence of a relatively small sels) and the pancreatic exocrine secretions are
main renal artery and a stripped ureter without drained into the small intestine (“enteric” drain-
any vascular supply. Subcapsular hematomas are age) and much less frequently into the bladder
not a contraindication to transplantation. (“bladder” drainage) [40].
The suboptimal kidney graft after unclamping In the last decade new surgical techniques
and restoration of blood flow is soft, marbled, have been reported in the field of pancreas trans-
and produces no urine. Avoidance of hypoten- plantation including simultaneous living donor
sion, aggressive fluid resuscitation including kidney and deceased donor pancreas transplant,
crystalloids and blood transfusions and adminis- laparoscopic living donor nephrectomy and distal
tration of diuretics before unclamping may help pancreatectomy for living donor SPK, en-bloc
to prevent the development of an ATN kidney. kidney and pancreas transplant, P-E (portal-
However, organ nonspecific factors such as long enteric) drainage with a venting jejunostomy, ret-
cold and warm ischemia times may also come roperitoneal placement of the pancreas transplant
into play and independently cause ATN despite with P-E drainage, the use of unusual vascular
all preventive measures. grafts and arterial bench work reconstruction
including the donor gastroduodenal artery [38].

Pancreas Transplantation
Intraoperative Inoperability
A pancreas transplant is technically less complex
than a liver transplant and more complex than a Like with kidney transplants, intraoperative inop-
kidney transplant [38]. However, technical com- erability is a rare occurrence in pancreas trans-
plications, transplant pancreatectomy, and pan- plant candidates. If it occurs, it is usually not a
creas retransplant can present extreme challenges result of technical reasons but of cardiovascular
and require solid knowledge in vascular, general, causes such as acute myocardial infarction (MI)
and gastrointestinal surgery as well as in urology. [40]. If an intraoperative MI is diagnosed, abor-
Unlike most other transplants, the extensive bench tion of the planned transplant is indicated even in
work required for a pancreas transplant can predis- the absence of hypotension and arrhythmias. If
pose to intra- and postoperative complications of the graft implantation is already completed when
which some can be life-threatening. Pancreas the MI occurs, the patient needs to be stabilized
transplants can be performed in three diabetic and after skin closure transferred to the intensive
recipient categories: [1] in uremic patients, a care unit with the goal to keep the systolic blood
simultaneous pancreas and kidney transplant pressure >120 mmHg and to avoid any hyperten-
(SPK); [2] in post-uremic patients, a pancreas after sive episodes. This is of particular importance in
kidney transplant (PAK); [3] and in non-uremic recipients who either simultaneously (SPK cate-
patients, a pancreas transplant alone (PTA) [39]. gory) or previously (PAK category) underwent a
From a technical perspective, the easiest proce- kidney transplant.
dures are in the PTA category because these
patients have fewer advanced secondary complica-
tions of diabetes and fewer comorbidities than the Arterial Challenges
uremic and post-uremic patients.
Although many different techniques for pan- Arterial complications during and after a pan-
creas transplants have been described, most trans- creas transplant are not uncommon since the
14 Management of the Most Difficult Perioperative and Technical Challenges… 151

arterial reconstruction can be quite complex. peripheral vascular disease should receive intra-
Rarely is the pancreas graft implanted, in its easi- operative systemic heparin before cross clamping
est way, on an aortic patch encompassing both of the artery. The placement of vascular clamps
the celiac axis (with the splenic artery) and the must be done in such a way that atherosclerotic
superior mesenteric artery (SMA) because the plaques are not cracked and dislodge distally,
pancreas and the liver share the same arterial causing an embolic event downstream. If this
blood supply. At the time of organ procurement, happens, an embolectomy or a distal bypass pro-
the celiac axis (with the common hepatic artery) cedure has to be emergently performed.
stays most commonly with the liver and the Intraoperative thrombosis at the anastomotic
splenic artery (severed at its takeoff from the site is rare, but if it occurs, the anastomosis has to
celiac axis) and the SMA stay with the pancreas. be redone after the Y-graft has been examined
Although an end-to-side anastomosis between and, if necessary, repaired or redone. If the
the SMA and splenic artery can be constructed, it thrombosis is caused right at the iliac anastomo-
is rarely done because that type of anastomosis is sis and the Y-graft is patent and intact, the iliac
under a lot of tension with a high likelihood of anastomosis has to be redone preferably at a
subsequent thrombosis. Arterial reconstruction more proximal site after the original arterial
is therefore required in most cases. Arterial opening has been patched with a venous or pros-
reconstruction of the pancreas graft usually thetic graft. If in preparation of the anastomosis
requires the use of a donor iliac Y-graft where the the recipient artery is already opened but a por-
donor’s external iliac artery is anastomosed end- tion of the external or common iliac artery is so
to-end to the SMA and the internal iliac artery damaged that flow would be compromised, the
end-to-end to the splenic artery. Upon comple- segment in question should be resected and an
tion of the Y-graft anastomoses, both arterial end-to-end interposition graft be placed. The
limbs should be flushed to detect any areas of Y-graft can then be anastomosed end-to-side to
leakage that may require repair. The donor com- the interposition graft or, preferably, at a more
mon iliac artery is then anastomosed end-to-side proximal location.
to the recipient’s right common iliac artery. The
construction of the Y-graft anastomosis can be
quite tedious, but any technical mistake will Venous Challenges
invariably result in bleeding complications, arte-
rial stenosis or even thrombosis [41]. The arterial When both the pancreas and liver are procured
thrombosis rate is significantly higher for pan- from the same donor, the portal vein stump that
creas than for kidney or liver grafts. remains with the pancreas is usually very short.
Specifically in the SPK and PAK categories, In order to construct a tension-free venous anas-
many patients have progressive vascular disease tomosis and to avoid any tethering, all internal
(i.e., micro- and macroangiopathy) as a result of iliac veins are doubly ligated and divided in prep-
their long-standing diabetes and frequently pres- aration of the venous anastomosis. Great caution
ent with advanced atherosclerotic aorto-iliac dis- needs to be taken to not cause any major bleeding
ease. If the common (and external) iliac arteries from the internal iliac veins as control of the
on both sides cannot be used because the vessels divided, distal stumps can be extremely difficult
are rock-hard and open arterectomies cannot be to obtain. The end-to-side venous anastomosis is
safely performed, the infrarenal aorta may have created between the donor portal vein and the
to be used for anastomosis. Meticulous suture recipient common iliac vein. If the recipient pel-
sewing techniques and avoidance of intimal flaps vis is very deep and narrow, a venous extension
are key to a low arterial thrombosis and stenosis graft on the portal vein may be required for a
rate. Tacking sutures may be required in the pres- completely tension-free anastomosis.
ence of atherosclerotic plaques. Patients with Of all organ transplants, the portal vein anas-
advanced atherosclerotic disease or known tomosis in pancreas recipients is most prone to
152 C.S. Desai et al.

thrombosis because the pancreas is a low-flow “only” urine (vs. stool) will spill into the abdomi-
organ. Rarely, the portal vein thromboses intra- nal cavity.
operatively, rather it occurs early posttransplant, If the donor duodenum appears not viable,
often within the first 24 h. If portal vein thrombo- there are two options. The first and the safest
sis occurs intraoperatively, the anastomosis has option is removal of the pancreas graft and abort
to be redone further proximally by avoiding any the transplant procedure. The second and riskier
twisting or kinking. In general, systemic heparin- option is to remove the graft duodenum from the
ization (30–50 U/kg) during and after pancreas perfused pancreas with the exception of a small
transplantation is routinely employed and has periampullar duodenal patch and then anasto-
significantly decreased the rate of graft loss from mose the patch to the recipient bowel or bladder.
thrombosis.

The Suboptimal Graft

Intraoperative Bleeding
The suboptimal pancreas graft may have been
Bleeding after unclamping is fairly common damaged at the time of procurement or it may
after a pancreas transplant. In contrast to liver become apparent only after unclamping.
and kidney, the borders of the pancreas are not Many technical injuries can be repaired on the
as clearly defined. Bleeding can occur from the back table when the bench work is performed.
pancreatic tail (after removal of the donor spleen Serious graft injuries that may result in cancella-
on the back table), the mesenteric stump and/or tion of the transplant include extremely short ves-
uncinate process (most common and most dan- sels, major parenchymal and/or duodenal
gerous) or from the anastomoses including the damage, and a swollen, edematous, or hemor-
Y-graft. Intraoperative bleeding is usually con- rhagic graft. The suboptimal pancreas graft after
trolled with suturing and ligation. On rare occa- unclamping and restoration of blood flow is
sions, the recipient vessels need to be re-clamped hypo-perfused, edematous, marbled, or blue.
as a last resort. Avoidance of hypotension, aggressive fluid
resuscitation including blood transfusions and
administration of administration of mannitol and
Challenges of Exocrine Pancreatic octreotide after unclamping may help to improve
Drainage the graft appearance and help to prevent the
development of graft pancreatitis. If graft pancre-
The most common forms of drainage of the exo- atitis develops and is edematous in nature, octreo-
crine pancreatic secretions are into the small tide (as well as heparin and mannitol) should be
bowel (“enteric” drainage) or into the bladder administered intraoperatively and continued for
(“bladder” drainage) [42]. Most SPKs are enteric- about 1 week. Consideration should also be given
drained since the creatinine level of the simulta- to placement of several drains for both (continu-
neous kidney transplant can be used as a harbinger ous) irrigation and suction. If hemorrhagic graft
of rejection. For solitary pancreas transplants pancreatitis develops immediately after reperfu-
(PAK and PTA), bladder drainage is more com- sion, graft pancreatectomy may need to be
monly used since it allows detection of rejection performed.
by monitoring urinary amylase levels. Sometimes, only the head or the tail of the
Intraoperative complications with the pancreas graft appears compromised. In such
duodeno-jejunostomy or duodeno-cystostomy cases, a graft hemi-pancreatectomy can be con-
arise when the donor duodenum is not well per- sidered which requires careful suturing of the
fused. In that case, bladder drainage is preferred remaining pancreatic cut surface to prevent the
over enteric drainage because in case of a leak, development of a pancreatic fistula.
14 Management of the Most Difficult Perioperative and Technical Challenges… 153

Challenges of Pancreas Graft creas retransplant is flexibility. The pancreas

Pancreatectomy and Re-explorations retransplant should, whenever possible, be
implanted at a previously undissected location,
Early vs. late graft pancreatectomy presents with either on the other side of the pelvis or more
very different challenges. proximal to aorta and cava. For venous drainage,
Early graft pancreatectomy usually becomes both systemic and portal drainage can be
necessary because of graft thrombosis (arterial or considered.
venous) or infection (leakage of the graft duode- If the previous graft is still in place, it may be
nal anastomosis, intraabdominal abscess, and removed and the previous anastomoses sites can
graft pancreatitis). Most risky is an early graft be re-used.
pancreatectomy due to venous thrombosis [43]. If the pancreas retransplant is performed years
The graft and the respective leg are massively after the previous transplant, the previous graft is
swollen and due to the large size of the thrombus often completely shriveled down from chronic
the patient is at high risk for development of pul- rejection to the size of a large walnut, and the
monary embolism. The safest way to gain intra- graft pancreatectomy is extremely difficult.
operative control of this perilous condition is to Under this circumstance, it might be prudent to
clamp the proximal iliac vein first, close to the leave the previous graft in place and implant the
inferior vena cava to avoid pulmonary dislodging new graft further proximally either to the com-
of the thrombus. Only then can the graft be man- mon iliac vessels or to the distal aorta and vena
ually examined and removed. A complete throm- cava. Irrespective of whether or not the previous
bectomy of the ilio-femoral venous system is key graft duodenum is shriveled, the duodenocystos-
to a full recovery. tomy should be taken down, and the duodenum
The most feared complication is the develop- should be amputated off the head of the
ment of an arterio-intestinal or arterio-cystic fis- pancreas.
tula, both of which are the result of massive If a previous kidney graft had been anasto-
perigraft infections and associated with a high mosed to the left iliac vessels, every attempt
mortality rate. Key to survival is complete control should be made to use the right iliac vessels for
over the patient’s iliac vessels and graft removal. the pancreas retransplant. If only the aorta and
Likewise, mycotic or infectious pseudoaneurysm vena cava can be used for inflow, a side-biding
requires a similar technical approach. clamp should be used to allow continued flow to
A late graft pancreatectomy can be extremely and from the kidney graft while the pancreas
difficult due to adhesions, scar tissue, vessel fri- graft is implanted. If the pancreas graft can only
ability, and graft shrinkage. Key to safe graft be implanted on the left side proximal to the pre-
removal are proximal and distal control of the vious kidney graft, adequate preparation before
recipient’s iliac vessels. clamping including fluid hydration, administra-
tion of furosemide, mannitol, and heparin (30 U/
kg), and quick completion of the anastomoses are
Retransplant Challenges paramount in order to prevent kidney graft loss
from warm ischemia.
An early pancreas retransplant (within days or a
few weeks after the previous transplant) is usually
not difficult from a technical perspective. This is Posttransplant Challenges
in stark contrast to a late pancreas retransplant
that presents a special challenge to the surgeon The two major complications in the immediate
because of its technical complexity due to previ- postoperative period after all types of abdominal
ous transplants, laparotomies, and/or infections. organ transplants are bleeding and thrombosis.
As with multivisceral and intestinal trans- These complications can occur at any time in the
plants, the key to the technical success of a pan- PACU, ICU, or on the regular floor.
154 C.S. Desai et al.

Liver transplant patients are at greatest risk for sion in liver transplant candidates. Liver Transpl Surg.
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but, when it occurs, it usually stems from the cirrhosis: hepatorenal syndrome and renal support strat-
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6. Garcia VD, Vasconcelos L, Abbud-Filho M. The risk-
bleeding complications after kidney transplanta- iest job in medicine: transplant surgeons and organ
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Zurstrassen MP, Lima IK, Novais HS, et al. Total
Graft thrombosis in the immediate postopera- hepatectomy and liver transplantation as a two-stage
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or arterial thrombosis) or liver (hepatic artery Proc. 2008;40(3):814–6.
thrombosis) transplant recipients. It is relatively 8. Montalti R, Busani S, Masetti M, Girardis M, Di
Benedetto F, Begliomini B, et al. Two-stage liver
rare in kidney transplant recipients. transplantation: an effective procedure in urgent con-
Ongoing bleeding causing hypotension and ditions. Clin Transplant. 2010;24(1):122–6.
tachycardia despite adequate blood transfusions 9. Sato K, Sekiguchi S, Kawagishi N, Akamatsu Y,
requires immediate re-exploration. Patient mor- Miyagi S, Yamaya H, et al. Hepatic venous recon-
struction using the superficial femoral vein in a right-
tality and graft loss due to bleeding are low. lobe living donor liver transplant patient with
Graft thrombosis in the immediate posttrans- interrupted inferior vena cava. Pediatr Transplant.
plant period is also associated with a low patient 2014;18(1):E13–7.
mortality but with a relatively high rate of graft 10. Chalret du Rieu M, Muscari F, Leobon B, Suc B. Liver
transplantation with reconstruction of the inferior
loss, specifically in pancreas, kidney, and intesti- vena cava for hepatocarcinoma on chronic Budd-
nal transplant recipients. These organs need to be Chiari: a case report. Transplant Proc. 2008;40(10):
removed, the patients immediately re-listed and 3797–9.
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N, Matsui Y, et al. Short hepatic vein reconstruction in
tal stay. Hepatic artery thrombosis can frequently biliary atresia patients with absent inferior vena cava.
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liver. If corrected late, bile duct damage and sub- Rela M. Living related liver transplantation in biliary
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Excellent surgical techniques and good graft 13. Tzakis A, Todo S, Stieber A, Starzl TE. Venous jump
quality are essential to prevent bleeding and grafts for liver transplantation in patients with portal
thrombotic complications early posttransplant. vein thrombosis. Transplantation. 1989;48(3):530–1.
14. Tzakis AG, Kirkegaard P, Pinna AD, Jovine E,
Misiakos EP, Maziotti A, et al. Liver transplantation
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diffuse portal vein thrombosis. Transplantation.
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 Dealing with the Most Difficult
Situations: A Point of View 15
from a Surgical Oncologist

Alberto R. Ferreres

death, cancer treatment and decision making

Introduction often give rise to some of the most compelling
and fundamentally difficult conflicts in medi-
As the number of cancer survivors increases cal and surgical ethics, and thus technical,
worldwide, the demand for surgical oncology moral, and ethical considerations.
care will grow and the appearance of personal- Besides, the concept of “value” may have dif-
ized or tailor-made treatments will add to the ferent meanings to the participants of the health
complexity of decision making in the field. care Alliance, which include clinical and surgical
Besides, cancer therapy is always exposed to oncologists and the patient and his or her rela-
difficult situations, which make therapeutic tives. For the patient, value may represent the
decisions mandatory for the best benefit of the equation between the perceived benefits of sur-
patient [1]. gery versus the costs of the treatment, not only on
Cancer has been known to affect humans a financial basis. This value includes, among
since it was first described in ancient Egyptian other factors, the following: the tolerance of risk,
writings some 3500 years ago. Although this the fear of surgery, the tolerance of pain, the
condition has been treated since antiquity, cancer length of disability and possible sequelae, the
still remains one of the major causes of death and preferred lifestyle, the requirements and needs
suffering worldwide. for peace of mind, and the wellness for living the
One aspect of Surgical Oncology that dis- rest of life.
tinguishes it from the treatment of other severe One third of elderly patients are operated on
illnesses is the awareness among patients and during the last 12 months of life and most of
physicians that cancer is often a fatal disease. them within the last month [2]. How are surgi-
Because the clinical encounter with a cancer cal decisions made? Usually they are adopted
patient may be influenced by the probability of after a meeting and discussion among the sur-
geon, the patient, and some surrogates (spouse,
children, partner, guardian). For many elderly
patients, quality of life and autonomy may be
more important than length of survival after the
A.R. Ferreres, M.D., P.h.D., J.D., M.P.H., F.A.C.S. operation.
(Hon) (*) Surgery and Surgical Oncology have five
Department of Surgery, University of Buenos Aires,
Vicente Lopez 1831 PB, Buenos Aires 1128, Argentina unique characteristics that set them apart from
e-mail: albertoferreres@gmail.com any other medical field [3]:

© Springer International Publishing Switzerland 2016 157

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_15
158 A.R. Ferreres

(a) Surgery harms before it heals. II. There is usually a set of well-defined alterna-
(b) Surgery penetrates the patient’s body and tives from which to choose.
thus is highly invasive. According to Judge III. Uncertainty regarding the consequences of
Benjamin Cardozo in Schloendorff v. Society the action. Example: Will the patient survive
of New York Hospitals (1914): “A surgeon the operation? Is the risk of surgical mortal-
who performs an operation without a ity worth taking in order to relieve the pain?
patient’s consent commits an assault.” IV. A set of preferences held by the decision
(c) Surgery is fallible, which means that surgery maker (surgical oncologist), which has to be
is encircled by human error. accepted by the patient and applied to the
(d) The surgeon’s decision making is performed, possible outcomes. It is worth mentioning
most times, under circumstances of uncertainty. that during the surgical procedure the sur-
(e) Surgery is prone to risks, accidents, compli- geon should bear in mind the patient’s
cations, and sequelae. choices or advance directives, the exception
being an intraoperative accident or unex-
Decisions about “how to treat” are a matter of pected findings.
medical science and knowledge, and decisions V. One or more constraints may limit the set of
about “why to treat” are related to moral and sur- available alternatives.
gical ethics grounds. VI. The most important point is that the decision
The art of decision making rests on six basic must be made, since delaying it or preserv-
elements [4]: ing the “status quo” is in itself a decision
with its pertinent consequences.
1. Information: when the data availability is
better, the surgeon is in a better position to There are different moments for decision
define a strategy, but this is not the usual case making in the field of Surgical Oncology:
or situation.
2. Knowledge: the theoretical and practical (a) In the preoperative period, while the surgical
aspects are valuable assets. indication may be discussed, in elective con-
3. Expertise: based on previous exposure to sim- ditions or emergency.
ilar circumstances. (b) During the intraoperative period, when the
4. Intuition patient is under general anesthesia and
5. Assessment: the evaluation of each of the ele- unable, of course, to participate. It is manda-
ments of the decision. tory that the surgeon needs to make the best
6. Judgment: combines information, knowledge, decisions on behalf of the patient, following
expertise, and assessment. previous guidelines, suggestions, and expec-
tations. Nonetheless, most times all the pos-
sible alternatives regarding unexpected
The Decision-Making Process findings or intraoperative situations could
not have been discussed in-depth with the
As in most medical fields, decision making in patients and his or her surrogates.
Surgical Oncology is most times performed (c) During the postoperative course, regarding
under uncertainty and is characterized by six fea- the early diagnosis and management of com-
tures, no matter how urgent or needed the deci- plications and the requirement of extraordi-
sion or life threatening the situation [5]. nary methodologies or resources.
(d) During the follow-up, preventing unneces-
I. Uncertainty, in different degrees, about the sary studies or procedures to search for even-
medical condition of the patient. For exam- tual recurrences.
ple, a mass in the head of the pancreas with- (e) End-of-life issues, trying to prevent futile
out a known histology. treatments [6].
15 Dealing with the Most Difficult Situations: A Point of View from a Surgical Oncologist 159

Successful decision making in Surgical 1. Paternalistic model: Though this model has
Oncology is achieved through the integration of been very much criticized, it is the one that
evidence, inference, and experience. These three many times characterizes the relationship
complementary qualities are necessary for between a surgical oncologist and his or her
acquiring knowledge and applying it to the clini- patient. This model usually places the patient
cal problem. The elements of knowledge are in a passive and dependent role vis-a-vis the
complex and include intuition and obedience. surgeon as the expert.
The acronym EIEIO summarizes all the founding 2. Informed decision-making model (informed
elements of knowledge in clinical surgery, as choice): The foundation of this model lies on
coined by Marshall: evidence, inference, experi- the information provided by the health agent,
ence, intuition, and obedience [7]. so it may be supposed the patient is in a better
Inductive reasoning lies at the foundation of situation to make an informed decision. This
evidence-based surgery. It is based on interven- is not always the case in the real world of can-
tion, observation, and application of the princi- cer treatment. This model sets aside the surgi-
ples of probability, first described by clergyman cal oncologist from the decision-making
and mathematician Thomas Bayes (1701– process by limiting the role to one of informa-
1761). The strongest evidence is that which tion provider. Besides, most times, the patient,
arises from the most powerful tool in inductive though legally competent, is impaired and
science: the randomized controlled trial. cannot make the best decisions regarding his/
Inference is probably the most commonly used her welfare, and information asymmetry is
faculty when making surgical decisions in indi- one of its main disadvantages.
vidual patients. When a surgeon has to make a 3. Professional as agent model: This model is
complex medical decision, there are seldom based on the fiduciary nature of the patient–
rigorous data from randomized controlled trials physician relationship, considering the latter
aiding his or her decision-making process. will make the best decision on the patient’s
Even if strong data are available, the surgeon behalf for the benefit and welfare of the
must tailor results to the specific circumstances former.
of the patient, and this is usually the case in the 4. Shared decision making or patient-centered
field of surgical oncology. care: The IOM defined this model as “care that is
Nonetheless, a surgeon’s level of experience respectful of and responsive to individual patient
guides his or her decision making in three broad preferences, needs, and values” and ensures
areas: (a) it is an imperfect arbitrator of published “that patient values guide all clinical decisions.”
knowledge; (b) the published knowledge must be This definition highlights the importance of sur-
integrated with the particular strengths, limita- gical oncologists and patients working together
tions, and values of the individual surgeon; and to produce the best outcomes possible.
(c) it must be used as a mechanism to adjust a
therapeutic approach to the particular needs and On the other hand, the patient–surgeon rela-
values of an individual patient. tionship is built upon trust, so it is preferable to
Surgical intuition derives from the integration speak about it from a fiduciary viewpoint, not as
of prior knowledge, experience, and cognitive a contract. As John Gregory (1724–1773) stated,
skills. It characterizes what we recognize as a the physician [9]:
master surgeon. The characterization of expertise
is expressed in quick pattern recognition and – Must be in a position to reliably know the
complicated scripts. Obedience is the uncritical patient’s interest.
adoption of the counsel of one’s teachers and pre- – Should be concerned primarily with protect-
decessors, often expressed as an aphorism. ing and promoting the interests of the patient.
Decision making in the field of Surgical – Should be concerned only secondarily with pro-
Oncology has different approaches [8]: tecting and promoting his or her own interests.
160 A.R. Ferreres

The concept of the surgeon as the patient’s Surgical decision making in the operating
moral fiduciary can be captured in the following room (OR) is a nontechnical skill but it is a must
considerations: and a requirement; it has to do with critical, cog-
nitive, and interpersonal skills that complement
– The surgical oncologist should make the pro- manual abilities. The surgical oncologist will be
tection and promotion of the patient’s interest confronted by difficult decision-making situa-
the primary consideration in the surgeon– tions in the OR environment and must be pre-
patient relationship as well as in surgical pared to make the best decisions on behalf of the
research and education. patient [11].
– This primary commitment holds self-interest Surgical oncology procedures are character-
in the background and makes it a systemati- ized by time pressures, changing goals, increased
cally secondary consideration. risk, high uncertainty, unexpected situations,
– Self-interest is thus blunted and not permitted unanticipated troubles, and inadequate data pro-
to generate the “vice” of selfishness in the sur- vision [12]. If the operation proceeds without sig-
geon’s professional character, making the nificant problems, there will be no reason to
fiduciary’s role morally demanding. change the course of action. But when confronted
with sudden or unexpected situations (bleeding,
The patient–surgeon relationship is attained unexpected findings, increased risks, accidents,
and perfected throughout the process of surgi- difficulties, etc.), the surgeon will be forced to
cally informed consent, which includes the fol- change the course of action.
lowing elements: The initial step is situation awareness of a
change in the governing conditions and is
1. Preconditions: competence and voluntary atti- closely related to the cognitive monitoring of
tude of the patient. the developing steps of a surgical procedure.
2. Information: disclosure and recommendations Once the surgeon detects some abnormality in
by the surgeon and the patient understanding the course of events, the second step is the situ-
the information. ation assessment, which includes definition of
3. Consent: decision making (acceptance or the problem, the assessment of risk, and time
refusal), communications, registration, and constraints. The strategy of decision making
the patient’s authorization to proceed. may adopt different mechanisms, one or more
than one at a time: intuitive, rule based, analyti-
Since surgical oncologists should in no way cal, or creative (Fig. 15.1).
offer an “a la carte” menu of surgical options to
patients, they are not forced to act contrary to
their knowledge, beliefs, standards of care, pro- INTRAOPERATIVE PROBLEM OR DIFFICULTY
vided they are coincident with the generally
accepted ones.
SITUATION AWARENESS
Decisions in surgical oncology are increas-
ingly being made by multidisciplinary teams,
which have been widely accepted as one of the EVALUATION
preferred model for cancer service delivery. GRADE OF RISK
AVAILABLE TIME
Nonetheless, the decision-making process is not
well established, and many times unawareness of
the patient’s preferences, lifestyle, and choices is
the rule and consequently the therapeutic deci- FOR DECISION MAKING AND
ADOPTION OF A COURSE OF ACTION
sions—though scientifically impeccable—are
not in the patient’s best interest [10]. Fig. 15.1 Intraoperative decision-marking steps
15 Dealing with the Most Difficult Situations: A Point of View from a Surgical Oncologist 161

The aim is to resolve the situation as soon as the relief of the postoperative pain and
possible and with the least amount of collateral suffering as well as on prevention of long-
harm to the patient. term suffering from added morbidity and
decreased quality of life.
(b) Appeal to consequences: special consid-
Surgical Ethics Tools to Aid eration is given to the risk/benefit
in Decision Making equation.
(c) Appeal to rights: full respect to the
Surgical oncologists should rely on tools that patient’s positive and negative rights is
provide them a framework for ethical analysis mandatory.
and aid them in decision making to help address (d) Appeal to justice and equality: takes into
and manage clinically difficult cases (Table 15.1). account financial, material, and human
McCullough et al. recommend a four-step resources.
approach [13]: III. Ethical argument: answers should be given
to the following questions: Are the reasons
I. Identify the facts of a case: a full and com- clearly stated? Are there other options that
plete knowledge of all the facts and data of a could apply to the case?
determined clinical case as well as all the IV. Issues of power and authority: the surgeon
therapeutic alternatives are the initial require- is “an authority” in view of his or her
ments for a sound and grounded ethical anal- knowledge, training, and expertise. At the
ysis. The awareness of the patient’s facts and same time, the patient decides on and con-
preferences is also pertinent. sents to whatever is to be done or not done
II. Ethical analysis: should consider the “four to the body.
appeals.” The first one addresses the fidu-
ciary role and the other three refer to the Jonsen et al. proposed “a four topic model” to
ethical principles of beneficence, respect for aid in solving ethical issues in clinical patient
autonomy, and justice. care, and which can be applied to oncologic
(a) Appeal to virtues: related to the short- and patients. This model demonstrates the interaction
long-term implications of the surgeon’s between the ethical principles and the concrete
virtues as fiduciary of the patient. For circumstances of a clinical case [14]. This model
example, compassion focuses concern on includes the following:

Table 15.1 Ethical tools for surgical decision making in (a) Medical indications: refer to the diagnostic
oncologic patient care and therapeutic choices for solving the medi-
• Gather the medical, social, and all other relevant cal/surgical problem and reflect the princi-
facts of the case. In addition, provide an appropriate ples of beneficence and nonmaleficence.
answer to the question “What should you do if you (b) Patient preferences: these express the choice
were in my situation?” It requires an account of the
of the patient and address the principle of
values that play a role in the case and the moral
guidelines and/or rules those values suggest respect for autonomy.
• Identify all relevant values including, but not (c) Quality of life: This describes features before
limited to, those of the patient, relatives, and and after the medical/surgical intervention
physician, nurse, other health professionals, the evidenced in the application of the principles
health care institution, and society. Determine if
the values are in conflict
of beneficence, nonmaleficence, and respect
• Propose possible solutions to resolve the conflict. for autonomy.
Generate options (d) Contextual features: The settings and
• Choose the better solutions for each particular resources of each particular case are identi-
case, justify them, and respond to possible fied, with the principles of justice and fair-
criticisms ness addressed.
162 A.R. Ferreres

Many surgical oncologists encounter or will difficult to adopt, and the ethical background
encounter the question: “Doctor, if this were you provides a very useful tool to assist in decision
or your patient, what would you do?” The ques- making in difficult situations in the field of
tion represents a request for expert advice, a situ- Surgical Oncology.
ation in which a surgeon should not refuse to say
what he considers the best option. One of the sig-
nificant issues here is advice based on personal Case Discussion #1
values, which may not be the same as those val-
ues of the patient [15]. Surgeons are confronted Male patient, 54 years old, with the following
daily with this question, which may be asked in history: 2 years ago, laryngeal squamous carci-
different situations: noma treated with radiotherapy, right cervical
lymphadenectomy with neoadjuvant chemo, and
(a) When the patient has a great deal of technical radiotherapy due to metastatic dissemination
information with mortality statistics and out- (2014), total laryngectomy and tracheostomy
comes, good and bad, which may be over- due to recurrent disease (2015). Presents to the
whelming and confusing: In such cases, the Emergency Room/ Department with cervical
patient is trying to convey that he or she is bleeding through the surgical incision, carotid
overinformed and not able to make a reason- diabrosis. Initial compression stops the bleeding,
able choice. but chest X-ray reveals suspicious pulmonary
(b) When the patient is making difficult choices metastatic disease.
and merely needs support. He or she is really Options:
asking, “Doctor, am I making the right
choice?” 1. Consider the patient as a terminal patient: per-
(c) When the patient is facing difficult alterna- form compression only.
tives—usually life or death choices or very 2. Right carotid ligature, with the known com-
different treatment options—the patient is plications and/or sequelae.
asking for assistance or for the physician to 3. Angiography and endovascular treatment.
make the choice.
The patient was aware and highly motivated,
The question in each of these three situations and requested every type of invasive measures.
requires a different answer, but each certainly Option 2 was performed. On postoperative day
deserves a reply. The task is to have a clear under- number 3, exposure of the stent and new hemor-
standing of what the patient and his or her rela- rhage on postop day 6, which ended with the
tives need and want from the surgeon in charge. death of the patient.

Conclusions Case Discussion #2

Every expert surgical oncologist should be Female patient, 73 years old, with history of a
superb in the domain of operative skills and the Whipple procedure for adenocarcinoma 3 years
decision-making process. Furthermore, all diffi- ago. She presents for follow-up consultation
cult circumstances encountered in clinical prac- with jaundice and abdominal pain. She tells her
tice should be tackled with a systematic approach surgeon she wants “everything” available for
and a flawless decision-making strategy, and the treatment, including surgery and/or chemother-
decision-making process must take into account apy and radiotherapy. Work-up shows an abdom-
the preoperative, intraoperative, and postopera- inal mass, considered as a recurrence with
tive stages, as well as the follow-up period and obstruction of the hepaticojejunostomy and liver
the last moments of life. The intraoperative dissemination. A biliary decompressive drainage
decision-making process is probably the most is placed for relief of symptoms. The patient
15 Dealing with the Most Difficult Situations: A Point of View from a Surgical Oncologist 163

returns 1 month later with weight loss, nausea, 5. Bravata DM. Making medical decisions under uncer-
tainty. Sem Med Pract. 2000;3:6–14.
and vomiting due to a small bowel obstruction
6. St Martin L, Patel P, Gallinger J, et al. Teaching the
due to the above-mentioned recurrence. slowing-down moments of operative judgement. Surg
Options: Clin North Am. 2012;92:125–35.
7. Marshall JC. Surgical decision-making: integrating
evidence, inference and experience. Surg Clin North
1. Ordinary measures for comfort and to prevent
Am. 2006;86:201–15.
pain. 8. Barry MJ, Edgman-Levitan S. Shared-decision mak-
2. Surgical exploration and eventual bypass. ing—the pinnacle of patient-centered care. N Engl
3. Referral to home or hospice. J Med. 2012;366:780–1.
9. McCullough LB. John Gregory’s writings on medical
ethics and philosophy of medicine. Dordrecht: Kluwer
The patient was in her right mind and decided Academic; 1998.
on option 1, including a DNR order. She died 10. Sivell S, Edwards A, Elwyn G, et al. Understanding
peacefully after 4 days. surgery choices for breast cancer: how might the the-
ory of planned behaviour and the common sense
model contribute to decision support interventions?
Health Expect. 2011;14 Suppl 1:6–19.
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geons face intraoperative challenges: a naturalistic model of
1. Lamb B, Green JS, Vincent C, et al. Decision making surgical decision making. Am J Surg. 2013;205:156–62.
in surgical oncology. Surg Oncol. 2011;20:163–8. 12. Flin R, Youngson G, Yule S. How do surgeons make
2. Glance LG, Osler TM, Neuman MD. Redesigning intraoperative decisions? Qual Saf Health Care.
surgical decision making for high risk patients. N 2007;16:235–9.
Engl J Med. 2014;370:1379–81. 13. McCullough LB, Jones JW, Brody BA. Surgical eth-
3. Ferreres AR. Ethical debate: the ethics of non per- ics. New York: Oxford University Press; 1998.
forming extended lymphadenectomy in patients with 14. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics:
gastrointestinal cancer. World J Surg. 2013;37: a practical approach to ethical decisions in clinical
1821–8. medicine. New York: McGraw Hill; 2010.
4. Rutkow I, Gittelsohn AM, Zuidema GD. Surgical 15. Kon AA. Answering the question: “doctor, if this
decision making: the reliability of clinical judgement. were your child, what would you do?”. Pediatrics.
Ann Surg. 1979;190:409–17. 2006;118:393–400.
 Difficult Decisions
in Cardiothoracic Surgery: Acute 16
Cardiogenic Shock

Zachary P. Baker, Jack B. Keenan,

and Zain Khalpey

Introduction hypo-perfusion) with a concomitant decrease in

cardiac index while maintaining a normal volume
Acute cardiogenic shock is a medical and, often status. Similar to any type of shock, invasive
times, surgical emergency. Treatment of any type blood pressure monitoring is preferred to imme-
of shock usually commences prior to definitive diately detect response to treatment. Determining
determination of etiology but promptly determin- cardiac index and overall volume status may
ing the cause is critical to initiating proper require more difficult, but essential, strategies.
treatment. Modalities to accurately diagnose the Invasive monitoring with a pulmonary artery
presence of shock may include invasive or nonin- catheter may be necessary to determine central
vasive blood pressure measurements, heart rate venous pressure and pulmonary capillary wedge
monitoring, X-ray imaging, and physical exami- pressure. It can also be used to measure cardiac
nation, or laboratory values, including arterial or output and subsequently cardiac index. Newer
venous blood gas measurements. Differentiating and less-invasive technologies have been made
etiologies of shock requires more specific testing. available to continuously monitor cardiac param-
In cardiogenic shock, the use of electrocardio- eters but have limited availability secondary to
gram, trans-thoracic echocardiography, cardiac cost, and thus, pulmonary artery catheterization
enzyme levels, pulmonary artery catheterization, remains the gold standard. Trans-thoracic echo-
CT imaging and/or coronary angiography are cardiography can also identify elevated ventricu-
keys to establishing a diagnosis. lar filling pressures that are seen in the setting of
The definition of cardiogenic shock includes a cardiogenic shock.
decrease in systemic blood pressure (multiorgan Cardiogenic shock is the most severe clinical
manifestation of acute heart failure. Early recog-
nition and effective treatment of this disease pro-
cess is critical to survival. During a
Z.P. Baker, M.D. (*) • Z. Khalpey, M.D., non-cardiogenic shock state, the heart attempts to
Ph.D., F.E.T.C.S. compensate for systemic hypo-perfusion by
Department of Surgery, Banner University
Medical Center, 1501 N. Campbell Ave, Tucson, AZ increasing cardiac output. With cardiogenic
85724, USA shock, there is either a mechanical or a functional
e-mail: bakerz@surgery.arizona.edu; zkhalpey@ inability to increase cardiac output and the
surgery.arizona.edu heart enters a cycle where increased demand
J.B. Keenan, B.S., B.S.H.S. leads to worsening coronary perfusion, ultimately
College of Medicine, University of Arizona, leading to a rapid progression of myocardial dys-
550 E Van Buren St, Phoenix, AZ 85004, USA
e-mail: keenan@email.arizona.edu function. Cardiogenic shock can also rapidly lead to

© Springer International Publishing Switzerland 2016 165

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_16
166 Z.P. Baker et al.

multisystem organ failure which can occur via phy, echocardiography, and CT imaging can be
both ischemic and congestive means. Cardiorenal useful and help define etiology and guide
and cardiohepatic syndromes have been previ- treatment in these settings.
ously described and both lead to a significant
decrease in mortality [1, 2]. Systemic inflamma-
tory response syndrome (SIRS) and sepsis are Treatment Trends
also commonly seen in the setting of cardiogenic
shock. Given the widespread effects on multiple Traditional treatment of acute cardiogenic shock
organ systems, mortality rates still remain are was limited primarily to pharmacologic support.
above 40 % [3, 4]. This underscores the need for These therapies include both inotropic and
more effective treatment modalities. vasopressor agents. Inotropic agents attempt to
Most commonly, acute cardiogenic shock is counteract the failing heart by increasing cardiac
secondary to myocardial infarction with left ven- output but can lead to tachycardia, as well as
tricular failure. The incidence is anywhere from arrhythmias, and thus an increase in myocardial
3.8 to 10 % [5–7] of acute coronary syndromes oxygen demand. Because of this, inotrope use in
(ACS) depending on the criteria used to define ischemic cardiogenic shock is controversial.
cardiogenic shock. It is necessary to determine Vasopressors increase systemic blood pressure
coronary artery disease as the cause of cardio- but can worsen end-organ perfusion and micro-
genic shock as early revascularization is critical perfusion, worsening multisystem organ failure.
and leads to decreased mortality rates, below Dobutamine remains the inotrope of choice in
50 % [6–8]. Electrocardiogram, elevation in car- many settings [9] but has limited effect on blood
diac enzymes, and ultimately coronary angiogra- pressure peripherally. Because of this, vasopres-
phy are the preferred initial modalities used. It is sors are often used simultaneously.
also necessary to promptly identify any compli- Norepinephrine is also used in the treatment of
cating factors of acute myocardial infarction cardiogenic shock given its combined central and
such as free wall, septal, or papillary muscle rup- peripheral effects. Unfortunately, to date, no
ture as treatment algorithms greatly differ from clear evidence is available as to increased benefit
percutaneous coronary intervention (PCI) alone of either drug and many guidelines differ on rec-
for noncomplicated ACS. Trans-thoracic echo- ommended therapy. Phosphodiesterase inhibitors
cardiography, and even trans-esophageal echo- (e.g., Milrinone) can cause significant vasodila-
cardiography, should be used as adjuncts to tion and hypotension and are not recommended
initial testing to detect any of these mechanical for use in the setting of acute cardiogenic shock.
complications. Identification of such complica- Newer agents including levosimendan [10] and
tions warrants emergent surgical evaluation and istaroxime [11] have shown some positivity but
intervention. data are limited on their use in the setting of acute
Non-ischemic causes of acute cardiogenic cardiogenic shock.
shock are much less common. Obstructive and With a lack of clear data and persistently high
restrictive etiologies include massive pulmonary mortality rates with pharmacologic treatment
embolism and cardiac tamponade. Acute valvu- alone, there has been a push toward the development
lar pathology secondary to aortic dissection, trau- of mechanical devices to be utilized in the treat-
matic chordal rupture, or endocarditis can also ment of acute cardiogenic shock. Less-invasive
lead to acute cardiogenic shock. Intrinsic causes mechanical circulatory support (MCS) devices
such as acute myocarditis and takotsubo cardio- are now numerous and are becoming more widely
myopathy are other known causes of non- available. These include the intra-aortic balloon
ischemic cardiogenic shock. History and physical pump (IABP), extracorporeal membrane oxygen-
exam with normal coronary angiography should ation (ECMO), TandemHeart® (CardiacAssist,
raise suspicion of non-ischemic causes. Other Pittsburgh, PA), and ventricular assist devices
diagnostic modalities including electrocardiogra- (VAD), including Impella® (Abiomed, Danvers,
16 Difficult Decisions in Cardiothoracic Surgery: Acute Cardiogenic Shock 167

MA). There has been a shift to less-invasive mortality in patients treated with IABP. One-year
approaches of these devices in an attempt to follow-up of the IABP-SHOCK II trial [13] also
reduce morbidity while maintaining effective- demonstrated no difference in mortality. This
ness and perhaps to ultimately improve outcomes highlights the ongoing dilemma that MCS can
and mortality. Combined medical and surgical improve hemodynamics during a shock state, but
therapies (hybrid therapy) are also being discov- no large randomized trials have demonstrated
ered and utilized. This trend emphasizes the need improved mortality rates [14, 15] (Fig. 16.1).
for a multispecialty approach to the treatment of The latest guidelines from the American
acute cardiogenic shock. College of Cardiology (ACC) and American
Heart Association (AHA), along with the
European Society of Cardiology (ESC) and
Current Debate European Association for Cardio-Thoracic
Surgery (EACTS), were revised in 2013 and
The rarity of non-ischemic causes of cardiogenic 2014, respectively. The current consensus opin-
shock limits the availability of randomized data ion is for the use of either left VAD or ECMO for
in these subsets of patients, and thus the surgical patients in cardiogenic shock who need tempo-
decision-making process is of utmost impor- rary support, and IABP can be considered in cer-
tance. Randomized, large-scale studies on car- tain cases where mechanical complications are
diogenic shock complicating myocardial present [8, 16–18] (Fig. 16.2).
infarction, however, have been carried out. The
SHOCK trial [8], published in 1999, looked at
all-cause mortality at 30 days in patients with Mechanical Circulatory Support
ischemic cardiogenic shock. Patients randomized Therapy
to emergent (<6 h from presentation) revascular-
ization did not show any mortality benefit at 30 MCS refers to surgically placed devices as well
days when compared to those who were revascu- as the less-invasive devices discussed in this
larized non-emergently (<54 h from presenta- chapter. Less-invasive MCS devices are used in
tion). There was, however, a survival benefit at 6 the acute setting and are typically a bridge to a
months. This ignited further investigational stud- more permanent surgically placed MCS device.
ies attempting identify factors that could aid in When it has been decided that MCS is to be used,
decreasing overall mortality. Many of these stud- one factor that will alter the direction of the treat-
ies, including the TRIUMPH trial [12], focused ment algorithm is determining whether the right,
on the pathophysiology of ischemic cardiogenic left, or both sides of the heart are failing. It is
shock and pharmacologic therapies. necessary to utilize echocardiography to identify
Unfortunately, despite some promise, there have and characterize cardiogenic shock. Increased
been no major advancements since the SHOCK left and/or right filling pressures as well as
trial in terms of medical and pharmacologic ther- mechanical complications can be visualized and
apies that affect overall mortality. measured. This, along with other diagnostic
Over recent years, less-invasive MCS devices modalities, mentioned previously in this chapter
have gained favor as another therapeutic modal- will ultimately guide treatment.
ity for acute cardiogenic shock. These devices, Werden et al. described four categories for
used in conjunction with pharmacologic therapy, less-invasive MCS devices that are used in the
have, once again, shown promise. Intra-aortic acute setting based on pressure offloading of the
balloon pump (IABP), for example was once left ventricle, volume offloading of the left ven-
considered to be a class I treatment for cardio- tricle, biventricular support, or biventricular sup-
genic shock complicating myocardial infarction port with membrane oxygenation [14]. The
but the randomized IABP-SHOCK II trial [4], following sections discuss the currently used
published in 2012, showed no change in 30-day less-invasive MCS devices.
168 Z.P. Baker et al.

SHOCK Study

IABP Shock II Study

TRIUMPH Study
90
Shock present
80
70
60
CFR (%)

50

Revascularization
Revascularization
40

+ Tilarginine
- Tilarginine
30
Shock absent

+ IABP
- IABP
20
10
0

11
05

07

09

13
88

90

91

93

95

97

99

01

03
75

78

81

84

86

20

20
20

20
20

20

20
19

19

19

19

19
19

19

19

19
19

19

19

Fig. 16.1 Trends in hospital case fatality rates (CFR) in Hochman JS. Mechanical circulatory support in cardio-
patients with acute myocardial infarction in settings both genic shock. Eur Heart J 2014;35:156–67; Modified with
with and without the presence of cardiogenic shock. The permission from Goldberg RJ, Spencer FA, Gore JM,
illustration shows persistence of high mortality rates in Lessard D, Yarzebski J. Thirty-year trends (1975–2005)
patients who have cardiogenic shock complicating acute in the magnitude of, management of, and hospital death
myocardial infarction despite decreasing mortality rates rates associated with cardiogenic shock in patients with
related to improved revascularization strategies. (Used acute myocardial infarction—a population-based perspec-
with permission from Werden K, Gielen S, Ebelt H, tive. Circulation 2009;119:1211–19.)

diac output, and increased myocardial oxygen

Intra-Aortic Balloon Pump demand in the setting of already compromised
myocardium.
Intra-aortic balloon pump (Fig. 16.3), often Advancements in technology have simplified
referred to as intra-aortic balloon counterpulsa- the use of IABPs. Smaller gauge and even sheath-
tion, was first developed and used clinically in less catheters are now available. Unfortunately,
the 1960s [19]. The balloon catheter is inserted complications remain high with most series
into the aorta usually through the femoral artery reporting a rate of 15–30 % [20]. Despite this,
with the balloon placed just distal (approximately however, IABP has become widely utilized in the
2 cm) to the left subclavian artery. The presumed settings of cardiogenic shock and in certain high-
benefit is two-fold. During diastole, the balloon risk patients undergoing coronary artery bypass
inflates causing an increase in coronary perfusion grafting. Only recently has IABP effectiveness
pressure. Ideal inflation should correlate with the and impact on mortality been questioned. In 2012,
dicrotic notch of an arterial pressure waveform, the IABP-SHOCK II trial [4] showed no differ-
which indicates closure of the aortic and pul- ence in 30 day all-cause mortality: 39.7 % mor-
monic valves at the onset of ventricular diastole. tality in the IABP group and 41.3 % mortality in
Deflation of the balloon occurs during ventricular the control (no IABP) group. The same authors
systole, thus reducing afterload and increasing published 1-year follow-up data, also showing no
cardiac output, up to 1 L/min. [14] This simulta- significant difference in mortality between the
neously leads to a decrease in myocardial oxygen two groups. Other results of nonrandomized stud-
demand. Timing of balloon inflation and defla- ies have shown similar results [21–23].
tion can be set off against the patient’s cardiac Mentioned previously, the most recent rec-
telemetry, blood pressure, pacemaker (if present) ommendations from the ACC, AHA, and their
or it can be set at a specific rate. Improper timing European counterparts still include the use of IABP
can result in increased afterload, decreased car- in certain settings. These include cardiogenic
16 Difficult Decisions in Cardiothoracic Surgery: Acute Cardiogenic Shock 169

Patient with acute myocardial

Infarction
and cardiogenic shock

No mechanical complication Mechanical complication

Inotropes and fluids

Inotropes and fluids
Early Revascularization (PCI) ?
Early Revascularization (PCI) ?
Multivessel PCI vs CABG?
Multivessel PCI vs CABG?
IABP?

Yes Yes
Weaning Adequate Adequate
support? support?
No No

Percutaneous short or mid-term Percutaneous short or mid-term

VAD or ECMO VAD or ECMO

Yes
Weaning Recovery? Surgical repair of defect
No Implantable VAD?
Transplantation?
Implantable VAD? Total Artificial Heart?
Transplantation?
Total Artificial Heart?

Fig. 16.2 Treatment algorithm for patients with cardio- shown to decrease long-term (6 months) mortality [8, 18].
genic shock complicating acute myocardial infarction. Percutaneous MCS devices are used as temporary support
Recent American and European guidelines recommend until recovery or more definitive surgical support can be
consideration of IABP in cases where mechanical complica- accomplished [18]. (Used with permission from Thiele H,
tion is present [18]. Further recommendations are for the use Smalling RW, Schuler GC. Percutaneous left ventricular
of either VAD or ECMO in patients who need early mechan- assist devices in acute myocardial infarction complicated by
ical circulatory support. [16–18] Early revascularization has cardiogenic shock. Eur Heart J 2007;28:2057–63.)

shock with mechanical complications, such as in Relative contraindications include tachyar-

the setting of acute mitral regurgitation (MR) and rhythmias, aortic aneurysms, and severe peripheral
ventricular septal defect (VSD). The decrease in vascular disease.
afterload ultimately leads to left ventricular
offloading, lessoning the effects of these mechan-
ical complications. IABP is also used, at times, Percutaneous Ventricular Assist
for support during coronary revascularization Device (VAD)
(PCI) and post-MI myocardial infarction refrac-
tory angina or refractory LV left ventricular fail- Percutaneous ventricular assist devices (pVADs)
ure. Further applications include its use during are small mechanical pumps that provide short-
cardiac surgery or in weaning from cardiopul- term circulatory support, typically from a few
monary bypass. Absolute contraindications to days up to 14 days, thus improving hemodynamic
the use of IABP include aortic regurgitation, parameters, metabolic derangements, and organ
aortic dissection, and thoracic aortic stents. perfusion. Indications for use include cardiogenic
170 Z.P. Baker et al.

Fig. 16.3 Illustration of an intra-aortic balloon pump

Fig. 16.4 Illustration of TandemHeart® Device
(CardiacAssist, Pittsburgh, PA)

shock, as bridge to long-term options such as

surgically placed VADs or heart transplant, RV hemodynamic support and is not dependent on
right ventricular failure, and support for high-risk rhythm. The device is, however, preload depen-
procedure, and interventions like PCI or ventric- dent and once started, pulmonary capillary wedge
ular tachycardia ablation [24]. pressure (PCWP) should be monitored to ensure
The TandemHeart® (CardiacAssist, Pittsburgh, adequate filling and flow [24]. It has been used in
PA) [14] (Fig. 16.4) System is a left atrial to fem- acute MI complicated by cardiogenic shock, peri-
oral artery bypass system. It provides circulatory operatively in high-risk patients undergoing PCI,
support by continuous withdrawal of oxygenated and decompensated heart failure from acute
blood from the left atrium by means of a trans- myocarditis. It can be used preoperatively to
septal cannula placed through the femoral vein unload the left ventricle, and postoperatively
and pumped into the systemic circulation via until cardiac function returns, or a surgically
a femoral artery cannula, thus bypassing the placed LVAD can be implanted for long-term
left ventricle [25]. The continuous flow centrifu- support. The TandemHeart® can also provide RV
gal blood pump with an electromagnetically support by placing the inflow cannula into the
suspended and driven propeller supports up to 4 RA and the outflow into the PA as well as biven-
L/min pump flow. The pump provides rapid tricular support when used together [26].
16 Difficult Decisions in Cardiothoracic Surgery: Acute Cardiogenic Shock 171

cooling of blood flowing through the pump.

Additionally, distal limb ischemia, bleeding,
infection, and air embolism are also potential
complications. Contraindications include a VSD
which increases the risk of hypoxemia from a
right to left shunt. Other contraindications
include aortic regurgitation, severe peripheral
vascular disease, and the inability to be systemi-
cally anticoagulated [25, 26].
The Impella® (Abiomed, Danvers, MA) [14]
(Fig. 16.5) system is a catheter-based miniature
axial-flow pump that aspirates blood from the LV
into the cannula portion and then expels it into
the ascending aorta above the aortic valve. The
power connections for the pump motor and the
sensors are located within the catheter and the
end of the catheter is connected to an external
console which consists of an integrated pump
and purge system. The pump provides circulatory
assistance in acute myocardial infarction compli-
cating cardiogenic shock and during high-risk
PCI for up to 5 days. Catheter models vary in
size, maximum flow capabilities, and insertion
technique and can provide between 2.5 and 5 L/
min flow. The 5 L/min pump typically requires
surgical cut down of the femoral or axillary artery
as larger catheter size is required [24, 25].
Impella® unloads the left ventricle by deliver-
Fig. 16.5 Illustration of Impella® device (Abiomed, ing blood directly to the aorta, reducing LV end
Danvers, MA) diastolic volume (EDV) and wall tension,
decreasing LV work and myocardial oxygen
Short-term use of the TandemHeart® for a mean demand. Operation of the device results in an
of 4 (+/−3) days has been shown to significantly increase in cardiac output, MAP, and a decrease
improve cardiac index, increase mean arterial in PCWP and ventricular afterload leading to
pressure (MAP), decrease filling pressures, as well improved systemic circulation and coronary flow
as reduce pulmonary edema and metabolic abnor- [28]. It has been found to improve coronary per-
malities. A reduction in preload and afterload fusion through both increased aortic pressure
decreases myocardial oxygen demand while the with LV unloading and decreased wall tension
increase in MAP increases tissue perfusion and and has been found to reduce ventricular remod-
decreases serum lactate [25, 27]. eling in STEMI patients. Impella is load depen-
Potential complications include tamponade dent as forward flow decreases with increasing
from the trans-septal puncture as well as inad- afterload and subsequently the ventriculo-aortic
vertent puncture of the aortic root, coronary pressure gradient. It exhibits phasic motor fluc-
sinus, or posterior free wall. There is also a high tuations during the cardiac cycle and highest
risk of thromboembolism and as such, systemic pump flow is seen during systole when the gradient
heparin anticoagulation is necessary. Systemic is minimal. While it is preload dependent, inflow
hypothermia is also possible when contact of the is usually sufficient to maintain normal pump
system circuit with room temperature leads to action except in cases of extreme LV filling
172 Z.P. Baker et al.

pressures, a small left ventricular cavity, or severe pressures, can lead to a perfusion mismatch and
RV dysfunction [24, 25]. ischemia. This worsens RV dilation and the fall-
Like other pVADS, Impella® does require sys- ing cardiac output further displaces the septum
temic anticoagulation. Complications include and under fills the LV, leading to a possible suc-
bleeding, vascular injury, infection, and hemoly- tion event and a loss of the contribution of the
sis. Pump migration can occur if the catheter is septum to RV contraction [24, 26].
dislodged. Contraindications include peripheral No large-scale randomized trials have been
vascular disease, moderate aortic stenosis and done to assess mortality but some data are avail-
insufficiency, a mural thrombus in the LV, the able comparing pVADs and IABP. Seyfarth et al
presence of a mechanical valve, recent stroke, [32] showed an increase in cardiac index and
renal failure, liver dysfunction or coagulopathy, MAP with the use of Impella compared to
or an abnormal aorta that would preclude surgery IABP. There was no difference, however, in mor-
[25, 26]. tality or major complications including bleeding
pVADS have an additional role as an adjunct or limb ischemia, arrhythmias, and infections
to high-risk PCI in the setting of cardiogenic between the two devices. Other small series show
shock or severe LV dysfunction. Both can be similar data in terms of mortality with minor
implanted at the time of high-risk PCI and differences in the rate of complications.
removed after the procedure, providing short-
term hemodynamic stability [24, 29]. Both have
also been used in unstable ventricular tachycar- Extracorporeal Membrane
dia (VT) ablation as induction of VT during abla- Oxygenation (ECMO)
tion for activation mapping can lead to further
instability. It has been shown to allow for identi- Extracorporeal membrane oxygenation (Fig. 16.6)
fication of a greater number of VT foci and allow was one of the earliest methods utilized for
for a longer time in induced VT as well as fewer mechanical circulatory support. It provides tem-
early terminations of VT for hemodynamic insta- porary support via an external pump and is used
bility. Evidence also shows reduced cerebral primarily in the setting of cardiopulmonary fail-
desaturation suggesting increased efficacy of ure. The femoral or jugular vein is typically used
peripheral perfusion [24, 30]. as an inflow source to the device when accessed
RV failure can occur in cardiogenic shock, percutaneously. Central access sites including
after MI, and postoperatively after heart trans- the cava may also be utilized but require more
plant or surgical LVAD placement. Early RV advanced surgical placement. The different
failure following LVAD implant is defined as modes of ECMO are thus separated by the out-
need for mechanical support of the RV or flow sources: venous and arterial. Veno-arterial
>14 days of inotropic support. [31] ECMO is illustrated in Fig. 16.6 and has become
Preoperatively, RV function can be modified an established treatment option in the setting of
with vasodilators, inotropes, and optimization of refractory cardiogenic shock [33].
RV preload, but in refractory situations, mechan- The ECMO circuit mimics a cardiopulmonary
ical support is necessary. While LVAD implanta- bypass machine used in the operating room and
tion decongests the LV and reduces back pressure includes a membrane oxygenator, a pump, and a
on pulmonary circulation, it also delivers a heat exchanger. Venous drainage, regardless of
greater RV preload. Additionally, an interven- the source, is best optimized by passing the cannula
tricular septal shift into the LV may restrict the in or near the right atrium which allows decom-
tricuspid leaflet, leading to significant tricuspid pression of the right heart. The blood is then
regurgitation and further RV volume overload. passed through the oxygenator and into the arterial
This demand on the RV to match LVAD-assisted outflow, which can ultimately lead to an increase
LV output, combined with reduced RV perfusion in left ventricular afterload. Its use in ischemic
pressure from high RV systolic and diastolic cardiogenic shock has thus been questioned [34].
16 Difficult Decisions in Cardiothoracic Surgery: Acute Cardiogenic Shock 173

Conclusion

Despite improved medical and surgical therapies,

acute cardiogenic shock remains a major clinical
problem with unacceptably high mortality. Most
commonly, cardiogenic shock is caused by isch-
emic changes from myocardial infarction. The
SHOCK trial [8] has been the only major clinical
breakthrough to show an improvement in mortal-
ity in patients who develop cardiogenic shock
complicating myocardial infarction, making
early revascularization a priority. Circulatory
support for all causes of cardiogenic shock con-
tinues to be less clear. The IABP-SHOCK II trial
[13] demonstrated that the physiologic benefits
of IABP don’t lead to decreased mortality. There
has subsequently been a push for improved thera-
peutic strategies, including less-invasive devices.
Complications, however, remain high in certain
series, and further prospective data are needed to
determine the effect these novel devices have on
mortality.
Future treatment modalities in acute cardio-
genic shock will likely include advancements of
the current devices along with hybrid therapies.
A recently published case series [37] showed the
use of a percutaneously placed biventricular
device in three patients with cardiogenic shock.
Fig. 16.6 Illustration of veno-arterial ECMO This novel approach allowed for decreased surgi-
cal trauma and earlier postoperative ambulation
which may optimize outcomes. Non-device ther-
To counteract this negative affect on afterload, apies, such as stem cell implantation, are also on
other studies have advocated for the use of IABP the forefront and will likely have a role when
whenever ECMO is utilized for ischemic cardio- combined with temporary circulatory support,
genic shock [35, 36]. There are, however, no ade- providing more durable long-term treatments.
quate trials to definitively clarify its role.
Similar to other percutaneous mechanical
assist devices, systemic anticoagulation is References
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 Dealing with the Most Difficult
Situations in Pediatric Surgery 17
Oliver S. Soldes

The resiliency and vigorous physiology of

Perspectives on the Practice children permits survival in circumstances that
of Pediatric Surgery would quickly lead to the demise of elderly
patients. Long hospital stays, frequently span-
The specialty of pediatric surgery is uniquely ning many months, are not uncommon for neo-
broad in the scope of the anatomic areas and age nates with multiple congenital anomalies. Staged
range of the patients cared for by its practitioners. procedures and repeat procedures are also quite
Pediatric surgeons manage problems from the common. Many patients have multiple related
head to the foot and from the first day of life into anomalies (i.e., VACTERL association) or
adulthood. They frequently manage problems genetic disorders that require multiple specialists
that require both broad and detailed anatomic to manage. A strategy to address each condition
knowledge with a range beyond that of surgical and in what order is frequently necessary. A sin-
subspecialists who focus on a single organ sys- gle pediatric surgeon or surgical practice may
tem. Most of the major neonatal anomalies, pedi- perform a dozen or more procedures on a single
atric solid tumors, and major surgical conditions patient with multiple anomalies. For example, a
are relatively rare on a population basis. The lit- hypothetical patient with multiple elements of a
erature on the management of some rare pediatric complex VACTERL association (vertebral, ano-
surgical disorders and of their late complications rectal, cardiac, tracheoesophageal, renal and limb
is sometimes limited to small case series, and at anomalies) may potentially have the following
times, anecdotal experience. There are few ran- procedures within the first few years of life:
domized trials. The breadth of the specialty and
rarity of many conditions places a premium on 1. Tracheoesophageal fistula and esophageal
clinical experience. Subsequently, training for a atresia repair.
career in Pediatric Surgery is long and intense 2. Broviac catheter placement and later
and the acquisition of new knowledge and expe- removal. Sometimes they may have multiple
rience never really ends. This makes for both a Broviac catheters placed over an extended
rewarding and challenging professional career. period of time.
3. Repair of duodenal atresia.
4. Temporary divided colostomy for imperfo-
O.S. Soldes, M.D., F.A.C.S., F.A.A.P. (*) rate anus.
Division of Pediatric Surgery, Akron Children’s 5. Posterior sagittal anorectoplasty (PSARP)
Hospital, One Perkins Square, Suite 8400,
Akron, OH 44308, USA for imperforate anus.
e-mail: osoldes@chmca.org 6. Colostomy closure following PSARP.

© Springer International Publishing Switzerland 2016 177

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_17
178 O.S. Soldes

7. Gastrostomy tube placement. uisite for success in the care of children. Those
8. Nissen fundoplication. who lack this insight are primed for failure and
9. Closure of gastrostomy site. may rapidly dismiss a career in Pediatric Surgery.
10. Multiple dilations of esophageal stricture The junior trainee often has minimal experience
and later removal of swallowed esophageal as a parent and may have an insufficient under-
foreign bodies. standing of the dynamic between a parent and
11. Redo tracheoesophageal fistula repair for young child. They may not have the emotional
recurrence. frame of reference to understand fully the grief
12. Redo Nissen fundoplication for slipped and anxiety that accompanies the illness of one’s
Nissen or herniation of the fundoplication child. Conditions that seem minor to the trainee
wrap. may be a source of major concern for a parent.
13. Repair of complex cardiac anomaly. Furthermore, minor misstatements regarding the
14. Etc. patient’s condition and treatment plan can create
a loss of confidence in the care provided by the
Subsequently, pediatric surgeons develop whole surgical team.
extensive experience with the long-term care Another major difference between pediatric
(years to decades) and follow-up of disorders of and adult surgery is that good health is presumed
infancy and childhood. These patients and their in children. Most parents’ expectations are that
families may have a strong attachment to the chil- they will have a healthy child. Thus, a health cri-
dren’s hospital and the practitioners who have sis in infancy or childhood is both unexpected
cared for them for many years. Forging strong and devastating. Furthermore, the parents of the
relationships with children and their families is vast majority of children are young adults and
especially important in these situations. they may have little personal experience with
major illness in a family member and limited
experience with the healthcare system. They may
Understanding and Working have uninformed or have unrealistic expectations
with Family of the limits of surgical or medical care. Setting
appropriate expectations and educating parents
From a parental perspective, there are three major early in the course of treatment is essential. The
expectations of providers and health care ability to reduce anxiety and inspire confidence is
organizations: a hallmark of the seasoned surgeon, as much as
technical proficiency and good surgical
1. Heal my child. judgment.
2. Keep my child safe from harm. The parents of ill children are like any other
3. Be nice to my child and to me. persons and have a variety of personality and cop-
ing styles. They may be anxious, passive, aggres-
Providers should keep these expectations in sive, hostile, detached, etc. Parents are also better
mind whenever caring for children. The first two informed than ever regarding their children’s con-
expectations are straightforward and are the ditions. Keeping the focus on the child and their
focus of evidenced-based medicine and surgery. care is helpful in dealing with all parents. A key
The third expectation may define the parental point is to devote adequate time and attention to
perception of the first two no matter how techni- the parents and their concerns. The simple act of
cally perfect the care. sitting down in the patient’s room to talk with an
When surgical trainees first care for ill chil- anxious or upset parent immediately, rather than
dren, encounters with anxious and distressed par- talking from the doorway during work rounds
ents may be a major challenge. Trainees who with the resident team, goes a long way toward
understand the parental point of view and can diffusing a difficult situation and establishing the
empathize with parents have an essential prereq- relationship essential for success. If the provider
17 Dealing with the Most Difficult Situations in Pediatric Surgery 179

is unable to devote sufficient time at that moment clinical situation and then applying a stan-
due to pressing clinical activities, it is best to set a dardized rule or guideline. It is infrequently
time when they can devote their full attention to used in the pediatric surgery as there are
the parents and their concerns. Avoiding misun- numerous clinical variations of any given clin-
derstandings and unnecessary conflict is equally ical problem and few randomized trials or
important. It may be difficult to maintain a pro- strict guidelines.
ductive therapeutic relationship once a relation- 4. Creative decision making: The practitioner
ship has gotten off on the wrong foot. devises a novel course of treatment for an
Surgical Decision Making uncommon or unfamiliar situation. It is infre-
Surgeons must make decisions about when quently applied in high risk, high pressure
(and when not) to operate, select an appropriate situations. It can at times be invaluable in
operation, and make real-time (and sometimes dealing with rare problems and unusual situa-
irreversible) decisions during a procedure [1]. tions. It is a source of innovation.
They must also review the patient’s post-op prog-
ress and make further decisions when the clinical In interview studies of surgeons’ intraopera-
course is difficult or if their plan fails [2]. The tive decision making, intuitive and analytical
ability to make sound surgical decisions is as decision making were most commonly employed
essential as the technical ability to operate. It strategies [2, 5]. Risk management was discussed
results through the acquisition of knowledge, by surgeons throughout the interviews in a study
professional experience, and reflection [1, 3]. regarding their intraoperative decision making
Decisions are made by collecting medical infor- [5]. Risk is a key consideration in such decision
mation, considering and interpreting the data making. Risk constitutes the risk for injury to the
within the knowledge, experience and abilities of patient, the surgeon (reputation, liability, etc.),
the surgeon and the formulating a management the clinical team members, and the healthcare
plan [1]. Flin et al. [4] described four types of organization. Risk management was divided into
naturalistic intraoperative decisions making: three areas: threat perception, risk assessment,
and the risk tolerance of the surgeon and the
1. Intuitive or recognition primed decision mak- patient [5].
ing (RPD): A clinical problem is recognized There are myriad clinically useful pitfalls and
and the solution is recalled from prior experi- pearls in surgical decision making. These include,
ence in a similar situation. The practitioner but are not limited to:
matches the problem to a pattern (pattern rec-
ognition) [2]. This process is rapid and seems 1. Incorrect identification of the situation and
automatic. It is employed by experienced then taking the wrong action: This can be
practitioners in familiar situations. It is also disastrous regardless of the type of decision
useful under situations with acute time stress making employed.
and emergency situations. 2. Excessive deliberation: Situations of high risk
2. Analytical decision making: The practitioner and high time pressure require speed and do not
enumerates and then compares various permit deliberation. Novices who rely on ana-
courses of action simultaneously, weighing lytic rather than intuitive decision making may
risk, benefits, alternatives, etc. to determine have more difficulties with this than do experts.
the best course of action. This process requires 3. Plan-continuation errors: These errors occur
more time and deliberation, and it is used in may occur whenever a surgeon persists with a
preoperative and postoperative situations, and therapeutic plan despite evolving clinical data
intraoperative situations with lesser time that suggests that the current surgical plan
stress. should be modified or abandoned [5].
3. Rule-based decision making: This method of 4. Morbidity and mortality conference (the
decision making requires identification of a “Surgical Audit”): When done properly, such
180 O.S. Soldes

conferences create an opportunity for reflec- lines, inguinal hernia repairs, consultations,
tion and analysis, which improves experience supervision of medical management of necrotiz-
and future decision making [1]. ing enterocolitis, etc.). In some of these hospitals,
5. It is impossible to become an expert without subspecialty Pediatric Radiology and Anesthesia
experience [3]: However, this does not neces- providers may be available only on a part-time
sarily mean that every specific clinical prob- basis. There may be substantial pressure from
lem needs to be managed multiple times to be administrators, medical colleagues, or parents to
competently managed. Surgical skills are provide complex and high-risk surgical care in an
transferrable from one situation to another environment where all the optimal services are
(i.e., the technique of handsewn anastomosis), unavailable on-demand. In these cases, the sur-
particularly after a base level of competency is geon may be fully capable of managing the prob-
achieved (i.e., completion of residency/fel- lem but the full clinical team is not. These
lowship training, board certification, etc.). situations may produce significant external and
Experience with similar cases often provides internal conflict for the surgeon. When these situ-
sufficient experience to achieve acceptable ations arise, the best course of action may be to
outcomes. transfer and then manage the social and profes-
sional fallout. Discussion with a colleague
(Would you do this case here?) may be invalu-
How to Stay Out of Trouble able. Situations of locum tenens coverage, which
and When and Whom to Call are increasingly accepted and common, may
present similar challenges because of unfamiliar-
A hallmark of the seasoned surgeon is the ability ity with the capabilities of the other local provid-
to recognize difficult or hazardous clinical situa- ers. The occasion may also arise where the patient
tions and formulate a plan to avoid the hazard or is too unstable to transport, even across town and
anticipate and manage it, if it arises. This skill a procedure must be undertaken with the avail-
generally develops from experience and repeti- able resources.
tion. It requires introspection and self-awareness Another quandary may be for the adult sur-
to acknowledge when a problem is sufficiently geon in a more rural area or far away from a
complex, unfamiliar, or difficult to proceed with- children’s hospital, who is well qualified and
out further preparation and resources. At these frequently called on to manage more routine
times, seeking the counsel of and working with pediatric problems (i.e., appendicitis in a
another experienced surgeon generally leads to 5-year-old, incarcerated infant hernia) which
satisfactory care. Recognizing when a clinical have subsequently taken a bad turn. In some
problem is outside of the capabilities of a health areas, the time/distance to a tertiary pediatric
care organization or a clinical team is an essential facility is such that it is impractical to transfer
first step in staying out of trouble and sign of sur- all patients. Most surgeons are generous with
gical maturity. their advice and time and feel a responsibility
All surgeons have found themselves in diffi- to assist their colleagues. The number of pedi-
cult clinical situations and requested the advice atric surgeons is sufficiently small that an esprit
and assistance of their colleagues. When to call de corps exists within the community of
for advice or assistance requires knowledge of surgeons, which facilitates these interactions.
one’s capabilities and the clinical team available Virtually, all pediatric surgeons have received
to them. Pediatric surgeons may at times find such calls. Most prefer to be called earlier in
themselves with a risky clinical circumstance the course of the disease, rather than later. The
when covering a NICU in a large community “who” to call depends on the regional and clini-
hospital where they may routinely provide less cal circumstance, but it is generally the closest
complex neonatal surgical care (placement of pediatric surgical center.
17 Dealing with the Most Difficult Situations in Pediatric Surgery 181

References 3. Hall JC, Ellis C, Hamdorf J. Surgeons and cognitive

processes. Br J Surg. 2003;90(1):10–6.
4. Flin R, Youngson G, Yule S. How do surgeons make
1. Francis DMA. Surgical decision making. ANZ J Surg.
intraoperative decisions? Qual Saf Health Care.
2009;79(12):886–91.
2007;16(3):235–9.
2. Campbell G, Watters DAK. Making decisions in
5. Pauley K, Flin R, Yule S, Youngson G. Surgeons’
emergency surgery. ANZ J Surg. 2013;83(6):429–33.
intraoperative decision making and risk management.
Am J Surg. 2011;202(4):375–81.
 A Surgeon’s Thought Process
in the Management of Burn 18
Patients

Gary A. Vercruysse and Walter L. Ingram

resuscitation. For example, anyone with a burn

Introduction less than 10 % TBSA who can eat and drink will
likely not require fluid resuscitation. We always
As a general rule, the vast majority of burn use Ringer’s lactate for initial resuscitation. If NS
patients do well, as most burns are small and is used, within a few hours, the patient will
most patients are healthy [1]. For the minority of predictably develop a severe hyperchloremic
patients who present with large burns (% TBSA metabolic acidosis in addition to the already seri-
in excess of 20 %) survival depends on the size ous lactic acidosis driven by the dehydration
and depth of the burn as well as the extent of experienced by those with large burns. We do not
other associated injuries and patient comorbid resuscitate children with large volumes of hypo-
conditions. The list of those requiring admission tonic fluids. It is important to understand that
to the hospital with burn services is depicted in these formulas are for initial IV fluid rates only.
Table 18.1. More critically ill burn patients If a patient is making adequate urine, and not
should be admitted to the ICU at a Burn Center physiologically deranged (not hyperglycemic, or
(Table 18.2). If there is a question as to the neces- acidotic), you should tailor the fluid rate to urine
sity for transfer, teleconsultation is a reasonable output. During pediatric burn resuscitation,
option and can save significant costs in transfer remember that children may have limited glyco-
and duplicated work up [2, 3]. If the decision is gen stores, so give part of the Galveston formula
made to transfer a patient to a burn center, they (the maintenance fluid component) as D5 LR to
will need resuscitation. Several formulae exist avoid hypoglycemia. As stated before, always
for initial resuscitation (Tables 18.3 and 18.4). adjust the IVF rates such that adults have a urine
Please keep in mind that not all patients will need output of at least 40 ml/hr, but they do not need to
make 500 ml/hr; and children have an output of
1 ml/kg/hr, but not 3 ml/kg/hr. Also make certain
that if present, the patient’s metabolic acidosis is
G.A. Vercruysse, M.D. (*)
Department of Surgery, Banner University Medical resolving. Remember, some patients require
Center, University of Arizona, 1501 N Campbell more fluid, some require less. On Post burn day
Ave., Rm 5411, PO Box 245063, #2 for larger burns (>30 % TBSA), a 5 % albu-
Tucson, AZ 85724, USA
min drip can be started at 1 ml/kg% TBSA burn
e-mail: gvercruysse@surgery.arizona.edu
for 24 h. This will help to mitigate unnecessary
W.L. Ingram, M.D.
interstitial edema [4, 5].
Department of Surgery, Emory University School of
Medicine, 69 Jessie Hill St., 3rd FL, Glenn Building, Exceptions to the 30 ml/hr or (1 ml/kg/hr)
Atlanta, GA 30303, USA urine output rule:

© Springer International Publishing Switzerland 2016 183

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_18
184 G.A. Vercruysse and W.L. Ingram

Table 18.1 Admission criteria for burns patients Table 18.3 Initial treatment
1. Full thickness (third degree) burns >3 % TBSA 1. Check airway and breathing
2. Burns with possible inhalation injury 2. Check blood pressure and establish IV access
3. Infected burns (those who did not seek care until 3. Draw Lytes, CBC, ABG with carboxyl
their burn became infected) hemoglobin, coags, type, and cross
4. Electrical burns 4. Obtain relevant history quickly:
5. Hydrofluoric acid burns (a) Cause and type of fire
6. Suspicion of child or elder or spousal/significant (b) Location, smoke exposure, loss of
other abuse consciousness?
7. Perianal and/or buttock burns (c) Time burn occurred
8. Lower extremity burns in diabetic patients or (d) Other trauma: does patient need a trauma
patients with peripheral vascular disease workup?
9. Any significant chemical burns (e) Allergies
10. New circumferential extremity burns (f) PMH, PSH
11. Any burn in a child greater than 10 % TBSA 5. Obtain CXR (chest X-ray) and other needed films
12. Any burn in an adult greater than 20 % TBSA 6. Estimation of wound size (% TBSA)
13. Any burn in an “elderly” (more than 50 years 7. Do not attempt major debridement in the ED
old) person greater than 10 % TBSA 8. Call Burn Center to begin transfer arrangements
9. Wash the patient with warm saline solution and
towel dry, then place in dry sheets and blankets to
Table 18.2 ICU admission criteria avoid hypothermia
A. Burns 20 % TBSA or greater, any age patient 10. Include all films and labs obtained to transfer
B. Burns 10–20 % TBSA if the patient is >50 or <5 with the patient
years old, or if most of the burn is full thickness (third 11. Prepare for transport to Burn Center
degree)
C. Burns <10 % TBSA if there is a significant
history of smoke inhalation Table 18.4 Basic burn resuscitation formulae
D. Any burn patient with severe medical problems Several longstanding formulae exist for the
E. Any patient with toxic epidermal necrolysis or resuscitation of burn patients. Below are some
Stevens-Johnson syndrome examples
F. Any patient that has to be sedated to the point of For burns in adults >20 % TBSA or the elderly > 10 %
unconsciousness to do wound care TBSA
G. Any patient that requires more than 4 L Nasal Parkland formula: 4 cm3 × (% TBSA of second and
Cannula oxygen third degree burn) × kg wt = cc/24 HR’s. Give
one-half of this fluid in first 8 h; use Ringer’s lactate
OR
A. Chronic renal failure: These patients require a Rule of tens for burn resuscitation
CVP Swan-Ganz catheter or other objective Using lactated Ringers
measure of resuscitation. 1. Estimate burn size to the nearest 10 %
B. Myoglobinuria: Not uncommon in large 2. Multiply % TBSA × 10 = Initial fluid rate in
burns or electrical burns; in this case you mL/h (for adult patients weighing 40–80 kg)
should try to achieve 100 ml/hr of urine 3. For every 10 kg above 80 kg, increase the
rate by 100 mL/h
output.
If the patient is an adult and weighs less than 40 kg
C. Hyperglycemia: More common in young use the Parkland Formula
patients. Glycosuria causes a high urine out- For children: burns >10 % TBSA
put in face of hypovolemia. Galveston formula. Find BSA from normogram
5000 cm3 × (BSA × fraction of BSA
One should keep in mind that patients with burned) + (2000 cm3 × BSA). Give one-half in first 8 h
large burns will be sicker than they may appear.
A patient with a 90 % burn who is 60 years old It is important that you remember that this is a
can have a normal conversation with you and be temporary phenomenon. The cytokine release
in only moderate distress for about 4 h post burn. that occurs during this period will cause shock to
18 A Surgeon’s Thought Process in the Management of Burn Patients 185

begin about 6 h post burn and the patient will cations are cyanosis of the extremity paresthesias
become soon be much sicker. and loss of capillary refill/loss of pulse-ox signal
Similarly, a patient with a much smaller burn from the extremity.
(~20 % TBSA) can look relatively well for a cou- After giving sedation, cut the eschar with a
ple of days before developing an infection that knife or bovie cautery. This can be very painful,
will become life-threatening in a matter of hours. so make certain that the patient has received suf-
These patients are severely immunosuppressed ficient narcotics. Classically, a medial and lateral
and are prone to acute deterioration [6, 7]. Our incision is made on the arms or legs. It is carried
current theories of multisystem organ failure sug- down to the subcutaneous fat to allow the extrem-
gest that Acute Respiratory Distress Syndrome ity to expand. After ensuring hemostasis, wrap
(ARDS) results from under-resuscitation of the limb with Silvadene after the procedure.
shock [8, 9]. One has to be cognizant that that Avoid cutting through normal skin during escha-
ARDS in burn patient may occur almost any rotomies if burned skin is available. Incisions do
time. It can be triggered by something as simple not need to be strictly medial and lateral, but
as an infected IV site, thus careful examination of should be adjusted to avoid non-burned skin
such patients is a must. Often, it is difficult to tell whenever possible.
when a burn patient has ARDS. A patient can be Always check the patient after an escharot-
at rest and have an oxygen saturation of 80–85 % omy has been done to make certain flow has been
without clinical symptoms [10]. While there are reestablished. Rarely, a fasciotomy will be
number of issues where surgical decision-making needed to reestablish adequate blood flow to the
process is of outmost importance, in this chapter effected extremity. Escharotomies are most com-
we will concentrate on the surgical aspects of the monly needed in patients who have circumferen-
management. tial deep second and third degree burns on the
chest or extremity and who will receive large vol-
umes of fluid for their resuscitation. If it is appar-
Escharotomies ent that the patient will eventually need an
escharotomy, do not wait until doppler signals
The decision to perform escharotomies may seem are lost. The most advantageous time to do this
straightforward, but it is not. In patients with cir- procedure is when the patient is in his room with
cumferential extremity burns, the arm or leg good IV access and fully monitored.
swells while the burned dermis does not stretch.
This can allow pressure to build up under the
eschar. When the pressure rises to above tissue Basic Wound Care and Dressings
perfusion, pressure ischemia will result. First, the
nerves will become ischemic and patients, if con- Antimicrobial Dressings
scious, will note tingling. Next, the muscles will
become ischemic, and, if nothing is done, rhab- After the initial debridement of the epidermis,
domyolysis and necrosis will result. If left under topical antimicrobial dressings are started on all
compression, the patient will develop a compart- burns. The goal of the antimicrobials is to limit
ment syndrome, which can be prevented by cut- bacterial overgrowth on and under the eschar and
ting the eschar and letting the swollen tissue thus prevent or limit burn wound cellulitis and
expand. Escharotomies are done for patients with burn wound sepsis, and which topical microbial
deep second and third degree burns that are cir- agent is used depends on the activity as well as
cumferential around the chest, extremities, abdo- side effects of such agents. Types of dressings are
men, penis, or neck [11–13]. as follows:
The most common indication for escharoto-
mies is loss of the palmar arch Doppler signal for A. 1 % Silver Sulfadiazine Cream (Silvadene®,
upper extremities and loss of the posterior tibial Hoechts Marion Roussel, Kansas City, MO):
Doppler signal for lower extremities. Other indi- A combined agent sulfonamide and silver
186 G.A. Vercruysse and W.L. Ingram

ion. SSD has fair eschar penetration. Apply absorption occurs, and it does not penetrate
once a day, and cover with gauze. Not used on eschar. It is used by placing the patient in
face or ears. SSD has good gram positive, large bulky dressings of gauze and pouring
gram negative, and antifungal properties. It is the Silver Nitrate Solution on them Q2-3H to
painless, but can cause leukopenia that usu- keep the dressings moist. The bulky dressings
ally spontaneously resolves. It is contraindi- are changed Q8-12H. This dressing is more
cated in true sulfa allergies. The sulfonamide of a historic footnote, but it can be used if
component of silver sulfadiazine can be other preparations are not available. These
absorbed through the skin. This is especially dressings can cause hyponatremia and hypo-
true in small children who have a greater kalemia due to the distilled water washing out
area-to-mass ratio. Sulfonamides can cause electrolytes. BMP should be checked at least
kernicterus in newborns. For these reasons Q8H initially. In addition, the nitrate ion can
silver sulfadiazine is contraindicated in chil- cause methemoglobinemia (the iron atom is
dren under 2 months of age. For these oxidized), which will impair oxygen delivery.
patients, gentamicin or bacitracin ointment Methemoglobinemia levels should be
should probably be used. As an ointment, it checked Q4-6H. If above 10 %, 1 amp of
does not contain propylene glycol and the Methylene blue (up to 1 mg/kg) (a reducing
absorption can easily be monitored by check- agent) should be given. Vitamin C (another
ing gentamicin levels. Silver sulfadiazine reducing agent) should be given 500 mg BID
cream is the most common dressing used for for patients on Silver nitrate dressings over a
initial wound care. It can also be used on large part of their body. This type of dressing
donor sites [14–16]. is used only for documented sulfonamide
B. Mafenide Acetate (Sulfamylon®, Mylan allergy, patients with toxic epidermal necrol-
Bertek Pharmaceuticals, Sugar Land, TX): A ysis (Stephens-Johnson Syndrome), or some-
2 % solution of sulfonamide that penetrates times on fresh skin grafts for a couple of days
eschar well and is rapidly absorbed. [19–21].
Sulfamylon has broad spectrum antimicrobial D. Bacitracin Ointment: Used on the face burns
qualities and is bactericidal at wound concen- or on small burns <5 % because it is clear. It
tration. It has good gram positive and gram probably does not inhibit epithelialization as
negative activity, including Clostridia, but has much as Silvadene. It is useful for superficial
little antifungal activity. It can be used BID partial thickness burns or clean donor sites
because wound levels fall as it is absorbed. It where the opsite or xeroform dressing has
causes pain when applied and it is a strong come off. It is best if used with nonstick
carbonic anhydrase inhibitor, causing loss of gauze.
bicarbonate in the urine and if used in great E. Nystatin-Silvadene: 50–50 mixture. Nystatin
amounts can cause polyuria [17]. It is mainly is a polyene antibiotic structurally similar to
used to control invasive wound infections Amphotericin B. They bind ergosterol in the
(until surgery can be done). It is often used fungus cell membrane. It has broad spectrum
alternately with Silvadene. Patients who are antifungal effect, but little antibacterial effect.
getting sulfamylon dressings need close mon- It is used with Silvadene in cases of heavy
itoring of their pH, and often need supple- fungal colonization of the burn wound or in
mental bicarbonate. This is often used on ear invasive fungal burn wound infections. It is
burns because it penetrates into the cartilage not systemically absorbed, and resistance is
and helps prevent chondritis [18]. rare.
C. 0.5 % Silver Nitrate Solution: Prepared in
distilled water (because of the solubility of Once the wound is washed and debrided and
silver salts). Broad spectrum antimicrobial antimicrobials have been applied, we dress the
action resistance is uncommon. Minimal wound with kerlex gauze, and either loosely
18 A Surgeon’s Thought Process in the Management of Burn Patients 187

applied elastic : netting, or ace wraps. Dressings confirmed by wound biopsy and frozen sec-
are then changed daily until a decision to operate, tion. The treatment is broad spectrum antibi-
or manage nonoperatively has been determined. otics and excision of the necrotic part of the
All along, patients and their families are encour- wound. Burn wound sepsis can attack normal
aged to participate in dressing changes as much tissue and thus make the burn deeper. It can
as possible, so as to learn to care for the wound also infect donor sites and convert them to
once the patient is discharged. full thickness wounds. On a large wound,
these infections can have a very rapid course
[25–27].
Antibiotics and Infections C. Pneumonia: This is the most common infec-
tion occurring in the ICU, usually in intu-
Burn injury causes suppression of all compo- bated patients. It is difficult to diagnose. The
nents of the immune system. Furthermore, when patients need to have three of the following:
burned, patients have lost the barrier function that (1) a new infiltrate on CXR; (2) numerous
the skin provides. This makes burn patients very white blood cells on gram stain of sputum;
prone to infection [22, 23]. Early diagnosis and (3) a predominant pathogen on sputum cul-
intervention are essential to care for the burn ture; and (4) some of the signs of sepsis (see
patient. Antibiotics should be directed as specifi- signs of sepsis in the burn patient). This infec-
cally as possible at the known or most likely tion most often occurs after the patients have
pathogens. The most common types of infections been intubated for 5–7 days. The pathogen is
are: almost always a gram negative rod;
Acinetobacter or Pseudomonas is common.
A. Burn wound cellulitis: This usually occurs in There is no one antibiotic or combination of
the first 3–5 days after the burn injury (but it antibiotics that kills all of the gram negative
can occur within 24 h of injury). The burn pathogens, so it is essential that you check the
acts as a portal of entry for Gram (+) organ- cultures and sensitivities daily. In the past,
isms (usually streptococcus and, less com- antibiotics such as Ticaricillian/clavulanic
monly, staph). The patient develops an acid, or Imipenem/Cilastatin with an amino-
erythema extending several centimeters from glycoside such as tobramycin or amikacin
the wound edge. There is swelling, especially have been effective [28].
if an extremity is involved. The patient will D. Peripheral and Central Line Infection:
almost always have a fever to Intravenous catheters are both essential to the
38–39.5 °C. Treatment is with a beta- burn patient and one of the most frequent por-
Lactamase resistant penicillin or a first gen- tals of infection [29].
eration cephalosporin (Ancef®, 1. Change of Lines: Central lines are changed
GlaxoSmithKline, Brentford, UK). The to prevent infection. The longer the lines
patients usually respond to therapy within stay in, the greater incidence of infection.
48–72 h, and then they can be switched to PO Line sepsis is a clinical diagnosis. To pre-
antibiotics. If penicillin-allergic, clindamycin vent sepsis, the site of the line should be
is a good alternative. Rarely, the cellulitis will changed if the patient has a fever, elevated
not respond to these measures, and gentami- white cell count, and is without an obvious
cin can be added, or the burn may need to be source. If the line site is purulent or ery-
excised [24]. thematous, change the line. In general, do
B. Burn wound sepsis: This is a systemic infec- not do changes over a guide wire unless
tion caused by proliferation of bacteria in the you have tried three times to change a line
burn wound. It has a high mortality. The diag- and have not met with success. There is
nosis is usually made clinically by the appear- little to be gained by culturing the tip or
ance of the wound. The diagnosis can be the intracutaneous portion of the catheter.
188 G.A. Vercruysse and W.L. Ingram

Never draw a blood culture from a central nized promptly and be properly treated. The
line unless you do it as you are inserting it diagnosis is made by history and physical exam.
[30, 31]. Peripheral lines should be The patient will report new pain or an increase of
changed when the patient arrives in the pain in the ear; the ear will be erythematous and
unit (field lines) and if they become ery- tender to palpation; and there will be an increase
thematous, or a palpable cord is present. in the auricularcephalic angle: the ear will pro-
2. Suppurative thrombophlebitis: When a trude laterally from the head. Chondritis usually
peripheral line becomes infected, pus can occurs 2–6 weeks after the burn, often after the
accumulate inside the cannulated vein, patient has gone home. It can occur after a super-
forming what amounts to an intravascular ficial second degree burn, as well as a third degree
abscess. The infection subsequently pro- burn. The ear must be carefully examined for
gresses up the vein. The patients develop a small abscesses. If any are present, they must be
fever, leukocytosis, and a painful swollen incised and drained in the OR, and any necrotic
IV site. Sometimes pus can be expressed cartilage must be debrided. Sometimes, an irriga-
from the insertion site. This is a common tion catheter is left in the ear and antibiotic irriga-
hospital acquired infection in burn tion is used post-op. The patients should be
patients. The organism responsible is usu- started on IV antibiotics. There is a technique for
ally a gram positive, though gram nega- making antibiotics go into the cartilage with a
tives and yeast can also cause it. Remember low voltage electric current (ionophoresis). This
that suppurative thrombophlebitis can technique can be used for refractory cases. The
occur in veins where the IV had been most common organism is Pseudomonas aerugi-
removed. The treatment is to administer nosa but gram positive infections are possible,
antibiotics and to excise the infected vein and cultures should always be sent. The infection
up to the point where it becomes normal in the cartilage can be very difficult to eliminate.
again. Rarely, suppurative thrombophlebi- Often it recurs after appearing initially to be erad-
tis can occur in a deep vein. Keep in mind icated. The patients occasionally develop chronic
that suppurative thrombophlebitis or an severe pain that can only be cured by amputating
infection in a site of an infiltrated IV can the ear [32].
be a life-threatening infection in a burn
patient. Line sepsis and suppurative
thrombophlebitis, like any infection, is Tar Burns
reported to M & M.
Tar or pitch blend is used in sealing roofs. It is
heated to about 450 °F to melt. Burns are usually
Special Problems/Nontypical Burns on the hands and forearms. Patients present with
a thick layer of adherent tar. Do not try to peel it
Ear Burns off. Apply petroleum ointment or a fleet’s oil
retention enema. This will slowly dissolve the tar
The ear is unique in that it contains cartilage that so that it can be removed. The burns are then
is just under thin skin. This cartilage can easily be treated with silvadene [33, 34].
exposed or injured by a deep second or third
degree burn. Because the cartilage has a poor
blood supply, it is very susceptible to infection Electrical Burns
and these infections are very difficult to cure.
Sulfamylon penetrates into the cartilage better There are two kinds of electrical burns:
than any other topical antibiotic so it is always
used on ear burns. It is important that ear carti- 1. Arc burns: Flash burns produced by heat gen-
lage infections, auricular chondritis, be recog- erated by an electrical arc.
18 A Surgeon’s Thought Process in the Management of Burn Patients 189

2. Current burns: Tissue destruction caused by saline for small children. Remove and dispose of
electricity passing through the human body. contaminated clothing. Be careful not to get any
chemical on yourself.
It is very important that you be able to distin- Chemical exposures to the eyes should be irri-
guish between these two types of burns. Arc gated with one liter normal saline, then a visual
burns are essentially thermal burns caused by acuity test and a fluorescein dye test should be
electrically generated heat. They are much more performed. Ophthalmology should be consulted
common than current burns. There usually is no on any patient with a significant eye chemical
history of tetany in involved muscle groups. The exposure.
neurological exam of the affected extremity is After irrigation, the burn should be debrided
usually normal. There is no entrance and exit and dressed like any other burn. Some chemical
wound. There is no deep tissue damage, no rise in exposures cause unique problems and require
compartment pressures, and urine myoglobin specific therapy. These are hydrofluoric acid
does not need to be checked. Arc burns are treated (HF), phenol, and white phosphorus burns.
just like thermal burns [35]. Current burns repre-
sent direct tissue destruction by electricity. There Hydrofluoric Acid Concentration
is a characteristic deep well circumscribed Symptoms and Systemic Toxicity
entrance and exit wound. The entrance and exit Hydrofluoric acid (HF) is used in chrome or rust
wounds are usually on widely different areas of cleaners and in industry for etching glass. It is
the body (i.e., entrance hand; exit feet). There is corrosive and the fluoride ion penetrates deeply
usually a history of tetanus muscle contracture. into tissues to cause progressive tissue destruc-
The neurological exam of the involved extremity tion. Burns are usually seen when HF concentra-
is usually not normal [36]. tions are >20 %. The fluoride ion is inactivated
by calcium ions.
Management Hydrofluoric acid is toxic. Even small amounts
1. Document and careful neurological exam. swallowed, inhaled, or absorbed through the skin
2. Watch closely for compartment syndrome. If can cause systemic symptoms. Toxicity from
there is any doubt, measure compartment isolated dermal exposure is uncommon when the
pressures directly with Stryker soft tissue HF concentration is less than 50 %. For HF concen-
pressure monitor. trations above 50 %, even small burns can be fatal.
3. If myoglobin is present in the urine, maintain The toxicity of HF is related to its ability to
urine output of 100 cm3/h. bind Ca++ and Mg++ ions and remove them from
4. Most of the patients will need operative the blood. The classic physical signs of
debridement within 48 h of admission. Often, hypocalcemia do not usually occur. The patients
multiple procedures are done with eventual develop ventricular arrhythmias (V-tach, V-fib)
soft tissue coverage of the defect. that are remarkably resistant to antiarrhythmia
drugs and tend to recur after cardioversion. The
arrhythmias occur even after the ionized calcium
Chemical Burns and magnesium have been corrected. It is thought
that the fluoride ion is directly cardiotoxic [37].
Burns from caustic chemicals are uncommon. It Patients who present with acute HF burns that
is important to ascertain exactly what the offend- are obviously full thickness and are >1 % TBSA
ing chemical was, how the exposure occurred, should be taken immediately to surgery to excise
whether or not any of the chemical was swal- the wound and thus remove the toxin. Intravenous
lowed or inhaled, and how long the chemical was doses of calcium chloride and magnesium sulfate
in contact with the skin before being irrigated. should be given to prevent cardiac arrhythmias.
The first aid for all chemical burns is copious Magnesium and ionized calcium levels should be
irrigation in shower for adults and with normal followed.
190 G.A. Vercruysse and W.L. Ingram

Inhaled HF causes severe pulmonary edema Delayed toxicity from the absorbed phenol can
and lung parenchymal destruction. The patients cause renal failure, intravascular hemolysis, and
develop an ARDS like syndrome that is rapidly altered hepatic function [39, 40].
progressive. Aerosolized calcium gluconate has
been used to treat the condition with mixed White Phosphorus Burns
results. Dilute the calcium gluconate with saline White phosphorus is an incendiary agent used in
to 2.5–3.0 % and aerosolize it with a nebulizer. fireworks and military ammunitions. White
phosphorus is used primarily by the military in
HF Hand Burns bullets, mortars, rockets, improvised explosive
HF hand burns are typically seen in those who devices, or bombs. Its use was outlawed by the
use industrial strength chrome cleaner at home Geneva Conventions years ago, but old stock-
without gloves to wash the chrome on their car piles exist, and it is used by terrorist groups and
(wheels). The hallmark of ongoing tissue destruc- rogue states, and non-state actors. The burn is
tion is pain. If the patient has persistent pain after progressive as long as oxygen is available. This
rinsing the involved part, begin calcium therapy. thermogenic reaction generates a number of
If there is no bleb formation or tissue blanching, phosphates and oxidates, which bind calcium
calcium gluconate gel (2.5 %) (available from the ions producing hypocalcaemia. It causes poten-
pharmacy) can be rubbed over the affected area tially lethal deep burns. It is highly lipolytic,
and put into rubber gloves and worn by the which penetrate the tissue producing systemic
patient. The glove is left in place until the pain effects. If still burning, soft tissue may need
and tenderness resolves or progresses to a more rapid debridement until all visible white phos-
severe burn. phorus has been removed. Soak wounds with
For more severe burns (tissue blanching or saline or water to avoid exposure to oxygen, then
bleb formation) not on the digits, calcium gluco- 2 % copper sulfate solution if available. Monitor
nate 10 % solution is injected into the subcutane- calcium and phosphorus levels closely. Debride
ous tissues with a 25 gauge needle; 0.5 cm3/cm2 the wounds until no more white phosphorus can
of burned area. be found in the wound. Sudden death from elec-
For HF digital burns that progress to bleb for- trolyte abnormalities has been seen for burns
mation or blanching, an intra-arterial calcium more than 10 % TBSA. Delayed hepatotoxicity
infusion is used. 10 cm3 of 10 % calcium gluco- is possible [41, 42].
nate is mixed with 40 cm3 of D5W. Place either a
radial or brachial art line. Infuse at 12 cm3/h (4 h
for the entire mixture) and then reevaluate. If the Surgery
symptoms have not resolved, infuse for another
4 h. These burns will rarely be severe enough to When to Operate
need palmer or digital fasciotomies [38].
Partial thickness burns will generally heal with
Phenol Burns simple wound care (see previous sections in this
Phenol is a solvent used by industry. It acts as a chapter). Full thickness burns (where all of the
local anesthetic so the patient may not realize that dermal elements have been destroyed) will very
he is burned. If removed promptly, it causes a slowly heal in the following manner if left alone:
partial thickness burn. Phenol is rapidly absorbed
through the skin and has systemic toxicity. The 1. The burn eschar (dead dermis) will slowly dis-
burn should be cleaned with polyethylene glycol solve (separate) by bacterial and neutrophil
(PE6 300 or 400), propylene glycol, or vegetable autolysis.
oil to remove the phenol. Eucerin® (Beiersdorf, 2. Granulation tissue will grow into the wound
Hamburg, Germany) lotion contains these sub- from small capillaries in the inflammatory
stances. Rinse off the lotion and apply Silvadene. zone around the burn.
18 A Surgeon’s Thought Process in the Management of Burn Patients 191

3. The granulation tissue will cause the wound to 3. Give antibiotics preop (excision of burn
contract, and epithelium will grow into the causes bacteremia). For patient in hospital <5
wound from the edges until the wound is days gram (+) coverage alone is OK. For gram
finally closed. Usually with a very thick scar (+) coverage alone, Ancef (l g). For patients in
and loss of function because of wound con- ICU > 5 days, gram (+) coverage and gram (−)
tracture, especially at joint lines (knees, hips, coverage will be needed. Vancomycin with
elbows, wrists, fingers, toes, neck). Cefepime and Gentamicin (double coverage
for pseudomonas) should be used.
In between these two extremes are deep
partial-thickness burns (deep dermal burn). This
burn has a thick layer of dead dermis (eschar) and Care of Grafts
a thin layer of remaining viable dermis with some
epithelial elements remaining. If left alone, the In the OR, skin grafts are harvested usually from the
eschar will separate and the neo-epithelium will upper thigh. The thickness is 10/1000 of an inch for
slowly cover the wound. Often the epithelium standard grafts, but in the elderly or very young who
forms a very thin covering that may intermit- have thinner skin, the donor sites are harvested at
tently spontaneously break down (unstable epi- 7–9/1000 of an inch. When using the same donor
thelium), and the wound/scar undergoes a sites for multiple harvests (as in large burns), der-
significant amount of contraction. To preserve matome should be set to 8/1000 of an inch.
form and function, all full thickness burns of any Thicker skin grafts (15–30/1000 of an inch) are
significant width need to be excised and grafted. used in areas where a better cosmetic result is
Most deep dermal burns of any significant size, needed (face, backs of the hands). The skin is not
especially those on the hands or over joint spaces, meshed in these areas but is applied as a sheet
need to be excised and grafted for optimal func- graft. Often the initial take is not quite as good, but
tional results. Often it is difficult to tell initially the wounds heal more quickly than meshed grafts
whether a burn will heal in 3 weeks, or will take and have a better cosmetic appearance when they
longer. It is common practice to watch a burn for do heal. If the graft is thicker than 20/1000 in., the
a few days in order to tell which portions will donor site may not heal spontaneously and may
need grafting and which parts will adequately need to be covered with a thin skin graft. This is
heal spontaneously. called the thick-thin skin grafting method.
For burns where a large area is to be grafted,
the skin is meshed with a 2:1 or 3:1 mesher.
How to Prepare the Patient Expansion ratios of 1.5:1 or 3:1 are possible using
for Surgery the Tanner mesher. Meshed skin retains its pattern
for years. It also contracts to a certain extent as it
1. For major cases (burns 10 % or larger), to heals. Meshed grafts form a thicker scar than a
avoid unnecessary blood loss, ask for two non-meshed (sheet) graft. For these reasons, sheet
bovies when posting. grafts should be used wherever possible.
2. Type and cross for at least 6 units of blood if The skin grafts are held in place with staples
platelet count is below 100,000. Make certain or 3-0 chromic sutures on taper needles (cutting
at least 6 units of platelets are available. If needles cause excessive bleeding). Do not use
PT > 14.5 give FFP preop, and correct PT staples on small children as they are very difficult
before surgery. If platelet count <50K, begin to remove. Dermabond® (Ethicon, Edinburgh,
to give platelets before the case starts, and run UK) can be used on the edges of small grafts to
them during the case. It often takes 4–5 h to avoid suturing or staples. More recently, fibrin
get platelets once they are ordered, so order glue has been developed to help speed up the
early. Make certain two large bore lVs are in process of skin grafting, but it is extremely
place (consider Swan introducer in femoral expensive and is not required for good graft take
vein for major cases) or healing.
192 G.A. Vercruysse and W.L. Ingram

Once in place, the grafts are covered with if properly grafted. It has both epidermal
Telfa® Clear (Kendall-Covidien, Dublin, Ireland), and dermal layers. Eventually the host will
then gauze, then a compression splint for the recognize the foreign epithelial cells and
trunk or a bulky wrap is applied. An attempt is especially the Langerhans cells in the epi-
made to keep the grafted area immobilized for dermis as foreign, and the host will cause
2–4 days. It is important to keep the grafts and an immune response that will cause the
underlying tissues moist (especially when trying graft to undergo epidermal lysis. At this
to graft fat). The primary substances used for this point, the graft must be replaced with
is Sulfamylon slurry (or silver nitrate 0.5 % solu- autograft or be removed. The point when
tion). The slurry is made by putting 50 g of the host rejects the foreign skin can be
Sulfamylon cream into 1 L of saline, making a delayed by giving the host cyclosporin and
0.5 % solution, and shaking it up. Sulfamylon steroids. This is rarely done. Occasionally
also comes in powder formula that can be mixed the host will only reject the epidermis and
with Saline solution. This solution is poured onto the dermis survives and can be covered by
the dressing of the fresh grafts to keep them moist host epithelium from a very thin skin graft
(the dressing is not changed). The first dressing or from cultured epidermis.
change is on POD# 4–5. The telfa clear is B. Frozen in glycerol: This is the much more
removed. The dressings are changed Q 24 h until common form. The skin is frozen in glyc-
the graft has taken and sticks well to the underly- erol to preserve it for longer periods of
ing tissue. Then it can be left open, and physical time. Unfortunately, the freezing process
therapy can be started. The patients usually go to damages the epidermis and possibly the
hydrotherapy (tanking) on POD #5–6. Often the dermis. The frozen skin often does not
extremities are wrapped with dry gauze to protect survive on the wound. It dies after 3 or 4
them during PT, especially in children who often days later. Occasionally, the frozen
have severe itching of healing wounds. cadaver skin will survive on the wound
and the foreign epidermis can be removed
and replaced with host epidermis with
Products Used by the Burn Service good results. Cadaver allograft is available
to Cover Wounds from the Red Cross, Lifelink, Lifecell, and
other skin banks. It usually costs less than
Advances in ICU care have allowed patients with the synthetics—around 600–800 dollars/
larger burns to survive. There, wounds become a square foot.
major issue in their care and rapid closure is essen- 2. Integra® (Integra LifeSciences Corp,
tial if they are going to survive in the long term. Plainsboro, NJ): This product is totally syn-
The basic split thickness autograft remains the thetic. It is made of two layers: an outer layer
gold standard wound closure technique. However, of silastic sheeting (the synthetic epidermis)
some patients do not have adequate donor site area and an inner layer of a porous material made
or are very prone to donor site complications. from bovine collagen and Chondroiten-6-
Several skin substitutes have become popular. sulfate from shark cartilage. When using
They generally try to either become a temporary Integra, the burn is excised down to viable tis-
coverage or to provide a dermal substitute [43]. sue; then the Integra is laid on top of the tissue
and held in place with staples. Over time, host
1. Cadaver allograft: This is skin from people fibroblasts grow into the porous part of the
who have died and are donating their organs. Integra and create a neo-dermis. This takes at
It consists of real human skin that has been least 2 weeks. After the 2–3 weeks waiting
harvested. It is available in one of two forms. period, the patient is taken to the OR and the
A. Fresh-never frozen. This is the best form. top silastic layer is peeled off and a very thin
It is alive and will grow on the wound bed autograft (about 0.004–0.006″ thickness) is
18 A Surgeon’s Thought Process in the Management of Burn Patients 193

placed on the Integra (with no further debride- before it is applied. Ideally, host fibroblasts
ment or bleeding). The graft adheres to the will grow into the dermal matrix and form a
neodermis and acts and looks like a thick new dermis without the need for any dermal
graft. In this way, donor site scarring can be contribution from the skin graft. This allows
minimized. Also, when the patient has the for very thin donor sites that heal quickly with
potential to be the sickest, we create no new a minimum of donor site scarring. Because
wounds (donor sites). The harvesting of the the grafts are so thin, they are covered with
donor sites can be delayed until the patient is N-terface® (Winfield Labs, Richardson, TX)
healthier. A problem with Integra is that coated with bacitracin ointment and then with
porous synthetic material has a tendency to moist Kerlex® (Covidien, Dublin, Ireland).
make the donor site bleed. It can only be The dressings are kept moist with sulfamylon
placed on a wound that has complete hemo- slurry and are not changed for 6–7 days. The
stasis. It is also very susceptible to infection grafts are very fragile and the patient cannot
because bacteria can attach to and proliferate be tanked for 10 days postop. The donor sites
within the porous matrix. The material is should heal in about 6–8 days. The main prob-
expensive: it costs about $ 1000.00 for one lem with alloderm is that the grafts often do
4″ × 10″ piece. They come 5 to a box packed not take. This can only be used on a wound
in isopropyl alcohol. The alcohol must be that is very vascular and free from infection:
washed off on the sterile field before it is used. the grafts get infected easily. On the average,
Integra is also relatively fragile and must not an 80 % take is expected. Usually the graft
be crushed. Once it is placed on the wound, it looks bad initially. In a few days, the epithe-
must be protected from any shear. It is more lium grows back over the alloderm. This is
fragile than a conventional graft [44]. most useful to close small areas on a patient
3. Alloderm® (LifeCell Corp, Bridgewater, NJ): that has been extensively harvested. Alloderm
This is a dermal template made from pro- is available from Lifecell. It costs about $ 5.00
cessed cadaver skin. The processing removes a square centimeter [45].
the epidermis and all of the cellular and 4. Dermagraft® (Organogenesis, Canton, MA)—
genetic elements, in theory. What is left is the TC: This product is made by attaching fibro-
collagen-elastin dermal protein matrix. The blasts harvested from neonatal foreskins to a
dermis of normal skin consists mostly of vicryl mesh. The fibroblasts secrete collagen
extracellular collagen and elastin. These pro- and other wound interactive molecules. The
teins give the skin its properties of strength fibroblasts and mesh are covered with silastic
and pliability. It is the loss of some of the der- sheeting. The material is applied to the excised
mal protein matrix that contributes to the loss wound bed and provides temporary coverage.
of strength and suppleness of burn scars. The The tissue does not leave a dermal analog so it
protein matrix is then freeze-dried and put in does not allow you to close the wound with a
packs for our use. In the OR, we excise the very thin donor site. Therefore, it does not
wound bed; then lay the alloderm on it, being minimize donor site scarring. We have no
careful to put the shiny side down. The allo- experience with this material. It is available
derm must be covered with a very thin auto- from Advanced Tissue Sciences. It is expen-
graft (0.004–0.006″). Both the alloderm and sive [46].
the overlying autograft must be meshed. The 5. Cultured Autologous Epithelium: This is epi-
alloderm is typically not expanded and the dermal cells from a biopsy of the burned
autograft is expanded. Alloderm comes in foil patient’s skin that are sent to a lab in
packs, each piece is a different size and differ- Massachusetts and, in 2–3 weeks, grown to 2
ent thickness. Often, one piece will be of vari- square meters (enough to cover the entire
able thickness. It is packed with a preservative patient). Note that only epidermal cells are
that must be washed off in a series of baths grown in culture: there is no dermal component
194 G.A. Vercruysse and W.L. Ingram

provided. The cells are sent back in small sheet. very large donor site. If this happens, remove
They are very fragile. They also do not attach to the xeroform and do silvadene dressings.
the wound well. An 80 % take rate is consid- 2. Opsite® (Smith & Nephew, London, UK):
ered good. An attempt is made to prepare the This is a clear plastic dressing that covers the
wound bed by trying to get cadaver allograft to donor site and sticks to the normal skin around
stick to it. To use CAE, you have to send two it (coating the skin around the donor site with
biopsies of the patient’s skin to Genzyme (the Benzoin helps it stick). It is not ever changed.
vendor). They grow the skin in the lab and sell As the donor site starts to heal, it falls off.
it back to the patient. It is expensive, about Advantages are: Usually very little pain; It is
$1000 for each 1 % TBSA of the patient clear, and you can see the wound.
grafted. It is only used for massive burns where Disadvantages are: Fluid or blood accumu-
there is no other way to cover the large wound lates under it, especially on larger donor sites;
bed. As this product does not create dermis, It cannot be used on large sites. Opsite is used
scar contractures can be very severe and the on small donor sites in otherwise healthy
resulting healed skin is not very durable patients. For large donor sites a large Vi-drape
[47–51]. (iodoform) can be used. If it does not stick
well, it can be stapled into place.
3. Silvadene or bacitracin dressing (Q24H): This
Care of Donor Site is the idea of treating the donor site like a partial
thickness burn. The silvadene or bacitracin
A donor site is an area of skin where the epithe- keeps it moist and limits bacteria overgrowth.
lium and a thin layer of dermis have been Advantages are: Can be used on any donor site
removed. There is no eschar (because there is no anywhere; It can be used when another method
dead dermis). If all goes well, donor sites will re- has failed. Disadvantages are: It is labor inten-
epithelize in about 2 weeks. Donor sites can get sive; There is some evidence that Silvadene
infected and have cellulitis just like a burn. They inhibits re-epithelization. This method is often
can also get infected with invasive organisms that used on very large donor site or on donor site
will destroy the viable dermis. This is known as a that has become macerated on infected.
donor site converting to third degree; it will then
need to be excised and grafted. Adequate nutri-
tion is required to heal both burns and donor Goals for Discharge
sites. It is important to ensure that burn patients
receive or consume adequate (1.5–2.0 g protein One of the most common questions that the fam-
per kg ideal body weight per day) to ensure ade- ily or the patient will ask is when can I go home?
quate healing. As long as nutrition is adequate, The patient going home marks the transition
donor sites will generally heal no matter how between inpatient care and outpatient care. We
they are dressed. Three common ways to care for are just as responsible for care of the patients
donor sites are: when they are at home as when they are hospital-
ized. There are certain milestones or goals that
1. Xeroform® (Kendall-Covidien, Dublin, the patients must achieve to be effectively man-
Ireland) gauze: Place and let it dry. As the aged as an outpatient. These are:
donor site heals underneath, it peels off on its
own and you trim the edges. Heat lamps A. Pain control: The patient must be able to have
(30 min every 2–4 h while awake) help it dry. all wound care and required physical therapy
If the xeroform gets soupy and looks infected, done with only oral pain medications. (At the
it should be removed. Disadvantages are: current time there is no safe reliable way to
Cannot see the donor site; Can be painful; It discharge patients on intravenous pain medi-
can get macerated (soupy), especially if it is a cations.) Remember: patients go home on the
18 A Surgeon’s Thought Process in the Management of Burn Patients 195

same pain control regime that is controlling the most challenging of all surgical patients.
their pain in the hospital [52]. Evolution in ICU care, and burn resuscitation,
B. Infection: The patient must be free of any nutrition, operative strategy, and available tech-
infection that will require intravenous antibi- nology has allowed the vast majority of even
otics. Patients can be converted to oral antibi- complex burn patients to survive and even thrive
otics and discharged 24 h later if it appears after recovering from their burn. With basic train-
that the antibiotics will control the infection. ing in burn care, and the advent of teleconsulta-
C. Wound care: Arrangements must be made for tion, it is possible for non-burn specialists to
getting the wound care done at home. The manage small burns. Large burns or all burns in
best way is to have a family member come in the hands of the relatively inexperienced should
and learn the dressing care. They must dem- be transferred to regional burn centers for all
onstrate to the nurses that they can do the aspects of care.
dressing properly. Home health nurses are
available to most patients, who can go out and
help with the dressing. Remember that the References
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 Decision-Making in Reconstructive
Surgery 19
Ethan E. Larson, Tolga Tűrker,
and Samuel Skovgaard

much? Is there deficiency of muscle or bone? Is

Approach to the Reconstructive there underlying fracture? Is there sensory or
Surgery Patient motor nerve dysfunction? Is there an active
infection or contamination of hardware? Are the
D. Ralph Millard, in his Principalization of necessary pieces merely displaced or distorted?
Plastic Surgery, has eloquently and succinctly Is there anything present in excess? These are the
outlined the 33 basic tenets of the specialty [1] questions that must be considered with each
(Table 19.1). These are principles which not only reconstructive problem. The more extensive the
inform the practice of plastic and reconstructive problem, the more essential it becomes to under-
surgery, but can be extrapolated to the betterment stand it thoroughly so that each facet can be
of surgical practice in general. The core of the thoughtfully reconstructed. Diagrams or lists can
issue is always the defect. However, there are be invaluable at this stage as can pre-injury pho-
many other concomitant issues. Exactly what is tographs, particularly when approaching facial
missing or deficient? Is skin missing? If so, how reconstruction. A detailed understanding of anat-
omy is crucial to the safe and effective practice of
reconstructive surgery and it is at this stage that it
E.E. Larson, M.D. (*) is first employed. Figure 19.1a–e provides an
Department of Surgery, University of Arizona, example of a complex reconstructive problem.
1501 N Campbell Ave, Rm 5334, PO Box 245062,
Tucson, AZ 85724-5062, USA Reconstructive defects come in a dizzying
e-mail: elarson@surgery.arizona.edu array of variety and complexity. There are trau-
T. Tűrker, M.D. matic defects, iatrogenic defects, congenital
Department of Orthopaedics, Banner University defects, oncologic defects, and purely cosmetic
Medical Center, 1609 N. Warren Avenue, Rm 110, defects. There are defects involving either form
Tucson, AZ 85724, USA or function or both. Nevertheless the same prin-
e-mail: tturker@ortho.arizona.edu
ciples can be applied to the shotgun blast to the
S. Skovgaard, B.A. face as to the acquired absent breast following
University of Colorado Denver School of Medicine,
4862 W 68 Ave, Westminster, CO 80030, USA mastectomy. It can be useful to apply a pneu-
monic adapted from general surgery to describe
Department of Plastic and Reconstructive Surgery,
University of Colorado School of Medicine, factors contributing to fistulas to guide thinking
Aurora, CO, USA on factors contributing to chronic wounds
e-mail: Samuel.skovgaard@ucdenver.edu (Table 19.2).

© Springer International Publishing Switzerland 2016 197

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_19
198 E.E. Larson et al.

Table 19.1 The 33 basic tenets of plastic surgery

Preoperational Principles
1. Correct the Order of Priorities. (Fix the most pressing problems first, build from a solid foundation outward,
form follows function.)
2. Aptitude should determine specialization. (Do what you are good at.)
3. Mobilize Auxiliary Capabilities. (A surgeon should explore interests beyond surgery. Revelations from these
pursuits often go on to inform and contribute to the practice of surgery.)
4. Acknowledge your limitations so as to do no harm.
5. Extend your abilities to do the most good. (A surgeon capable of operating on multiple types of problems all
over the body will be the most use to society.)
6. Seek insight into the patient’s true desires.
7. Have a goal and a dream (What is the best possible outcome, what is technically feasible?)
8. Know the ideal, beautiful normal.
9. Be familiar with the literature.
10. Keep an accurate record.
11. Attend to Physical Condition and Comfort of Position. (While often overlooked, the mental calm, freedom
from annoyance and physical comfort of the surgeon are of great importance to the final outcome.)
12. Do not underestimate the enemy. (Know the defect and respect it.)
Executional Principles
13. Diagnose before treating.
14. Return what is normal to normal position and retain it there.
15. Tissue losses should be replaced in kind.
16. Reconstruct by units (Define the basic building blocks that are missing, skin, muscle, bone, etc., and replace
them.)
17. Make a plan, a pattern, and a second plan (lifeboat).
18. Invoke a Scot’s Economy. (Take steps to optimize use of operative time, energy, tissue, and costs.)
19. Use Robin Hood’s tissue apportionment. (Borrow from areas of abundant tissue to supplement deficits.)
20. Consider the secondary donor area. (Be aware of the price that must be paid for reconstruction of the primary
defect.)
21. Learn to control tension. (Increasing skin tension is deleterious to blood supply, scar and healing. Appropriate
tension is occasionally necessary for form.)
22. Perfect your craftsmanship.
23. When in Doubt, Don’t.
Innovational Principles
24. Follow-up with a critical eye
25. Avoid the rut of routine.
26. Imagination Sparks Innovation.
27. Think while down and turn a setback into a victory. (“Too often when a complication occurs the inexperienced
surgeon may panic and, in his frantic effort to recover, multiply the damage.”)
28. Research basic truths by laboratory experimentation.
Contributional Principles
29. Gain access to other specialties problems.
30. Teaching our specialty is its best legacy.
31. Participate in Reconstructive Missions.
Inspirational Principles
32. Go for Broke.
33. Think principles until they become instinctively automatic in your Modus operandi.
Know the Ideal, Beautiful, Normal. Diagnose what is present, what is diseased, destroyed, displaced, or distorted
and what is in excess. Then guided by the normal in your mind’s eye, utilize what you have to make what you
want—and when possible, go for even better than what would have been!
19 Decision-Making in Reconstructive Surgery 199

Fig. 19.1 Occasionally multiple rungs of the reconstruc- clean wound after serial debridement. (c) A pedicled para-
tive ladder must be used simultaneously to optimize out- scapular flap is designed to cover the axilla. (d) After skin
comes. (a) Necrotizing fasciitis of an extremity. (b) A grafting with flap in place. (e) Healed wound
200 E.E. Larson et al.

Table 19.2 FRIENDS pneumonic to describe factors gencies, they certainly do exist. Scalp, digit, ear
contributing to fistulas and to chronic wounds
and extremity replantation certainly warrant
F: Foreign body immediate intervention when replantation is pos-
R: Radiation, Rejection sible. Compartment syndrome and necrotizing
I: Infection, Immunocompromise, Inflow (vascular fasciitis are similarly emergencies. Contaminated
supply and pressure necrosis)
wounds should be irrigated promptly but do not
E: Epithelialization
necessarily require emergent closure. Dead tissue
N: Neoplasm, Nutrition
should be urgently removed when contributing to
D: Diabetes, Disease (autoimmune)
systemic symptoms. Auricular, nasal, septal, and
S: Smoking, Steroids, Stretch (tension), Self-inflicted
(Munchausen’s, substance abuse, mental illness retrobulbar hematomas also require urgent drain-
age. Beyond that, most other issues afford time
for consideration.
The Decision to Intervene Reconstructive Luminaries Gillies and Millard
both stated “Never do today what you can honor-
Through careful consideration of the patient, pro- ably put off until tomorrow” [1]. Rushing into a
cedural and internal factors, ultimately the sur- procedure before it has been carefully thought
geon must decide whether or not to engage in the out and thoroughly considered from multiple
reconstructive effort on a particular patient. This angles can be foolhardy and dangerous. A rash
is, in essence, the point of no return. It is useful approach can endanger the patient and destroy
then to ponder the question of what would hap- reconstructive options that might otherwise have
pen if no surgery was offered? Defects in the been viable. Careful planning is often paramount
medial canthal region and forehead, for example, to success. A new day can bring new insights and
can heal by secondary intention with acceptable certainly a refreshed surgeon, assistant, and oper-
cosmetic results. What would the potential risks ative staff.
of non-intervention be to the patient? Is there a Revision surgery is of particular interest in
chance they will heal on their own and if so, with discussing timing. Rhinoplasty, for example,
what, if any, permanent deficits? What are the should be allowed a year to heal prior to revision
risks of surgery itself? What is the worst that surgery in order to prevent compounding defor-
could happen from a chosen intervention and mities. Scars should be given time to complete
how can that be avoided? What is the desired out- the remodeling phase of healing, usually at least
come? What are the best and worst case scenar- 8 months before operative revision. In children, it
ios? How many surgical procedures are this likely is typically best to wait until they are old enough
to be required? Am I the right surgeon for the to understand and participate in their own care,
job? usually around the age of kindergarten, to mini-
Whenever possible these issues should be dis- mize the risk of youthful impetuousness destroy-
cussed with the patient and their family. In more ing an otherwise well-performed surgery.
complex situations, these questions should be
discussed with colleagues and mentors.
Electronic communication makes it easier than Patient Considerations
ever to reach out to respected minds in the field to
seek help in the decision-making process. Surgical trainees may feel tempted at this point to
skip over the less exciting topics like optimiza-
tion of nutrition status and comorbid diseases and
Timing of Intervention operate. However, appropriately identifying
and—when possible—correcting these patient
Once the decision to operate has been made, the factors before taking them to the operating room
first question should always be “Is this an emer- can make the difference between failure and suc-
gency?” While there are few reconstructive emer- cess (and is for the most part very simple to do).
19 Decision-Making in Reconstructive Surgery 201

The health of the patient has a great deal of you may find them to be shockingly protein mal-
influence on the course and success of recon- nourished due to excess carbohydrate intake and
structive efforts. Very few patients are young, this should be taken into consideration when
athletic, well-nourished non substance abusers planning surgery.
with no comorbidities. In fact, quite the opposite Smoking and nicotine use are obvious risk
is typically the case. Patient factors can certainly factors for delayed healing. Elective reconstruc-
make or break the surgery and should be care- tion should only be performed with extreme cau-
fully considered and in every possible instance tion in the smoking patient. Similarly the
optimized prior to surgical intervention. Again, non-compliant, mentally ill or suicidal patient
the FRIENDS pneumonic (Table 19.2) can be may not benefit from extensive surgical interven-
useful here. Patient nutrition is a frequently tion. For example, the patient who created mul-
overlooked source of complication. A patient tiple cutaneous wounds by picking at their skin
must have adequate intake of nutrients, particu- cannot be expected to refrain from disrupting
larly protein, to maintain an anabolic balance surgical wounds until their underlying issues are
postoperatively. Preoperative nutritional indices addressed.
such as albumin, transthyretin, zinc, and vitamin Diabetes, heart disease, and chronic steroid
C levels are very important. In the case chronic use as well as immunocompromised and autoim-
wounds such as decubitus ulcers good nutrition mune states should be taken into account and
is particularly important in tipping the scales optimized. Often, multiple medical comorbidi-
from wound stasis to wound healing. At the ties serve as a relative contraindication to surgi-
other end of the spectrum obese patients tend to cal heroics. A good rule of thumb is the more
have more difficulty with wound healing and complicated the medical history of the patient,

Fig. 19.2 (a) A squamous cell carcinoma of the forehead in a patient desiring immediate closure. (b) Excision margins
and local flap design with multiple rhomboid flaps. (c) Primary wound closure. Healed well
202 E.E. Larson et al.

the simpler and more reliable should be the surgi- Table 19.3 Rungs of the reconstructive ladder
cal procedure chosen. In Fig. 19.2a–c, we show 1. Healing by secondary intention
an example of a patient with multiple comorbidi- 2. Healing by primary closure
ties who required cancer excision with immedi- 3. Healing by delayed closure
ate coverage. 4. Skin graft
Another crucial consideration is that of the 5. Local flap closure
desires of the patient. Often in a fit of reconstruc- 6. Regional flap closure
tive zeal the surgeon is tempted to forge on long 7. Remote pedicled flap such as cross leg or groin flap
after the patient is willing to cut their losses and 8. Tissue Expansion
accept a deformity. The desires of the patient 9. Free Tissue Transfer
must always be considered tantamount in the Adapted with permission from Janis, JE, Kwon, RK,
decision process. Related to this is seeking under- Attinger, CE. The new reconstructive ladder:
Modifications to the traditional model. Plas Recon Surg
standing of patient expectation. Even if a surgeon 2011 Jan;127 Suppl 1:205S–212S
is very happy with an outcome, the final arbiter of
whether the outcome is acceptable is the patient
themselves. Gaining understanding of the Another worthy consideration when planning
patient’s desires prior to embarking on a surgical surgery is to avoid retreading the mistakes of the
course can stave off disaster and heartache for all past, particularly when addressing revision or
parties involved. The surgeon can carefully guide salvage surgery. A useful maxim is “If plan A
expectations with discussion, diagrams, and pho- failed, DO NOT repeat plan A.” It is difficult to
tographs when applicable. expect repeat primary closure of a wound to suc-
ceed when it has failed in the first place, likely
with additional resultant tissue loss. Instead, if a
The Procedure(s) previous plan has failed, it is wise to explore
other options that utilize additional tissue.
Classically, the choice of the method of recon- Similarly, the reconstructive surgeon must
struction has been guided by the reconstructive always bear in mind the next potential step, or
ladder [2]. This speaks to the paradigm within lifeboat, if a given intervention fails and leave as
reconstructive surgery that the simplest method many future options open as possible in the event
that can be safely applied to safely and effec- of unanticipated complication. One example of
tively treat the defect should be used. An evolu- this would be to use a V to Y closure for a sacral
tion of this concept is the reconstructive elevator ulcer instead of a rotation flap. A rotation flap can
[3, 4], which more aptly asserts that the method be re-rotated a number of times should the ulcer
that best reconstructs the defect should be used, recur. A V-Y flap gets progressively smaller with
regardless of its technical complexity. Younger each advancement and closes the door on future
surgeons often use the ladder. As a surgeon’s skill local flaps to the area.
set builds, the elevator is often the better choice. It may be useful to stage procedures to opti-
The rungs of the reconstructive ladder [2] are pre- mize outcomes. This should be communicated to
sented in Table 19.3. the patient in order to prevent frustration. The
Basic understanding of these various interven- surgeon must make sure they have the time avail-
tions is given to all surgeons as part of their train- able before embarking on an extensive staged
ing. Deeper understanding of when to use each of reconstruction that requires multiple surgeries in
these tools requires much further study into the a short amount of time such as with serial debride-
potential pros and cons of each as well as the sur- ment. The choice of procedure should be made
gical finesse and necessary donor tissues to based on a variety of factors. These include the
ensure their correct utilization. suitability of the proposed tissue to replace that
19 Decision-Making in Reconstructive Surgery 203

Fig. 19.3 The needs and desires of the patient must be margins were excised and a dermal substitute graft was
taken into account. This elderly gentleman had an exci- applied following burring of the outer table of the calvar-
sion of squamous cell carcinoma and was left with ium. This was later skin grafted to good effect. (a) initial
exposed calvarium and positive margins. He required re- presentation. (b) After excision of margins and applica-
excision. Free flap reconstruction with a latissimus flap tion of dermal substitute graft. (c) Dermal substitute graft
would be the most expedient treatment. The patient is now incorporated and ready for skin grafting. (d)
declined this involved surgery due to his age. Instead the Healed skin graft

which is deficient, the morbidity of the donor What Tissues Are Needed?
site, the capabilities of the patient, and the capa-
bilities of the surgeon. Further confusing the It follows from a thorough understanding of the
issue is that in many cases, different paths can be defect what tissues should preferentially be
successfully followed to the same surgical end. involved in any reconstruction. Skin, muscle,
Often there are multiple “right” answers to a bone, and cartilage should be replaced in kind
given single reconstructive dilemma. Selection whenever possible. In particular, skin from an
between the various options is guided again by adjoining area with similar solar exposure is
patient factors and any particular expertise or preferential to remote donor sites when possible
experience of the surgeon (see Fig. 19.3a–d). to ensure better color match. This is particularly
204 E.E. Larson et al.

Fig. 19.4 Care must be taken to evaluate the defect. ejection from motor vehicle. (b) Primary closure was pos-
Occasionally what at first blush appears to be a total loss sible as the degloved eyelid remained viable
is actually salvageable. (a) Initial presentation following

true in the head and neck. Cartilage should be Donor Site Considerations
replaced with cartilage of similar conformation
or should be shaped surgically to provide simi- It stands to reason that nothing is accomplished
lar structure. Flap thickness is a particular issue, when a tissue donor site creates a problem that is
even in perforator fasciocutaneous flaps given as bad as or worse than the primary defect. Donor
the tendency of the North American population sites must be carefully chosen to minimize the
towards obesity. Whenever possible, flap thick- secondary morbidities of the surgery. Whenever
ness should be chosen or tailored to best match possible, it is necessary to educate the patient
the demands of the recipient site. Similarly, preoperatively regarding exactly what they will
muscle, bone, and fascia replacement should be be sacrificing in order to achieve reconstruction.
executed with donor tissues of similar structure There truly is “no free lunch” in reconstructive
and composition. It is also important to consider surgery, each donor site carries with it a specific
performing reconstruction with sensate tissue set of morbidities that should be carefully consid-
especially in the hand and, more importantly, at ered by the surgeon and ideally discussed with
the fingertips. For example, if there is a defect of the patient before selection.
the pulp, a local advancement flap that has neu- With regard to skin grafting, particularly in lim-
rovascular structure may not only cover the ited defects, the donor defect is fairly minimal and
defect but also provide sensory feedback. typically cosmetic only. All full-thickness wounds
Sensory feedback improves the dexterity of a will leave as their sequela a scar as a permanent dis-
hand. Occasionally it will appear that tissues are figurement. As larger flaps of tissue are used, there
missing but in fact they remain viable, as in are often much greater consequences and potential
Fig. 19.4a,b. for morbidity. A toe to thumb transfer can improve
Truly, the goal should be to “replace like with grip at the expense of gait. Autologous breast recon-
like.” Whenever possible, tissues should be cho- struction can be achieved but often at the cost of
sen or shaped to exactly replace what is missing. some shoulder or abdominal wall strength. In certain
A paucity of tissue creates tension and increases instances, the donor site cannot be closed and leaves
scar formation and can be detrimental to healing. a secondary wound. Donor sites can become infected
A dearth of tissue can contribute to pin-cushioning or necrotic and may require reconstructive surgery
and distortion of form and function. as well (see Fig. 19.5a–d).
19 Decision-Making in Reconstructive Surgery 205

Fig. 19.5 As a reconstructive plastic surgeon it is impor- graft could be placed. (a) The tumor in situ. (b) Defect
tant to be ready for anything. You never know what a following excision of the tumor with full thickness partial
given day will bring. This is a patient who flew in from calvarium resection. (c) A hemi scalp flap is mobilized to
India as she was told there that she had an incurable can- cover the defect emergently. (d) Hemi scalp flap is inset
cer. This was a large squamous cell carcinoma of the over the mesh. Dermal substitute graft is placed over the
scalp. This was excised and I was called to reconstruct the remaining periosteum to provide more robust coverage as
same day. The patient returned to India before her skin radiation is anticipated

In order to decrease the morbidity at the donor big radial artery which is easy to dissect versus
side, surgeons may look for alternative the same area can be covered with posterior inter-
approaches and improve their practice. For osseous artery flap which has smaller vessels and
example, a defect in the hand may be covered requires more delicate dissection; the latter is
with radial forearm flap that is based on relatively related to minimal morbidity as it does not sacrifice
206 E.E. Larson et al.

a major artery and the donor area may be primar- In the elective reconstructive setting, if there
ily closed. is tension between the surgeon and the patient
In particular, a thorough understanding of the from the beginning, this is often a very useful
potential morbidity from use of musculocutane- warning sign of a relationship that will sour in
ous flaps in reconstruction is necessary. Take for time. Once the decision is made to operate, the
example the scenario of a patient with a traumatic surgeon is obligated to the patient for the fore-
below-knee amputation with extensive soft tissue seeable future. Surgeon ignorance can be another
loss in the distal extremity. A free latissimus flap important factor in the provision of appropriate
could be used to cover this defect. Loss of that treatment. A Surgeon’s “no-decision” or assump-
muscle, however, could lead to difficulty using tions that “the tissue will heal itself” could be
crutches or a wheelchair down the road and so its another potential danger for patients. Failing to
sacrifice must be carefully considered and other provide appropriate treatment may cause signifi-
options entertained. cant functional deficit.
With regard to institutional considerations,
one must always consider the availability of
Surgeon Considerations necessary instrumentation. Is there reasonable
access to care adjuncts such as hyperbaric oxy-
Sir Archibald McIndoe said, “A plastic surgeon gen, nutrition consultation, and physical ther-
cannot close the abdomen over his work, but it is apy? Are the nurses properly trained in
exposed for all to judge and he soon builds his postoperative care? Are there sufficient con-
monument or digs his grave” [1]. The expertise of sulting services available? Is there adequate
the individual operator is the final arbiter of the operative assistance available? All of these
success or failure of a given operation. Training, items must be considered before deciding to
dexterity, temperament and experience combine to begin a complex reconstruction. Occasionally it
provide a reconstructive surgeon with their arma- is necessary to transfer care to a facility better
mentarium of skills and procedures. Prior to equipped to deal with the problem. This is espe-
embarking on a reconstructive course, it can be cially true for cases involving complex burns,
useful to decide if you can see the thing through to functional complex extremity injury, free tissue
the end, anticipating that there may be complica- transfer, and tissue allotransplantation. These
tions that require increasingly sophisticated proce- cases often require experienced teams and mul-
dures to solve. In larger institutions, make full use tidisciplinary collaboration to achieve predict-
of other reconstructive surgeons to help augment able success.
talent pools and supplement any deficiencies.
One should readily admit if a problem is too
difficult. This should be doubly considered by a Conclusion
surgeon who is early in his career. Often, recruit-
ing help from other specialties can help surmount A surgical intern on his first week goes to the
this issue. If a given reconstruction is simply esteemed Chairman of the surgical department
beyond the scope of a surgeon’s skill set, then and asks “How do I become a successful and
they should endeavor to find someone capable, if renowned surgeon?” The old surgeon briskly
they exist and transfer care of the patient. replies “Make good decisions.” After trying for a
Continuing to participate in the patient’s care few days to implement this advice, the intern
after transfer to a more capable provider can returns to the Chairman’s office and asks “How
provide an invaluable learning opportunity. If do I make good decisions?” Not looking up from
there is ever a grey area or a doubt, defer surgery. his papers, he replies “Use good judgement.”
Medical ethics boards and peers should be able to Again, after a few days of trying to live by the
help guide the surgeon in these instances. Chairman’s advice, the intern was frustrated.
19 Decision-Making in Reconstructive Surgery 207

Despite fearing an angry outburst at his repeated doing yoga and other exercises. She had a very
questioning, the intern returns once more. “How minimal amount of subcutaneous fat. She was
do I learn good judgement?” he sheepishly asks. otherwise well nourished and healthy with no
The Chairman pauses, looks up at the intern, and comorbidities. She developed wound complica-
replies “By making bad decisions.” tions bilaterally and ultimately had her expanders
Decision-making in reconstructive surgery is removed. She also had several areas of erosion
multilayered and complex. Similarly there may through the mastectomy flaps and these were pri-
be no one right answer. Many roads lead to marily closed. The same surgeon returned 3
Rome. A detailed understanding of the defect is months later and replaced the expanders, this
combined with a thorough knowledge of the time using a different set of incisions at the level
available treatment modalities. This is weighed of the inframammary fold. The patient went on to
against the comorbidities and desires of the develop wound healing complications a second
patient and the skill and experience of the sur- time and all expanders and acellular dermal
geon in a complex calculus to define the right matrix were removed.
procedure at the right time for the right person. The patient came to the senior author (EL) 2
Much of this knowledge is gained through expe- months after the last episode very keen on having
rience and occasionally failure. By utilizing an breast reconstruction. Her mastectomy flaps were
organized and consistent framework in decision- criss-crossed with scars and the nipple remnants
making, however, the reconstructive surgeon is were malpositioned. While the patient was petite,
able to rationally approach a surgical problem she was interested in a breast reconstruction in
and deduce the next logical step in treatment with the B or C cup range.
the greatest chance of success. Similarly, a con- We discussed her breast reconstruction
sistent and rational approach provides an excel- options. It was clear that given the thinness of her
lent framework in which to discuss the surgical mastectomy flaps as well as the multitude of
options with the patient and allows effective ret- chest scars that it would be imprudent to “repeat
rospective critique of decisions made. plan A” and attempt placement of tissue expand-
ers again. Unfortunately she did not have any
adequate donor sites to complete an entirely
Case Discussions autologous reconstruction. We discussed using
latissimus dorsi flaps to resurface her breast skin
The following case discussions represent situa- and add bulk; however, given her high activity
tion when a plastic surgeon has to make often dif- level, she was not interested in sacrificing those
ficult decisions. muscles. Similarly performing bilateral
Transverse Rectus Abdominus myocutaneous
flaps was not an appealing option due to the need
Case 1. Difficult Breast to sacrifice core strength. We discussed fat graft-
Reconstruction ing to bulk up her mastectomy flaps; however,
given her scar burden, I was doubtful that we
A 35-year-old woman presented to me to discuss would be able to complete an aesthetic recon-
bilateral breast reconstruction. She had under- struction in this way. Finally we discussed free
gone bilateral nipple sparing mastectomy for a Deep Inferior Epigastric Artery Perforator
right-sided stage one ductal carcinoma and had (DIEP) flaps. I explained that bilateral flaps could
bilateral immediate staged breast reconstruction be performed to replace the scarred breast skin
with placement of tissue expanders and acellular and to add some subcutaneous bulk. The DIEP
dermal matrix by an outside surgeon. She did not flaps have the advantage of sparing the abdomi-
require radiation. The patient was very slender nal muscles, minimizing the risk of abdominal
and athletic, playing soccer almost daily and weakness, and bulging in this active young
208 E.E. Larson et al.

woman. While she had very little abdominal fat, skin flap. I have been assured by numerous sur-
there was enough to make the surgery worthwhile geons that a mature flap can endure this sort of
to resurface the chest wall but not reconstruct a insult; however, I was reluctant to place
breast. This would be the first stage of surgery. implants at that time and jeopardize the skin
The next would be to place implants under her further. I closed the patient and explained to
flaps after they had a chance to heal. We did also her my thinking.
discuss the option of multiple simultaneous free Three days postoperatively she developed a
flaps to reconstruct the breast mound. As a solo right-sided hematoma. While I most likely tran-
surgeon in my practice, this would be quite tech- sected the pedicle on the right, I had not noted
nically difficult and I recommended that if that any significant bleeding. Apparently the vessel
was the option she would like to choose, she had gone into spasm immediately and ultimately
should seek a center where they do that routinely let loose causing significant bleeding. In hind-
and have a larger operative team. She was not sight, it would have been prudent to explore fur-
interested in the extra scar burden this would ther and attempt to ligate that cut vessel if it could
entail and did not want to travel out of state for be found. The hematoma was evacuated; how-
her reconstruction. She opted for reconstruction ever, she suffered from some subcutaneous vol-
with free flaps with implants. ume loss on the right side as a result. I allowed
Once the breast implants were in place, I her to heal for 2 months and then returned to
explained that they could be gradually upsized replace the lost volume with fat grafting har-
until the desired breast size was achieved. vested from the thighs. I did not want to attempt
Tissue expanders placed under flaps have been to reconstruct overly thin breast skin as that had
overly complicated in my experience and grad- been the trouble from the beginning.
ual upsizing of implants is preferred to avoid The fat graft took quite well and I was able to
complication. restore the lost soft tissue. I waited another 3
The first stage of the reconstruction was per- months to ensure good graft take. I then placed
formed. The scarred breast skin and malposi- bilateral subpectoral saline implants of 175 ml
tioned nipples were discarded and the mastectomy volume. She healed well from this but was
skin was resurfaced with bilateral free DIEP unhappy with her size. The saline implants were
flaps. The surgery went well and she went on to chosen, however, because they have a greater
heal without incident. Despite the surgery, she tendency to distend the overlying tissue via a
was essentially left with a flat chest but with ade- “water hammer” type effect. Ultimately, I knew
quate soft tissue bulk to hopefully support a they would function to expand the pocket and
breast implant. allow for placement of a large implant without
We waited 3 months and at a second surgery the more rapid strain and complication of formal
I attempted placement of small bilateral saline tissue expansion.
breast implants in the partial subpectoral posi- We waited 4 months until the implant pockets
tion. Submuscular placement is preferred to had loosened up enough to allow placement of
maximize the new collateral circulation into larger implants. Her saline implants were then
the overlying flap in the event of disruption of exchanged for 350 ml shaped silicone implants.
the pedicle. During elevation of the pectoralis She went on to heal well and has since had some
muscle on the right, I noticed that the flap skin minor scar revision and nipple reconstruction.
had turned dusky. I was worried that I had cut While her result is not perfect, the patient is very
her deep inferior epigastric flap pedicle and happy. She also has suffered in no limitation of
severed the primary blood supply to her breast her athletic endeavors (see Fig. 19.6a–d).
19 Decision-Making in Reconstructive Surgery 209

Fig. 19.6 Occasionally multiple surgeries and modalities flap breast reconstruction with subsequent placement of
are required to reach a reconstructive goal. (a, b) implants and nipple reconstruction
Preoperative views of patient. (c, d) After bilateral free

Case 2. Difficult Wound to be coiled. I was called the following day for
Reconstruction wound coverage.
I took the patient to the operating room to
The patient is a 65-year-old man with a history of explore the cavity. The rind was quite thick, mea-
a left thigh sarcoma treated with excision, radia- suring 2–3 mm. The exposed femur remained
tion, and chemotherapy in 2004. He developed vital, however. The remaining thigh skin was
extensive fibrosis of the left thigh anterior skin simply too fibrotic to allow for primary closure. I
but was otherwise ambulatory with a slight limi- reasoned that primary closure had also ultimately
tation in left knee extension. Ten years later he failed in that he had developed a seroma.
developed an expanding seroma of the left thigh. Additional tissue was needed.
This was percutaneously drained. Several days I considered the reconstructive ladder. Both
after that he developed an expanding hematoma primary and secondary closures were not possi-
of the left thigh, he was taken to the operating ble and there was no viable bed to support a skin
room by another surgery team to evacuate the graft. I decided a regional pedicled flap would be
seroma. Upon opening the thigh he was found to the best choice for closure. I raised a pedicled
have a large mature cavity with a fibrotic and vertical rectus abdominus muscle myocutaneous
hemosiderin stained thick rind with extensive flap. The long gracile muscle could be laid over
clotted blood. This was evacuated. About three the bone to provide coverage of this with its bulk
quarters of the anterior femur was completely obliterating and ultimately hopefully remodeling
devoid of periosteum and exposed within the the seroma cavity. The skin paddle was used to
cavity. The surgery team attempted to decorticate facilitate coverage of the wound. The surgery
the fibrotic tissue. Unfortunately, this leads to went well and the entire wound cavity was oblit-
extensive bleeding with the violation of the pro- erated and a tension free skin closure was
funda femoris artery. This artery ultimately had obtained. The flap was perfusing quite nicely.
210 E.E. Larson et al.

The flap did well for 3 days. I had the patient myocutaneous flap was performed. The flap com-
immobilized at the hip with a plaster splint. On pletely obliterated the cavity again with the mus-
post op day four, however, I noticed the flap was cle bulk. In fact it was a bit too large and a portion
purple. While the flap was supposedly being of the muscle was left exposed and covered with
evaluated every 4 hours by the house staff, this a split thickness skin graft. It is never wise to
color change was overlooked. I took the patient forcibly inset a flap under tension as this can
to the operating room emergently to explore the compress the vessels, particularly as the flap
flap. There was thrombosis of the vessels swells with reperfusion. The skin graft can
throughout the flap and it was beyond the point of always be excised later if needed for cosmesis.
salvage. I discarded the flap and placed a wound. The flap healed well initially.
VAC. Plan A had failed and it was time to engage One month later an abscess formed at the lat-
the life boat. eral margin of the skin paddle inset. I incised and
The patient was in otherwise good health. I drained this and washed it out. There was a rela-
was at a loss to explain the loss of the flap. I eval- tively small defect measuring 8 × 3 cm along the
uated him for clotting diathesis and none was lateral skin paddle inset. I reasoned that we
found. At this point the only regional option should be able to get this to heal with a wound
would be omentum. He was relatively slender VAC. I ensured his nutrition was optimized with
and my fear was that the omentum would not a multivitamin and at least 100 g of protein per
supply enough bulk or reach distally enough to day. To my dismay, after 2 months of negative
obliterate the cavity. He would need a free flap pressure therapy, the wound had not budged. I
and a large one. I chose the latissimus dorsi myo- considered hyperbaric oxygen; however, this is a
cutaneous flap to provide the necessary bulk and rather time-consuming option and not in any way
skin paddle. a guarantee of success.
Given the extensive distortion of the anatomy I went back to the drawing board. I rea-
by the previous surgeries and radiation, I enlisted soned that I had healthy non-radiated skin
the help of the vascular surgery team to help me from the back skin paddle adjacent to the
to find suitable recipient vessels. An angiogram wound. Perhaps a local fasciocutaneous flap
was obtained to help delineate these. Also, it is would work?
my practice to seek the advice and assistance of a I returned to the operating room and devised a
second reconstructive surgeon when I have per- second local flap based on the skin paddle of the
formed a first procedure that has failed. This has free flap. This was a rhomboid-type flap. The
the double benefit of adding additional perspec- wound was once again vigorously debrided (the
tive while bolstering my own confidence that we key to healing any contaminated wound). The
can do the right thing in the face of a previous rhomboid flap was raised and rotated into the
failure. We were essentially looking at the last defect. A skin graft was used to cover the rhom-
best chance to salvage the patient’s leg. boid flap donor site. The wound went on to heal.
The vascular surgeon was able to locate sev- The patient is ambulatory and there is no evi-
eral appropriate caliber vessels quite proximally dence of osteomyelitis or degradation of the fem-
outside of the zone of radiation. A free latissimus oral bone (see Fig. 19.7a–g).

Fig. 19.7 Failure is always a possibility in recon- wound to cover femur following microvascular anas-
structive surgery. Each failure must be met with a new tomosis. (e) Healing flap after abscess drainage. Note
idea. (a) Failed rectus abdominus flap for wound clo- proximal skin graft placed to avoid flap compression
sure, “in the bucket.” (b ) exposed femur with associ- from “overstuffing.” (f) Healed operative site after
ated rind of fibrotic, radiated tissue. (c ) Myocutaneous secondary local flap surgery from free flap skin pad-
latissimus flap on the back. (d ) Flap being inset into dle. (g ) Flap donor site
19 Decision-Making in Reconstructive Surgery 211
212 E.E. Larson et al.

References 3. Gottlieb LJ, Krieger LM. From the reconstructive lad-

der to the reconstructive elevator. Plast Reconstr Surg.
1994;93(7):1503–4.
1. Millard DR. Principalization of plastic surgery.
4. Bennett N, Choudhary S. Why climb a ladder when
Boston: Little, Brown and Co; 1986.
you can take the elevator? Plast Reconstr Surg. 2000;
2. Janis JE, Kwon RK, Attinger CE. The New reconstruc-
105(6):2266.
tive ladder: modifications to the traditional model. Plast
Reconstr Surg. 2011;127 Suppl 1:205S–12.
 Decision-Making
in Reconstructions for Traumatic 20
Defects in Extremity Surgery

Tolga Tűrker and Ethan E. Larson

deceived by the color of the extremity. Seeing a

Introduction pink extremity does not always means the tissue
has proper perfusion. Figure 20.1 represents an
As always, careful examination is very important acute table saw injury. According to the color of
in extremity defects. The injury is frequently the middle finger, it appears that there is proper
either under- or overestimated. Knowledge of the circulation in the finger; however, when an exam-
anatomy is key to providing appropriate treat- iner carefully examines the finger, he/she would
ment for the patients. After a trauma, careful notice that there is no capillary refill and the only
inspection and a vascular exam should be per- connection to the distal of the finger is a small
formed. Because of bleeding and clothing, skin bridge at the radial dorsal side of the finger
inspection is better performed in the operating (Fig. 20.2). If this is left as it is, the loss of the
room after the extremity is cleaned up. finger is inevitable. In contrast, the examiner may
Reconstructive decisions should not be made reach the false conclusion of “no circulation” in
based on pictures, but after careful examination. some circumstances as with a significant amount
Following inspection, one should check the of blood loss, low blood pressure or cold ambient
circulation of the extremity. This exam should not temperature. In addition, the examiner may have
be based on the presence or absence of pulses, but difficulty evaluating circulation of an extremity in
also on capillary refill. It is very important to patients with dark skin color. If there is any doubt,
understand peripheral circulation for the recon- imaging techniques such as SPY angiography or
struction process; however, one should not be duplex Doppler may be used to evaluate circula-
tion. The simple pencil type bedside Doppler may
be false positive [1]. Following the vascular
exam, if the patient can participate in the exam,
performing a neurologic exam is very important.
This exam starts with a sensory exam. Because of
T. Tűrker, M.D.
Department of Orthopaedics, Banner University the trauma, patients may report a false negative or
Medical Center, 1609 N. Warren Avenue, Room 110, positive sensory feedback. A two-point discrimi-
Tucson, AZ 85724, USA nation test can be used with a paperclip in order to
e-mail: tturker@ortho.arizona.edu
perform the sensory exam (Fig. 20.3). Even
E.E. Larson, M.D. (*) though 2-point discrimination is normal at 3 mm,
Department of Surgery, University of Arizona,
5 mm can be accepted as normal after a trauma.
1501 N Campbell Avenue, Room 5334, PO Box
245062, Tucson, AZ 85724-5062, USA The examiner should instruct a patient about
e-mail: elarson@surgery.arizona.edu 2-point discrimination and the patient should be

© Springer International Publishing Switzerland 2016 213

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_20
214 T. Tűrker and E.E. Larson

Fig. 20.1 A 57-year-old male. Left hand dorsal view of

table saw injury to the index and middle fingers. Color of
the middle and index finger may indicate a proper
circulation

Fig. 20.3 Two-point discrimination test. The paperclip

is reshaped and a thumb is being examined

dons. This may trigger proprioception, thus

patients may report normal sensory exam when in
fact the nerve is cut. Finally an examiner should
perform a motor exam. It is important to check
individual joint active range of motions in both
upper and lower extremities. Some key functions
may tell more about a nerve. For example, Thumb
interphangeal joint flexion is specific for anterior
interosseous nerve of the forearm. Ankle exten-
sion cannot be performed if there is a peroneal
nerve injury.
After performing an exam, obtaining a con-
ventional X-ray is very important to understand
Fig. 20.2 The same patient’s left hand volar view. Volar bone pathology. An X-ray should be performed
aspect of the index finger is intact. The injury to the mid- to include at least one distal and one proximal
dle finger can be appreciated in this view. The middle fin- joint of the injured area. If harvesting a bone
ger did not have circulation in the exam graft is considered from another part of the
body such as fibula, medial condyle of the
asked to look away from the examined area. It is femur or iliac crest, that potential donor area
important that the examinee should be able to should be X-rayed in order to see if there is any
give a solid answer to the examiner if she or he other pathology at the donor area before recon-
feels one or two tips. Answers from examinee like struction takes place.
“I guess two tips” or “I think one” are not valid. If In reconstruction for acute trauma, a definitive
a light touch is chosen as a sensory exam for fin- decision should not be made before a proper ini-
ger injuries, examiner should pay attention not to tial debridement and re-evaluation. If there is a
move finger passively while the sensory exam is severe injury, serial debridements should be per-
being performed because passive motion to a fin- formed and the extremity should be re-evaluated
ger will passively apply traction to the flexor ten- for definitive reconstructive decision-making.
20 Decision-Making in Reconstructions for Traumatic Defects in Extremity Surgery 215

Fig. 20.4 A 42-year-old

male patient right ankle
lateral view. Open
reduction and internal
fixation for an open
ankle fracture was
performed. The open
injury had been closed.
Subsequently wound
dehiscence and exposed
hardware is encountered

One should not forget Newton’s third law. For formed using a bone graft or bone flap. The nec-
every action, there is an equal and opposite reac- essary bone is chosen according to the defect.
tion. Therefore one should expect soft tissue inju- This could be auto graft that can be obtained
ries with multiple comminuted fractures in an from iliac crest to reconstruct small defects or
extremity. If energy passes through an extremity fibula can be used for longer cortical defect. The
and creates a comminuted fracture, there is most fibula may be applied as a free flap to reconstruct
likely soft tissue injury accompanying it. Soft tis- a femur in order to provide durable stable cortical
sue problems may present later. Figure 20.4 rep- support (Figs. 20.5 and 20.6). Allograft is another
resents a simple example of a soft tissue problem option to perform bone reconstructions. After
in an open ankle fracture. The wound was pri- obtaining the bone graft, internal fixation is the
marily closed after bone fixation by internal fixa- preferred method over external fixation.
tion. Over a period of time, the soft tissue problem However, one should consider using external
became more prominent and the patient ended up fixation for bone stabilization (Fig. 20.7), espe-
with exposed hardware. Surgeons should analyze cially for significant soft tissue defects at high
all exam data and imaging and should take into risk for infection. Kirscher wires (K wires) are
consideration the patient’s age, demand, and also commonly used hardware, especially in
health status to come to a definitive reconstruc- hand surgery. Using K wires could be related to
tion decision for the extremity defect. less risk for infection, except pin track infections,
Every tissue has a different personality and and can be done in a relatively short period of
should be treated accordingly. Assuming a good time. There are a couple drawbacks in this
debridement is performed, reconstruction approach, however. First, K wires may create
should be started immediately for patients if tethering in the tissues; therefore, occupational
there is a circulation deficit. After the extremity therapy may not be performed at the desired
is vascularized, the reconstruction either can intensity [2]. Second, the wires may not provide
proceed immediately or can be continued in the the same stability that a plate can provide; there-
following days. fore, hardware failure may be seen in K wire fixa-
If there is no vascular problem or after the tions while rehabilitation is in progress. It is
compromised vascularity is addressed, the atten- known that early rehabilitation is the key to
tion is turned to bone reconstruction. The bone is regaining function; therefore, one should con-
either repaired or reconstruction should be per- sider providing stable bone fixation (Fig. 20.8).
216 T. Tűrker and E.E. Larson

Fig. 20.5 A 22-year-old female. Comminuted open dis-

tal femur fracture with bone defect. Preoperative antero-
posterior X-ray
Fig. 20.6 Postoperative anteroposterior X-ray image of
free fibula bone graft for reconstruction of the open femur
defect. One and a half year follow-up image

Fig. 20.7 Right elbow

motorcycle accident.
The distal humerus has a
fracture and exposed.
15 cm portion of the
radial nerve is missing
due to the accident.
External fixator was
applied for skeletal
stabilization. Since the
radial nerve cannot be
repaired, the
brachioradialis muscle
flap was employed to
cover the elbow open
wound
20 Decision-Making in Reconstructions for Traumatic Defects in Extremity Surgery 217

Fig. 20.8 Right hand gunshot wound to the middle finger pal artery flap. In order to start occupational therapy, open
with tissue loss. The ulnar digital nerve was repaired with reduction and internal fixation was preferred
an allograft and the wound covered with a dorsal metacar-

Lower Extremity Reconstructions tant. If amputation is inevitable, keeping the

amputation level below the knee provides better
Since the lower extremity is required to keep the functional results with prosthesis. Figure 20.10
body in a standing position and is essential for shows a patient who had a traumatic lower
walking, surgeons have to consider the risks and extremity amputation. Since the aim is to keep the
benefits of a prosthesis and reconstruction. extremity amputation below the knee. A free flap
Providing a stable and long lower extremity is was considered to cover the exposed tibia. When
crucial for ambulation. Since the patient will be a free flap is considered, the surgeon should not
using the lower extremities mainly for walking only consider how to adequately cover the defect
and not for grasping, writing, etc., reconstruction but also consider creating minimal morbidity in
is relatively easy as compared to the upper extrem- the donor area. In this patient, free latissimus
ity, which typically requires more sophisticated dorsi with a skin island is considered to be the
reconstruction. As mentioned in the previous best option. The patient was felt to be likely to be
chapter, lower extremity reconstructions are also able to achieve stable gait with a below knee pros-
performed according to the reconstructive ladder. thesis, and the relative risk of sacrificing the latis-
Figure 20.4 shows a patient with an open ankle simus muscle and potentially diminishing future
fracture. As skin graft and rotational flaps are not wheelchair propulsive power was considered. The
the best option, a sural flap is used to cover benefits of sacrificing this muscle were felt to out-
exposed hardware (Fig. 20.9). One should be weigh the risks. As mentioned before, every tissue
aware of the health status of the patient. Providing has its own personality and a surgeon should
a sensitive sole is important and reconstructions know that denervated muscle will atrophy with
should be performed to prevent pressure ulcers. time to allow a better contour on the extremity for
Wounds on insensate feet tend to recur rapidly. fit of shoe or prosthesis. As expected, the muscle
Patients with severe diabetes, kidney disease, and became atrophic over a period of time. In order to
malnutrition may be better off with an amputa- minimize pressure ulcer development over the
tion. Attention is also given to keep the knees at tibia, the designed skin island was placed
the same relative level in order to provide better over the tibia (Fig. 20.11 ). In final follow-up,
gait. If salvage is not possible, preparation of the the patient was able to use the prosthesis with
lower extremity for good prosthesis fit is impor- minimal difficulty.
218 T. Tűrker and E.E. Larson

Fig. 20.9 Sural flap

coverage for right ankle
exposed hardware
patient in Fig. 20.4. The
flap was brought over
the exposed hardware
through a subcutaneous
tunnel

Fig. 20.10 A 51-year-

old male with a
traumatic fork lift
injury-related
amputation of right
lower extremity.
Exposed leg muscles
with tibia. The arrow
shows the level of the
knee

Upper Extremity Reconstructions

Upper extremity reconstruction requires more

sophisticated techniques. In contrast to lower
extremity reconstructions, upper extremity
reconstructions should provide not only structure
but also ideally fine motor function. The main
concerns should be how to provide function and
how to cover the affected functional unit.
Amputation should be the last resort and should
be performed after all possible reconstructions
have been attempted. Again, the reconstructive
ladder guides surgical decision-making. Like
lower extremities, upper extremity bone defects
can be reconstructed with bone grafts. Upper
extremities tolerate shortening better than lower
Fig. 20.11 Intraoperative anterior view of Patient in Fig. 20.10. extremities; therefore, if the defect is of reason-
Latissimus dorsi free flap and skin graft reconstruction for open tibia
expose. Please note that the skin island with muscle flap was placed able length, shortening of the upper extremity
over the tibia in order to provide better cushion for the prosthesis may be preferred over performing a complicated
20 Decision-Making in Reconstructions for Traumatic Defects in Extremity Surgery 219

Fig. 20.12 A 19-year-

old male. Motor vehicle
accident. Left upper
extremity X-ray of
severe left hand, wrist
injury

tion. In Fig. 20.14, a severe thumb injury is

treated with bone stabilization and then revascu-
larization with a vein graft. This procedure
resulted in an optimal outcome (Fig. 20.15). If
there is a functional motor deficit after bone
reconstruction, one should consider a variety of
reconstruction techniques from simple tendon
reconstruction using tendon grafts to tendon
transfers. Nerve transfers can be used to neuro-
tize a muscle or multiple muscles. Free functional
muscle transfers such as a free gracilis muscle
flaps can provide a motor unit in the forearm and
increase range of motion. Nerve repairs should
be performed even if poor outcome is expected.
After motor unit reconstruction, upper extremity
reconstruction employs a variety of local, pedi-
cled, and free flap options to cover the defect(s).
Because the upper extremity requires neurovas-
cular repair and frequently flap surgery, micro-
surgical skills are essential in order to perform all
procedures. In reconstruction, one should con-
sider the use of all available tissues that has mini-
Fig. 20.13 Anteroposterior X-ray view of fusion of mal donor site morbidity. For example, for a
metacarpal to the radius for Patient in Fig. 20.12 patient with a segmental radial nerve defect and a
lateral elbow coverage defect, a brachioradialis
bone reconstruction. Figure 20.12 shows a sig- muscle can be easily used to cover the lateral
nificant upper extremity defect and the metacar- elbow defect as a rotational muscle flap
pals are directly placed on the distal radius (Fig. 20.16). Since the muscle will be atrophied
(Fig. 20.13). However, soft tissue reconstructions due to denervation in due time, it can be used to
are more complicated and demanding in the cover the defect before this happens. It is also
upper extremity. Amputations should be avoided, very important for occupational therapy to be
even at the distal phalanx level. For example, started as soon as possible. A well-trained occu-
simple fingertip injuries should be reconstructed pational therapist is a key element in successful
with soft tissue that not only provides a cushion upper extremity reconstruction. Reconstructive
to the fingertip, but also provides sensation. heroics will ultimately be a waste of resources if
Sensation is essential for finger defects in order it results in significant stiffness due to lack of
to keep dexterity, and allow for fine motor func- occupational therapy.
220 T. Tűrker and E.E. Larson

Fig. 20.14 A 53-year-old female. Motor vehicle accident. Left hand images of severe crush injury. Exposed proximal
phalaks and compromised circulation

Fig. 20.15 Postoperative 6-month follow-up images of the patient in Fig. 20.14

Conclusion structive techniques for keeping the extremity

versus amputation and prosthetic usage should
There is no one algorithm to reconstruct be well considered. This should be decided
extremity defects. A surgeon should examine according to the patient’s health status, their
the injury appropriately, think of possible treat- desires, and the odds of a good outcome. In the
ment options and be aware of all available upper extremity, all attempts should be made to
reconstructive procedures. In the lower extrem- keep the extremity and maximize function.
ity, the balance between employing all recon- After all if an extremity is saved, in a worse
20 Decision-Making in Reconstructions for Traumatic Defects in Extremity Surgery 221

Fig. 20.16 A 20-year-

old male. Motorcycle
accident with radial
nerve defect and subtotal
amputation of the right
elbow. The elbow open
dislocation was fixed
with an external fixator
and distal humerus
fracture was fixed with
an internal fixation.
Since the extensor
muscles are denervated
due to radial nerve
injury, the exposed
hardware was covered
with a brachiradialis
muscle flap

Case Discussion: Reconstruction

of the Left Upper Extremity

The patient is a 37-year-old male involved in a

motor vehicle roll-over accident. He sustained a
left upper extremity degloving injury with open
elbow dislocation. Initial debridement was per-
formed and all extensor tendons and muscles
were removed except extensor carpi radialis lon-
gus (ECRL), extensor digiti minimi (EDM), and
extensor carpi ulnaris (ECU). An external fixator
was applied to the elbow for stabilization. The
patient underwent serial debridement and ulti-
mately an anconeus muscle and rotational flap
were performed for elbow coverage. A split
thickness skin graft was used to cover the wrist
and the elbow.
The patient was evaluated 2 years after the
original injury (Fig. 20.18). His elbow was sta-
ble. He was suffering from stiffness at the left
Fig. 20.17 Flexion and extension of the left hand of wrist and was unable to perform finger flexion
patient in Fig. 20.12. Subtotal hand amputation. The hand especially of the MP joint. He was unable to per-
was saved by several reconstructive surgeries. Even form active extension of the thumb, second, third,
though patient has a limited range of motion, the hand and the fourth fingers. His sensation was intact
serves as a helper to the right upper extremity
except the dorsal aspect of the left forearm and
there was no motor nerve deficit to the remaining
case scenario, it may serve as a helper extrem- forearm musculature.
ity to the other non-injured extremity The Patient’s problems included:
(Fig. 20.17). For a patient who would other-
wise have nothing, even a slight return of func- 1. Inability to perform flexion with left hand sec-
tion can make for a huge improvement in the ond, third, fourth, and fifth finger metacarpo-
quality of life. phalangeal joints due to extensor tendon
222 T. Tűrker and E.E. Larson

Fig. 20.18 Preoperative pictures of the left upper extremity. The elbow and the dorsal hand were coveraged with skin
grafts. Significant scar is observed at the dorsal side of the left wrist

Fig. 20.19 Intraoperative pictures of the extensor tendon tethering in the scar tissue at the dorsal side of the left hand
at the MP joint level

tethering and metacarpophalangeal joints scar tissue as expected (Fig. 20.19). The ECRL,
stiffness. EDM, and ECU were intact. All the extensor ten-
2. Inability to extend the thumb, second, third, dons of the thumb including extensor pollicis lon-
and fourth fingers due to extensor motor unit gus, and the extensor digitorum of the second, third,
loss. and fourth fingers were released from the scar tissue
3. Significant scar and stiffness of the dorsal side and tenolysis was performed for the EDM. After
of the left hand and the forearm causing a releasing all the extensor tendons and with joint
wrist flexion deficit. mobilization by scar lysis, passive finger flexion
was achieved intraoperatively. Despite the fact that
The patient did not have any flexor muscle or free functional muscle flaps could be transferred to
tendon injury and the exam showed that he restore extension for the fingers, the best option was
needed metacarpophalangeal joint mobilization the palmaris longus (PL) tendon transfer for the
and release of the extensor tendons from scar thumb and the flexor carpi radialis tendon (FCR) for
tissue at the dorsal aspect of the hand. However, the second, third, and the fourth fingers. However,
he also needed extensor motor power to per- since the extensor tendons were debrided previ-
form extension of the thumb, second, middle, ously, and the distal extensor tendons were at the
and the ring fingers. MP joint level, tendon grafts were needed in order
First, exploration was performed at the left dor- to transfer the PL and FCR to the digits. Even
sal forearm. The extensor tendons were stuck in the though there are several donor areas for extensor
20 Decision-Making in Reconstructions for Traumatic Defects in Extremity Surgery 223

Fig. 20.20 Left wrist dorsal view after

tenolysis and tendon transfer using tendon
graft. Previously scarred area was
completely removed

Fig. 20.21 Postoperative images of the donor areas. Left: lateral arm graft. Right: incision scar for ECRL and ECRB
harvesting

tendon graft harvesting, split ECRL and Extensor

carpi radialis brevis (ECRB) tendon harvesting was
considered from the opposite side of the forearm.
If split tendons are harvested from the ECRL and
ECRB, the remaining tendons are strong enough to
perform wrist extension.
One of the harvested tendons was used for the
PL to the thumb tendon transfer and the second
strip of the tendon was used to bridge FCR to the
extensor tendons of the second and the third digits.
The fourth extensor power was reconstructed with
EDM by end to side repair (Fig. 20.20). Since
there was tendon exposure, good quality tissue
coverage was required to allow tendon gliding. At Fig. 20.22 Postoperative picture. The patient is able to
this point, skin grafting was not an option on perform full flexion without tendon tethering
224 T. Tűrker and E.E. Larson

Fig. 20.23 Left hand, active finger extensions after tendon transfer

of the left forearm injury. The radial artery flap

could be another option but in this case, additional
skin grafts would be needed to cover the donor
area. Therefore a free flap was considered. A lat-
eral arm flap was employed as a free flap option
with preservation of the lateral forearm cutaneous
branch. The flap was sutured end to side to the dor-
sal branch of the radial artery and end to end a
branch of the cephalic vein.
The donor site in the right upper extremity was
closed primarily and healed without any problem
(Fig. 20.21). The patient went on to have active
flexion of the all fingers (Fig. 20.22) and was able
to extend all digits, including the thumb, after ten-
don transfer (Fig. 20.23). The free flap healed
without any complication (Fig. 20.24). The
patient returned back to his original job and even
started work at a second job.

References
Fig. 20.24 Postoperative picture of dorsal aspect of the 1. Tűrker T, Capdarest-Arest N. Acute hand ischemia
left wrist after lateral arm free flap application after radial artery cannulation resulting in amputation.
Chir Main. 2014;33(4):299–302.
2. Gonzalez MH, Hall M, Hall Jr RF. Low-velocity gun-
grafted tendons. Rotational or axial pattern local
shot wounds of the proximal phalanx: treatment by
flaps and free flaps were considered. The posterior early stable fixation. J Hand Surg Am. 1998;23(1):
interosseous artery flap was not an option because 150–5.
 Part III
Special Issues in Surgical Decision Making
 The Surgeon’s Burnout: How
to Deal with It 21
Bellal Joseph and Tahereh Orouji Jokar

Introduction What Is Burnout?

Most of us at some point in our career go through Burnout is one’s unhealthy relationship with
situations where we feel helpless, lose interest, work and in term refers to a mental or physical
feel unappreciated; everything looks bleak, and collapse caused by overwork or stress. It has
it’s difficult to muster up the energy to care. been described in the literature that as a triad syn-
There comes a time when dragging ourselves out drome of emotional, mental, and physical exhaus-
of bed requires the determination of Hercules, tion, high depersonalization, and a feeling of low
problems look overwhelming and even breathing personal accomplishment caused by excessive
becomes a task [1]. The impact of such feelings and prolonged stress [1, 2].
forces individuals to reconsider their self-worth It is well established that emotional exhaus-
and this cascade of events eventually leads to tion lies at the center of the problem and exces-
helplessness. Experiencing such feelings most of sive psychological and emotional demands result
the time may lead them to suffer from burnout in emotional exhaustion. Depersonalization is a
and this can ultimately threaten one’s job, rela- tendency to view others in a markedly detached
tionships, and health. manner and represents the individual’s attempt to
protect against further emotional exhaustion. All
these components are self-perpetuating and ulti-
mately lead to a mixed matrix propagating the
other components. Burnout is a continuous vari-
able ranging from emotional exhaustion to low
personal accomplishment [3].
The burnout syndrome is an endless list of
problems including physical illness, emotional
B. Joseph, M.D. (*)
Department of Surgery, University of Arizona problems, increased turnover, absenteeism, poor
Medical Center, 1501 N Campbell Ave., Room 5411, job performance, drug abuse, and negative atti-
Tucson, AZ 85724, USA tudes that have been associated with burnout.
e-mail: bjoseph@surgery.arizona.edu
These problems present as a part of a “general-
T.O. Jokar, M.D. ized psychological distress” which is variable in
Department of Surgery, University of Arizona
each individual [3]. Burnout leading to burnout
Medical Center, 1501 N Campbell Ave., Tucson,
AZ 85724, USA syndrome ultimately occurs in individuals who
e-mail: torouji@surgery.arizona.edu require spending time and intensive involvement

© Springer International Publishing Switzerland 2016 227

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_21
228 B. Joseph and T.O. Jokar

with other people. Given the severity and impact for the Surgery of Trauma, 40 % of the trauma
an individual has, it is important to deal with surgeons reported symptoms of post-traumatic
burnout in a defined stepwise approach. stress disorder (PTSD) and 15 % had a diagnosis
of PTSD [6].
Burnout is not limited to practicing physicians
Population at Risk or surgeons, and as matter of fact there are other
vulnerable groups including medical students
The phenomenon of burnout has been investi- and residents who suffer from burnout. More
gated in a wide variety of occupations, including than half of the medical students in US manifest
physicians and surgeons. Up to 40 % of practic- burnout while in medical school. High levels of
ing surgeons suffer from considerable stress and stress and burnout have also been reported in
subsequent burnout during their career that may nurses. It is also reported that burnout is higher in
affect their personal and professional perfor- acute pediatric nurses compared to non-acute
mance. Campbell et al. reviewed burnout among group. Similar results have been reported in
582 American surgeons and found that one-third nurses working night shifts and those involved in
(32 %) of them had high levels of emotional the intensive care setting [7].
exhaustion, whereas 13 % had higher deperson-
alization, and 4 % indicated a low level of per-
sonal accomplishment [3]. Burnout vs. Stress
Burnout more likely occurs in young female
surgeons who have younger children or delay Often burnout and stress are words that are used
childrearing, and assume greater parental respon- interchangeably; however, they are not the same.
sibility while they have similar clinical duties as Constant stress causes an individual to initiate
male surgeons [4]. A more likely explanation is losing interest that may have been a motivator to
that younger surgeons are in fact experiencing take on a certain role in the first place. Like burn-
more emotional stress as a result of different out, stress can also affect the quality of family
social expectations regarding the balance of relationships and the nature of the doctor–patient
career, family, and personal growth and develop- relationship. The difference lies in that people
ment. The implication is that we continue to fail who are stressed have the ability to imagine and
to prepare our young trainees to survive in their visualize rationally. Often the condition is revers-
personal and professional lives while they are ible and once the stress is managed or dealt with,
mentally healthy. The impact of this failure is people are often able to successfully manage
substantial as literature demonstrates that many their professional performance and feel better.
of these young burned out practitioners leave sur- On the other hand burnout deters one’s ability to
gical specialties to retrain in other specialties or rationalize or imagine and ultimately the ability
begin retiring earlier [3]. to reverse the condition is complex, requiring
Although some evidences demonstrated that management of more than one condition.
physicians in private practice might be at a greater Burnout is often associated with a devoid of
risk for burnout, there is no difference in burnout motivation. It can result in feeling as though one
among surgeons based on practice setting. “has nothing left to do,” negative attitudes toward
However, some limited evidence suggests that patients, and a reduced feeling of competence.
there may be some differences in burnout among People with high levels of burnout are hopeless
different surgical subspecialties [5]. The surgical and cannot see the positive changes in their situ-
specialties involved with the care of emergencies ation. In contrast to stress, burnout is character-
and acute adverse events are usually at higher ized by disengagement. It produces blunted
risk of burnout due to their longer work hours and feelings and causes helplessness, hopelessness,
stressful nature of the field. In a survey conducted loss of motivation, and ideals. It may lead to
on the members of the Eastern Association for detachment and depression. Primary damage in
the Surgery of Trauma and American Association burnout is emotional and may make life seem not
21 The Surgeon’s Burnout: How to Deal with It 229

worth living [8]. However, burnout is a psycho- lifestyle and personality traits contribute to burn-
logical construct to investigate the stress. out. Being younger and having a spouse employed
outside the home is associated with a higher risk of
burnout. It means that lack of balance among
Measuring Tools career, family, and personal growth in the younger
surgeons is directly associated with burnout. On
The Maslach Burnout Inventory is a reliable the other hand, having children is associated with
measurement instrument to sample large popula- a lower risk of burnout [5]. Causes of burnout are
tions for stress [4]. This measuring tool has sepa- presented in Table 21.1 [5, 8].
rate subscales to evaluate each domain of burnout One or combination of these factors can pre-
[9]. There are some standard categorical thresh- dispose a professional to burnout. Excess work-
olds to classify each domain score as high, mod- load, inefficiency, loss of self-sufficiency, and a
erate, or low. According to this classification lack of meaning in work seem to be central fac-
scoring system, surgeons are considered as high tors to cause burnout among surgeons [10]. There
scores in depersonalization and emotional is a probability that gender differences may be
exhaustion [4]. However, burnout in the surgical another cause of burnout. Female physicians
environment is sparsely reviewed and the quanti- have a higher level of burnout in comparison to
tative assessment of surgical burnout is limited. their male counterparts. However, among sur-
geons, gender disparity does not have a robust
impact on burnout [7].
Burnout in Surgeons

It has been reported in a study that 30–35 % of Table 21.1 Causes of burnout
surgeons suffer from burnout [5]. This substantial Occupational Related
number indicates that there is a concern in per- • Lack of control over the work
sonal and professional life of the surgeons. • Insufficient reward for decent work
Surgeons work hard, work long with irregular • Doing unchallenging work
hours, deal repeatedly with their patients, and • Working in a stressful environment
make considerable sacrifices to practice in their • Disconnect between own core values and the job
field. They have an unwritten but understood values
• Favoritism and work-related unfairness in
code of rules and expectations. This code includes
assignments and promotions
coming in early and staying late, working nights
Lifestyle Related
and weekends, performing a high volume of pro- • Unbalanced lifestyle between work and personal
cedures, meeting multiple simultaneous dead- life
lines, never complaining, and keeping personal • Lack of time for relaxation and hobbies
problems away from work. • Lack of sleep
Ultimately, all of these qualities are both defined • Lack of supportive resources and ability to
and rendered by the surgeons; however, when there delegate work
is no fine line between dedication and hard work, it • Research and educational situation
can lead to an unhealthy and self-destructive behav- • Lack of social support
ior, which can affect patient care as well. • Lack of regular time off
Personality Type and Attitude Related
• Type A personality
• Perfectionistic feeling
Burnout Causes
• Negative view of oneself and world
• Pessimism
There are several causes for burnout. Originally it
• Poor skills fit for the job
stalks from the occupation; however, anyone who
Data from [5, 8]
is overworked is at the risk of burnout. Additionally,
230 B. Joseph and T.O. Jokar

Burnout Signs and Symptoms Burnout Prevention

Burnout occurs gradually over a period of time. Considering the early symptoms of burnout as
Signs and symptoms of burnout are subtle at first, warning signs is important. By having insight to
but they get worse over time. It is associated with these warning signs and recognizing them early,
depression and anxiety. In a study, evaluating we can prevent a major breakdown and the devel-
members of the American College of Surgeons, opment of burnout [8]. Taking steps to get life
approximately 30 % of study participants back into balance can prevent burnout from
screened positive for depression [5]. Some litera- becoming a full-scale failure. Individual efforts
tures also suggest that the exhaustion component to develop a balance between personal and pro-
of the burnout syndrome may be related to fessional life may help reduce burnout rate in sur-
depression. geons. Overall, enhanced institutional support
Burnout and depression among practicing sur- and increased opportunities for professional pro-
geons are independent predictors of medical gression can decrease burnout rate among sur-
errors. Inherent stressful nature of the surgery geons [2]. One effective method to prevent
along with excessive and erratic work hours put burnout among surgeons is to actively protect
surgeons at a much higher risk for burnout and their personal and professional well-being at all
may also affect personal relationships. The levels of physical, emotional, psychological, and
increasing incidence of divorce after 30 years of spiritual. These efforts need to occur from medi-
marriage is the highest among surgeons, regard- cal school through retirement.
less of the amount of work resources or hours
worked. Moreover patients with chronic burnout
have specific cognitive impairments in non- Burnout Prevention in Surgeons
verbal memory and attention [11].
There are several tips, which will help in burnout
prevention among surgeons. Starting the day with
Symptoms of Surgeon’s Burnout a relaxing protocol and meditation will help
inspire the individual. Surgeons should adopt
Signs and symptoms of surgeons’ burnout can be healthy eating, exercising, and sleeping habits.
broadly classified into three groups: physical, By getting plenty of rest, they will have enough
behavioral, and emotional. Physical signs and energy and flexibility to deal with the environ-
symptoms include feeling tired most of the time, mental irritations. They should halt overextend-
change in appetite or sleep habits, frequent head- ing themselves and set their limitations. Creativity
ache and body pain, and reduced immunity. is another factor, which can help decrease the
Among the emotional symptoms, loss of motiva- burnout rate. Additionally, it is exceedingly
tion, negative attitude, feeling failure, decreased imperative that a surgeon knows how to manage
satisfaction, feeling hopeless and helpless, and his stress. All these elements can have a crucial
detachment are remarkable. Furthermore, isola- role in preventing burnout.
tion, careless attitude, generalizing frustration Moreover, co-worker and spouse support, as
towards others, skipping work, and procrastina- well as positive patient interactions, can buffer
tion are among the emotional factors associated work overload and emotional demands, thereby
with burnout. positively influencing surgeon’s well-being. In
Surgeons, with high level of burnout, are more order to decrease unnecessary tension and fortify
likely to report increasing intake of alcohol, support mechanisms for surgeons, Wallace et al.
keeping things to themselves, engaging in less believe that a categorized group can strengthen
sports or recreation and mixing less with friends functional teams by providing team construction
in response to work-related stress [7]. and social events, enabling feedback and working
21 The Surgeon’s Burnout: How to Deal with It 231

for common aims. This will help alleviate tension Table 21.2 Strategies to prevent burnout
and its consequences [12]. Personal
Other personal strategies that may help increase • Identification of tension and coping strategies to
well-being of individual surgeons include partici- prevent burnout
pating in research, following educational activities • Goal setting and time management
outside work environment, paying particular atten- • Develop healthy personal relationships and
spiritual practices
tion to important personal relationships, perform-
• Find medical and/or mental health care when
ing spiritual practices, recognizing the importance needed
of one’s work, promoting personal interests out- • Appropriate nutrition and physical fitness
side work, engaging in mentorship, and creating a • Create and sustain work-life balance
balance between personal and professional life [2]. • Positive thinking and avoidance of negative
Surgeons who are able to determine what is impor- thinking
tant in their life and put energy for their goals may • Self-monitoring of stress
have a lower risk for developing burnout. Organizational
Additional coping factors to decrease burnout • Develop an administrative leadership to identify
include getting regular sleep, obtaining personal surgical residents who are at risk
medical care, and exercise [13]. There are several • Making a safe training situation
• Providing tension controlling training
organizational strategies for coping with burnout
• Creating healthy relationships between residents
that are represented in Table 21.2 [14, 15]. and their families
Coping with all predisposing factors will help • Identification of the critical factors leading to
prevent burnout. Surgeons must be proactive burnout among female and young residents
about any work issue, which exists in the work • Providing research and educational situations
environment, and try to approach and elucidate • Creating constructive mentorships and relation
them. The individual should be completely aware between residents and their mentors
of his responsibility in his work place and ask his • Support flexibility in work hours
mentor about all of the dimensions of his duty. • Provide leadership skills training
Doing a constant duty for a long time may result • Create specific programs to support physicians
suffering from symptomatic burnout
in impatience and tiredness. Therefore it is help-
Data from [14, 15]
ful to ask for a new category or territory.

Recovering Conclusion

While burnout happens with its warning signs, it Both symptoms and diagnosis of burnout are
is crucial to take it serious and try to recover from common among medical field personnel espe-
it. If the preventing tips are still helpful, recovery cially in surgeons. Further understanding of the
needs additional stages. First step of recovery is factors that predispose surgeons to burnout may
to slow down and take a break. It is equal to time be of benefit to the patients and the profession. It
for healing. Ultimately if burnout is inevitable, lays responsibility on national organizations to
the best solution is to ask for a complete break help set new standards of identification and treat-
time from work to recover and recharge one’s ment of burnout. Advocating active surveillance
mood and perspective. Sharing feelings with oth- and development of targeted interventions by
ers and trusting them can relieve tension and national organizations may promote wellness
burnout criteria. Finally surgeons should reevalu- among surgeons.
ate and set goals and priorities that they define as
reachable and important contributors to their Acknowledgments There are no identifiable conflicts of
overall happiness. interests to report.
232 B. Joseph and T.O. Jokar

The authors have no financial or proprietary interest in nurse specialists working in the National Health
the subject matter or materials discussed in the Service. Colorectal Dis. 2008;10(4):397–406.
manuscript. 8. Financial futures: The Financial Employment
Newsletter by Adams, Inc. 2015; http://jobs.adams-
inc.com/adams/newsletters/September2014Article.
htm.
References 9. West CP, Huschka MM, Novotny PJ, et al. Association
of perceived medical errors with resident distress and
1. Helpguide. Preventing burnout: signs, symptoms, empathy: a prospective longitudinal study. JAMA.
causes, and coping strategies. 2015. http://www.help- 2006;296(9):1071–8.
guide.org/articles/stress/preventing-burnout.htm. 10. Shanafelt T, Dyrbye L. Oncologist burnout: causes,
2. Bertges Yost W, Eshelman A, Raoufi M, Abouljoud consequences, and responses. J Clin Oncol.
MS. A national study of burnout among American trans- 2012;30(11):1235–41.
plant surgeons. Transplant Proc. 2005;37(2):1399–401. 11. Peterson U, Demerouti E, Bergstrom G, Samuelsson
3. Campbell Jr DA, Sonnad SS, Eckhauser FE, Campbell M, Asberg M, Nygren A. Burnout and physical and
KK, Greenfield LJ. Burnout among American sur- mental health among Swedish healthcare workers.
geons. Surgery. 2001;130(4):696–702; discussion J Adv Nurs. 2008;62(1):84–95.
702–695. 12. Wallace JE, Lemaire J. On physician well being-
4. Dyrbye LN, Shanafelt TD, Balch CM, Satele D, Sloan you’ll get by with a little help from your friends. Soc
J, Freischlag J. Relationship between work-home Sci Med. 2007;64(12):2565–77.
conflicts and burnout among American surgeons: a 13. Warren AM, Jones AL, Shafi S, Roden-Foreman K,
comparison by sex. Arch Surg. 2011;146(2):211–7. Bennett MM, Foreman ML. Does caring for trauma
5. Shanafelt TD, Balch CM, Bechamps GJ, et al. patients lead to psychological stress in surgeons?
Burnout and career satisfaction among American sur- J Trauma Acute Care Surg. 2013;75(1):179–84.
geons. Ann Surg. 2009;250(3):463–71. 14. Espeland KE. Overcoming burnout: how to revitalize
6. Joseph B, Pandit V, Hadeed G, et al. Unveiling post- your career. J Contin Educ Nurs. 2006;37(4):
traumatic stress disorder in trauma surgeons: a 178–84.
national survey. J Trauma Acute Care Surg. 15. The happy MD. Physician burnout bibliography.
2014;77(1):148–54; discussion 154. Physician wellness and physician resilience research
7. Sharma A, Sharp DM, Walker LG, Monson JR. Stress papers. 2015. http://www.thehappymd.com/physician-
and burnout among colorectal surgeons and colorectal burnout-and-hospitalists.
 The Surgeon’s Response
to a Patient’s Death 22
Terence O’Keeffe

We differ somewhat from other physicians as

Introduction we are neither internists who manage chronic ill-
ness for our patients, sometimes over many
Surgeons have many aphorisms that we love to decades, nor are we gerontologists, looking after
use such as “a chance to cut is a chance to cure” people in the twilight of their years, knowing that
or “the only way to heal is with cold steel,” and the march of time cannot be halted. Therefore we
even “all bleeding stops eventually” [1]. The enter into our medical “contract” with the patient,
humorous nature of these phrases underlies a so to speak, with the desire to cure our patients in
more serious belief that most surgeons have in the strictest sense of the term, i.e., relieving the
their abilities to stave off the effects of disease and person of the symptoms of disease and returning
save their patient’s life. These sayings may also them to health, without recurrence. However, we
serve to help insulate the surgeon again the emo- have seen an explosion in the elderly population,
tional distress that they may feel when the out- many of whom are now coming to us for opera-
come is much less beneficial than intended. Given tions that may or may not be well advised, given
that the entire raison d’etre of most surgeons is in their age and/or co-morbidities, such that we may
attempting to cure the patient of their suffering, often need to revise our expectations of cure,
one of the worst consequences that we suffer in with those of a more palliative nature. Indeed,
our profession is the death of a patient, despite our palliative surgery is becoming more and more
best attempts. Additionally, as our profession recognized in its own right as an important
involves the inflicting of wounds through surgical contribution, with a number of surgeons taking
technique, there are at times when a well-inten- palliative care boards.
tioned operation of procedure can be the actual Many of us have faced desperate patients and/
cause of a patient’s demise. However, to be effec- or families who wish to have “everything done,”
tive as surgeons, we have to banish these thoughts regardless of the actual chances of success or the
to the back of our minds, in order to focus on the possible consequences. One of our roles needs to
task in front of us. be in taking counsel with the other caregivers of
these patients to make sure that we are of course
T. O’Keeffe, M.B., Ch.B., B.Sc., F.R.C.S., “doing no harm,” but additionally that we are
M.S.P.H., F.A.C.S. (*) able to provide realistic expectations of the out-
Department of Surgery, Banner University Medical
Center, 1501 N Campbell Avenue, Room 5411D,
comes of surgery, so that hopes are not unduly
Tucson, AZ 85724, USA raised, only to be dashed again if complications
e-mail: tokeeffe@surgery.arizona.edu occur.

© Springer International Publishing Switzerland 2016 233

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_22
234 T. O’Keeffe

Clearly, there are a wide spectrum of opera- Anger

tions, as well as many different types of sur-
geons, but at some point, whether in training or We may externalize our pain and turn it outwards
in practice, a surgeon will be faced with a towards others in trying to cope with a patient’s
patient who succumbs to their disease and dies. death. Surgeons have a long tradition of always
How we deal with this can be challenging and blaming anesthesia for surgical complications,
painful, and can even lead to some maladaptive but this humorous practice can quickly become
behaviors, which can be problematic for our problematic in the case of a poor outcome lead-
professional and personal relationships if left ing to a patient’s death, and could end up in front
unchecked. of the hospital’s peer-review process, or worse
still, evolve into legal action. Understanding that
this reaction is part of the normal grieving pro-
Grief and Bereavement cess is helpful to accepting one’s reactions and
preventing them spiraling out of control both at
Surgeons can go through many of the same pro- work and at home.
cesses that the loved ones of the patient, although
these feelings are obviously likely to be much
more abbreviated. The five stages of grief, as Bargaining
described by Kubler-Ross are: denial, anger, bar-
gaining, depression, and acceptance, many of There will always be retrospection after a case that
which are familiar to us [2]. Relatives of the has gone awry, particularly if the outcome is death,
deceased clearly have reason to grieve, but as a but it should be understood that Surgery is both a
surgeon, you may feel you have no “permission” science and an art, and there will never be the pos-
to express your emotions. The surgical culture of sibility of perfect outcomes. However, the science
stoicism and hardened professionalism that is a background of our profession will always lead us to
facet of our specialty may also make it harder to seek answers as to what went wrong, how we can
acknowledge these feelings. do better the next time, etc. Although postmortems
have fallen out of fashion in modern medical prac-
tice, they are a useful way to provide further closure
Guilt to the family, and help the surgeon understand the
cause of death in cases where it was not expected.
Guilt can be a powerful emotion that the surgeon Similarly, the cathartic process of the surgical mor-
has to deal with after the death of a patient, par- bidity and mortality conference, if done well, can
ticularly if the surgeon ascribes some blame to help move the surgeon along in coming to terms
themselves for the cause of the death. In his book with the death, as well as helping them understand
Complications: A Surgeon’s Note on an Imperfect how they can improve in the future.
Science, Dr. Gawande describes his emotions “I
felt a sense of shame like a burning ulcer. This
was not guilt: guilt is what you feel when you Depression
have done something wrong. What I felt was
shame: I was what was wrong.” These emotions It is thankfully unusual for a patient death to cause
can be especially damaging to surgeons early in depression in their surgeon, but combined with
their career, such as residents, who may not have other life events, as well as other work stressors,
yet dealt with a patient’s death. A good peer sup- this event may be enough to precipitate this prob-
port system in the residency, in addition to a sym- lem in a “primed” and/or susceptible individual.
pathetic program director can make sure that the Self-awareness, the surgeon’s partners and physi-
resident is able to move through this trauma cian wellness programs may all play a role in
effectively. helping a surgeon recover from this.
22 The Surgeon’s Response to a Patient’s Death 235

Acceptance Table 22.1 Coping strategies

Negative Positive
Accepting that death is unfortunately an integral Alcohol or substance abuse Talking openly
part of the life of a doctor, and that we are on with family
many occasions merely trying to slow the inexo- “Bottling things up inside” Attending the
patient’s funeral
rable march of a disease, is an important part of
Feeling guilty and blaming Supporting the
dealing with this process. Depending on the sur- yourself surgical team
geon, end-of-life care may be a larger or smaller Brooding over events Guidance/support
part of a surgeon’s practice. Studies have shown from colleagues
that burnout is highest amongst intensivists and Obsessing how things could have Support from
also very high in general surgeons, which is been different your family
unsurprising considering the number of life and Blaming others: anesthesia, nurses, Seeking
colleagues, patient, family professional help
death circumstances that are encountered by these
Data from [3]
specialists. In addition, much has been written on
compassion fatigue amongst nurses, oncologists,
and intensivists, but little data exist in the litera- somewhat changed my view of end-of-life care
ture regarding the incidence and difficulties sur- as well as patients that I meet with this disease.
geons experience with it. Unless the surgeon is Most of us will still remember the first patient
careful, this can be an unfortunate consequence of that we cared for who died; I certainly still have
overexposure to the seriously ill and dying. a strong recollection of that event. Over time
physicians who deal with death on a regular
basis, develop coping mechanisms to at least
Expected vs. Unexpected Deaths partially insulate themselves from the emotional
distress that they may feel from this. These cop-
A patient dying of metastatic cancer may often ing strategies may be healthy ways to cope with
have a different impact on their surgeon that a the burden that the surgeon may feel, but can
patient who had been doing well to all intents and often slip into maladaptive responses and behav-
purposes, and then suddenly passes away from an iors. Table 22.1 lists some “good” and “bad”
unexpected complication. In the former case, the coping mechanisms [3].
patient’s death is more likely to be an expected
consequence with possibly even relief for the
patient, their family and even the surgeon, who Patient Factors
may wish for a merciful release for their patient if
recovery cannot be hoped for. Nevertheless, There are a number of patient factors that can
many surgical oncologists and/or surgeons who make it either easier or harder for the surgeon to
perform palliative surgery may still form strong accept their death. These may include their age,
bonds with their patients. To a certain extent this the type, and/or severity of the underlying illness,
may depend on how the surgeon identifies with the degree of the patient’s suffering, and the
their patient as well as with their family, their belief systems of both the surgeon and their
social circumstances, and the specific disease. I patient. It is generally accepted that between 70
remember all too well a patient I cared for his 30s and 80 % of people in the United States believe in
(a few years older than me at the time), who was God, and 72 % believe in miracles [4]. This can
diagnosed with stage IV metastatic colon cancer, make the process of death harder for some fami-
and had two children and a loving wife. These lies to accept, especially if this has been an unex-
patients will stick in our memory for a long time, pected event. Dealing with a patient’s family
despite our inability to significantly impact their members, who do not accept their death, can cer-
disease process. In addition, it is clear to me that tainly increase the physician’s stress and discom-
my mother’s death from ovarian cancer has fort, which can be especially problematic with
236 T. O’Keeffe

brain death, as the patient’s body remains warm Fear of Litigation

and vital, despite the lack of brain function and
clinical diagnosis of death. The vast majority of surgeons are exposed to law-
suits during their careers from unexpected out-
comes, complications, and even the death of a
Performance Issues and “Getting patient. One of the fears that may lurk in the back
Back on the Horse” of the mind of the surgeon after a patient’s demise
is apprehension over possible litigation.
One of the very hardest things that the surgeon Unfortunately, this concern, whether warranted or
may face is to "shrug off" the death of a patient so not, may hamper our ability to interact effectively
that they can continue with the rest of their work- with the family in their moment of need, and pre-
day. In general, in the case of an unexpected vent full disclosure of the events surrounding their
intraoperative death on an elective list, the sur- loved one’s death. There are some data that a pol-
geon would be wise to postpone or reschedule icy of full disclosure in the event of an untoward
other non-urgent cases to give them time to event actually leads to fewer claims, lawsuits, and
regain their equilibrium and to be able to devote liability costs [7]. This should of course never be
the necessary physical and mental energy to a the primary concern of a surgeon in the immediate
new operation. Acute care surgeons find them- aftermath of such an event, but appropriate coun-
selves in the situation of more hopeless cases sel from senior colleagues and involving the risk
with greater frequency, and so are likely to expe- management team may help assuage any concerns
rience this event more often, and may not have regarding immediate legal action.
this option to step “away” from call commit-
ments in this event. Nevertheless, experiencing a
patient’s death in the middle of a busy 24-h call How Can Surgeons Find Effective
can be a significant drain, and if at all possible, at Coping Mechanisms?
least a few minutes of time away from patient
care to compose oneself is advisable, and very Although things do seem to be changing, we are
necessary. Having a debrief with the rest of the taught in medical school to maintain a certain
surgical team is very important to ensure that all degree of emotional detachment, and the pre-
members can continue to function at their best, as dominant culture in the US medical establish-
it is easy to suffer from compassion fatigue in the ments would see a physician’s emotional
aftermath of a patient’s death. The challenge of response to death as a sign of weakness and pos-
continuing to perform at one’s best for each new sibly even incompetence [8]. Nevertheless, it is
consult or subsequent operation cannot be under- important to acknowledge the death of a patient
stated, and although surgeons are proud of their in whose care we have been involved, and also to
“grit,” we must be mindful of our own vulnera- acknowledge the feelings that are evoked within
bilities and respond appropriately for the safety us. This will help us to become more aware of the
of all our patients [5]. In his book Complications: needs of our patients and also to recognize our
A Surgeon’s Note on an Imperfect Science, Atul own needs.
Gawande writes about a colleague who had At the outset it may be helpful, to some degree,
made an error: “Afterward, he could barely bring to share feelings of loss with members of the
himself to operate. When he did operate, he family of the deceased. The grief of the family
became tentative and indecisive. The case must of necessity take precedence, but some-
affected his performance for months.” Seeking times family members can gain a great deal of
guidance from a senior colleague may be helpful comfort from sharing experiences with someone
in these circumstances to help the surgeon find who has been involved with the care of their
their equilibrium anew [6]. relative. All too often in medicine we do not
22 The Surgeon’s Response to a Patient’s Death 237

acknowledge events such as this, and our own their family and the surgeon. Clear expectations
feelings get lost because we then become should be laid out before attempting any heroic
involved with new cases and new situations. surgical efforts that carry a high risk of patient
The support of our peers is another avenue mortality, primarily for the sake of the family.
from where we can draw assistance. This includes
our partners, senior colleagues, a mentors or oth-
ers in positions of authority. This may be more Burnout
difficult if the surgeon is a solo practitioner, and
especially in the case of the rural surgeon who The ultimate concern of course is that continual
may not have professional colleagues in close exposure to patient’s dying may contribute to the
vicinity. Academic or group practice will afford surgeon becoming “burnt out.” Surgeon burnout
more opportunities for peer-to-peer counseling is covered eloquently in another chapter of this
and support. book (Chap. 21), so will not be covered exhaus-
The importance of family connections obvi- tively here, but it is clear that there are many
ously cannot be overemphasized here, whether it forces at play, not just the emotional distress from
is a spouse, siblings, or other family members in dealing with the dying patient [9]. Previous work
the medical profession, who may be sources of has suggested that burnout can also be a conse-
support, sounding boards, or even able to provide quence of systemic organizational problems, and
advice from their own real-life experiences. this may need to be remembered as more and
Having good family relationships that allow the more surgeons become employees of large
surgeon to decompress, relax and discuss the healthcare systems, as opposed to group or aca-
issue in an unguarded fashion is absolutely essen- demic practice [10, 11]. In one recent study, sur-
tial for their emotional well-being. The uncondi- geons that placed greater emphasis on finding
tional love that we receive from our families at meaning in work, focusing on what is important
times like these, allows us to remain grounded in life, maintaining a positive outlook, and
and get through what can be very difficult times. embracing a philosophy that stresses work/life
Many surgeons find solace in their pastimes, balance were less likely to be burned out [12].
whether these consist of physical activities or
more cerebral pursuits. Having a sport, hobby, or
social outlet outside of work may also be a good Conclusions
way to find work-life balance, and enable the sur-
geon to move through the emotional turmoil of We can longer pretend that we are the stone-
the death of a patient. Physical exercise with its hearted surgeons of a supposed “golden era”; our
endorphin-promoting effects may be a particu- patients demand more from us, both in shared
larly effective way to mitigate against the mental decision making in the beginning, and a shared
and emotional stresses associated with such an interest in the outcome of surgery. We must
event. accept that we will have patients that will leave a
Unfortunately, although professional organiza- mark on us when they die, and be prepared to
tions are starting to recognize more and more the draw upon our peer and family support to see us
emotional strain that modern medical practice puts through those days. Burnout is a real phenome-
upon the practitioner, there are few resources that non in our profession, and we must have insight
exist currently to help surgeons deal with these to maintain our emotional balance.
stressors, which are felt to be part and parcel of the
profession. As the public’s perceptions of health- Acknowledgments There are no identifiable conflicts of
care change, and people become more medically interests to report.
The author has no financial or proprietary interest in
sophisticated in general, expectations have risen,
the subject matter or materials discussed in the
which can lead to tension between the patient, manuscript.
238 T. O’Keeffe

References 7. Boothman R, Hoyler MM. The University of

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Metropolitan Books; 2002. p. 269.
 When Should Surgeons Quit
Operating? 23
Stanley J. Dudrick

During their professional lifetimes, surgeons operating. Yet, this is both in their best interests
must make many decisions, virtually daily, often and in the best interests of their patients, espe-
continually, mostly “on the spot,” sometimes cially from the standpoints of trust, safety, effi-
“life or death,” and almost always critically cacy, optimal outcomes, and personal and
important to the optimal care, outcomes, and professional responsibility, duty, honor, and
well-being of their patients. These decisions are character.
based primarily on the cumulative knowledge, It would be uncommon for all surgeons to
experience, judgment, and wisdom gained agree completely to follow an identical pathway
throughout years of education, training, mentor- or algorithm in the decision-making process
ing, conferences, consultations, study, and intro- related to the management of any surgical prob-
spection; coupled with dedication, motivation, lem. Although the mechanisms and principles of
persistence, resilience, integrity, equanimity, obtaining a comprehensive history and physical
core values, ethics, and courage along with a examination together with appropriate indicated
wide variety of additional, often unique, virtues hematologic, biochemical, nutritional, immuno-
which comprise the individual essence and char- logic, genetic, and imaging (ultrasonic, radio-
acter of each of the multitude of surgeons logic, magnetic resonance) studies have been
throughout the world. However difficult and well-established, the decisions to use them judi-
demanding many of these decisions have been, ciously and in a specific order of priority vary
often accompanied by lingering anxiety, self- quite a lot among surgeons, as does the subse-
doubt, and other manifestations of emotional and quent use of more complicated, sophisticated, and
psychological distress, no more formidable and expensive techniques and technologies in estab-
personal challenge must be faced and confronted lishing a provisional or definitive diagnosis, pro-
by the practicing, operating surgeons than the posing a therapeutic plan, and informing and
decision as to when it is time for them to stop educating the patient regarding the risks, potential
complications, and prognosis, together with the
S.J. Dudrick, M.D., F.A.C.S. (*) preoperative preparations and measures, and the
The Commonwealth Medical College, essentials of postoperative care, recovery, conva-
Scranton, PA, USA lescence, and rehabilitation requisite for optimal
Misericordia University, Dallas, PA, USA outcomes. Many other general and specific
Yale University Medical School, patient-centered aspects must be incorporated
New Haven, CT, USA into wise decision-making, including personal,
40 Beecher Street, Naugatuck, CT 06770-2721, USA family, financial, healthcare insurance, employ-
e-mail: sjdudrickmd@comcast.net ment, social, spiritual, religious considerations,

© Springer International Publishing Switzerland 2016 239

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_23
240 S.J. Dudrick

etc. There are myriad other compounding and/or not responded as predicted, planned, and
confounding factors which can significantly com- expected, based on our previous experience or
plicate the process, particularly in patients with historical expectations? Was the failure to achieve
multiple complex problems, patients with various the ideal or “perfect” result predetermined by a
kinds and degrees of organ and/or system failures, combination or set of confounding circum-
undernutrition, trauma, infections, old age, frailty, stances, which would interdict our usual efforts
etc. Thus, it is obvious that making the same or attempts, despite our strict observance of and
series of decisions in all patients with the same adherence to the highest standards of care? Were
apparent problem is promulgated by the myth of we naively expecting that this commonly straight-
“routine care for routine patients.” There are no forward patient could have the “routine” problem
uniformly routine situations in real life, and it is “slam-dunked” by the surgeons’ skill, expertise,
this type of “one-size-fits-all” thinking and rote and experience? I teach students, residents, and
decision-making that can result in surgical man- others that there are no “routine surgical patients,”
agement failures, operative errors, and misadven- but there are some “routine surgeons.” Most of
tures that can lead to undue complications, the time they can play the poker game well and
morbidity, and mortality, which continue to exist comfortably, but when they are dealt an unusual,
at unacceptable, recalcitrant levels despite current weak, or strange hand, they will lose their money
measures to avoid or minimize them. The appar- or chips if they think that they can win the pot
ently untoward, unanticipated, unavoidable, unin- every time because they are such superior poker
tended occurrence or result can almost always be players. As recorded in the Country Western bal-
traced back to a conscious or subconscious deci- lad, The Gambler: If one chooses to play in a
sion on the part of the surgeon not to follow his or game, one should be willing to learn to play it as
her own established principles and practices pro- well as it can be done safely and effectively in
ficiently, meticulously, and conscientiously. order to be a winner as much as possible, for win-
Why do these unfortunate, preventable, quix- ning is the ultimate goal of the game. Accordingly,
otic consequences continue to occur arguably to one must also know intuitively and/or intelli-
the most intelligent, educated, experienced, dis- gently when holding off one’s wager or even
ciplined, hard-working, motivated, accom- folding up one’s cards and walking away from
plished, respected surgeons on earth? If the the game is the better part of valor and judgment
answer to this question were obvious and readily [2]. Even the world’s best poker player cannot
discernible, the situation would have been win the pot if he or she is dealt an extremely poor
arrested, reversed, diminished, avoided, or pre- hand of cards, and even the best of surgeons can-
vented years ago; but it persists today virtually not cure all of their patients, because not only are
unabated, tragically, and stubbornly, despite they compelled to work with the patient that they
apparent national, institutional, societal, profes- are dealt, but also, despite their exceptional
sional, and personal efforts to solve, correct, and efforts, skills, and talents, the desired outcome
obviate the problems. Perhaps it has continued to may elude them when the odds are so greatly
exist because we have only nibbled at the edges against success. Although ethical surgeons are
of the problems and have been treating symptoms not gamblers, they must know and cope with sim-
or modulating untoward consequences rather ilar sets of probability, percentages, and unknown
than identifying and attacking all of the root other inherent factors such as risks, luck, and
causes of poor outcomes. In accordance with the chance that influence the results of their decision;
wisdom and pronouncement of Pogo, “We have and “bluffing” is never allowed or acceptable in
met the enemy, and he is us” [1]. As surgeons, we surgery.
have all experienced a less-than-optimal result of My first Professor of Surgery, Dr. Isadore
even our best efforts to alleviate or correct a seri- S. Ravdin, frequently pointed out to the medical
ous patient condition ordinarily amendable to students, surgical residents, and others that, “one
judicious surgical treatment. Why has the patient cannot make a silk purse out of a sow’s ear,”
23 When Should Surgeons Quit Operating? 241

especially when the operative goals could not be judged to be “over the hill” by his assistants, sub-
achieved as planned, secondary to an impossible ordinates, or colleagues, or, even worse, not to be
pathologic situation and/or untoward or unin- informed, counseled, or advised by colleagues as
tended consequences. Indeed, the wisdom that he to their concerns, but rather to be allowed to con-
and my other mentors imparted to me, starting as tinue to perform below standards and, perhaps,
a medical student and then throughout my surgi- thereby not to be aware of secondary adverse
cal residency training and research fellowship, consequences to the patient and to the deteriorat-
has influenced me greatly throughout my surgical ing reputation of the surgeon.
career. In those days, it was either conventional By the time that I had completed my Chief
or the rule that a surgeon relinquish a leadership Residency year in General Surgery, I had made
role as a Chairman or Chief of a Surgical Service the prospective decision that I would stop operat-
at 65 years of age. This also applied to operative ing at age 65 in order not to embarrass myself,
surgery, or at least to major operative surgery, and not to compromise the ideal standards of opera-
most surgeons would plan their projected length tive care, and not to cause any untoward compli-
of time practicing operative surgery from the cations or outcomes in my patients related to my
completion of their training and board certifica- diminishing competencies and skills secondary
tion on that basis. However, this conventional to my aging.
“mandatory retirement” was not uniformly In his Presidential Address to the Forty-first
accepted or applied throughout the country, and Scientific Meeting of the North American
subsequently, after the legislation dealing with Chapter of the International Society for
age discrimination was enacted in 1986, many Cardiovascular Surgery in Washington, DC, in
surgeons have continued to operate well beyond June, 1993, Lazar Greenfield chose to address the
the year of their 65th birthday. end of mandatory retirement as the broader ques-
When I was a student and intern at the bottom tion of the performance of aging surgeons [3]. He
of the surgical food chain, I witnessed more than stated that:
a few conversations among the older residents “This is a touchy issue because most of us feel that
regarding the quality of the attending surgeons’ we are constantly getting better at what we do,
decisions in patient management and/or perfor- when, in fact, we are aging…. Although very little
mance of the operative procedures. After a case is known about the behavior of aging surgeons,
there is a great deal of interest in the older worker
which might not have had an ideal intraoperative in general, particularly with reference to job safety
experience or result, a resident would comment and productivity. In fact, it is surprising to learn
negatively about the surgeon thus, “Did you see that in the science of applied ergonomics, which
how the old man ripped out the gallbladder and addresses the interaction between the worker and
job demands, the older worker is defined as anyone
caused all that bleeding?” Or, “Can you believe over 40 years of age. You will be delighted to learn
how roughly he tore through the adhesions and that this is believed to be the time of the onset of
into the intestine?” Or, “He was in such a hurry slowed performance, decreased ability to learn
that the patient lost at least two units of blood new skills, increased accidents, rigidity, poor
health, irritability, and resistance to supervision
because he wouldn’t stop to clamp all the vessels [4].” [3]1
he cut across.” Or, “Why does he keep doing
these big cases when they all seem to get compli- Greenfield [3] collected much information on
cations secondary to his roughness or impa- this subject from various sources. Decline in
tience?” These were very disturbing, often motivation, creativity, and ability to cope with
whispered conversations among the house staff,
which obviously frustrated and frightened them 1
Used with permissions from Greenfield LJ. “Farewell to
and me. I was in no position to judge them or the Surgery.” Presented as the Presidential Address at the
staff surgeons involved, but I was indelibly Forty-first Scientific Meeting of the International Society
for Cardiovascular Surgery, North American Chapter,
impressed that I would never want to find myself Washington, D.C., June 7–8, 1993. J Vasc Surg
in a comparable position as a surgeon who was 1994;19:6–14.
242 S.J. Dudrick

stress is supported by other studies [5]. If this is voice [10]. Compensation takes the form of
correct, and if there is any relevance to surgeons, developing strategies to optimize performance
it could be beneficial to consider the physiology [11]. As one ages, it takes longer to retrieve infor-
of aging. It is known that joint mobility decreases mation from memory and to make decisions that
only slightly between the ages of 20 and 60, but need to access particular short-term memories. In
the incidence of arthritis increases significantly all likelihood, the most common age-related
beyond age 45 and there is also reduced motion physiologic changes occur in eyesight. This is
of the lumbar spine [6]. Other factors arise: due to a variety of factors: pupil shrinkage, hard-
decreased overall elasticity can limit leg and arm ening/yellowing of the lens, loss of accommoda-
movements; increased rapid shoulder muscle tion, increased light scattering in the ocular
fatigue occurs [6]. Skeletal muscle strength is at media. Improved lighting, incorporating visual
maximal potential between the ages of 20 and 30; aids, and reducing glare can improve visual per-
it then declines gradually into the forties, and the formance. Optimal performance requires about
rate increases thereafter, with it being faster in 50 % more illumination for those 40 to 55 years
the legs and trunk than in the arms. In women, old and about 100 % more for those over age 55
muscle strength stays at approximately 67 % that [12]. A decrease in tolerance to heat can be expe-
of men, whereas in both genders, arm and finger rienced by those who are older, leading some
strength declines after age 40. Additionally, max- older surgeons to complain about the temperature
imum grip strength declines by 50 % between in the operating room. These findings have stimu-
ages 25 and 79 [7]. In summation, 25 % of lated recommendations to: 1. Use ergonomic job
strength is lost by age 65, resulting from the fol- design; 2. Place older workers in supervisory
lowing factors: muscle wasting/weakness, a capacities, thereby retaining the benefit of their
decline in the number of functioning motor units, knowledge, experience, and skills. It is clear that
and reduced nerve conduction impulse velocities. additional and more longitudinal studies of per-
Concomitantly, maximum oxygen capacity is at formance must take place to verify the validity of
its highest at about age 20; it then declines gradu- these age-related changes [13]. Aging is a vastly
ally so that at age 65 it is about 70 % of what it complex phenomenon involving multiple organ
was at age 25 [8]. Some of this change is proba- systems: a model system to investigate these
bly secondary to the effects of regressive activity. mechanisms and their interactions is essential
Moreover, an age-related reduction in the ability and greatly needed [3].
to diffuse lactate after maximal exercise begins at Greenfield [3] states further:
about age 30. This decreases endurance [9]. With “Because we are not likely to be able to influence
age, there is also a decrease in heart rate during the rate of physiologic aging any time soon, what
maximal exercise, from 195 beats per min at age are the problems related to aging that surgery must
24 down to 175 beats per min at 50 years and face? One is the end of mandatory retirement.
Federal legislation enacted in 1986 now prohibits
then to 165 beats per min at 65 years [8]. So, employers from requiring their employees to retire
work-load capacity decreases while perceived when they reach a specific age. An exception to
effort increases this law allows colleges and universities to require
What matters for surgeons, however, is perfor- tenured faculty to retire at age 70 years, but only
until Dec. 31, 1993. However, in 1991, Michigan
mance quality as opposed to work-load; this is passed its own legislation barring any age-related
defined as the time allowed for a specific task mandatory retirement. At the University of
relative to the actual time the job takes. Studies Michigan the number of faculty who are age 60
have demonstrated a decline in mean perfor- years or older has increased 37 % in the past 12
years, whereas the overall size of the faculty has
mance ratings with increasing age, related to a increased only 2 %. With the option to continue
reduced signal/noise ratio from sensory organs to after age 70 years for the past 3 years, 60 % have
the brain and within the brain, in part explaining chosen to stay and one study predicts a future
why the older person requests that you raise your 1-year retention rate of 85 % for faculty reaching
70 years of age. In the United States today only
23 When Should Surgeons Quit Operating? 243

11.5 % of medical faculty are 60 to 69 years old 2 years after the driver is 70 to 75 years of age,
and only 2 % are over 70 years of age.” [3]2 and that consideration be given to issuing
Greenfield [3] reports interesting comparisons restricted licenses that would not allow driving in
and conclusions. Academic departments and pri- high-risk traffic areas [3].
vate practices are facing medicolegal and eco- Greenfield [3] proceeds with great under-
nomic challenges, as mandatory retirement is standing of, and further discussion on, the age
nonexistent. These include: cost of compensa- issue. Sensitivity has been expressed to any sug-
tion, restricted ability to recruit younger surgeons gestion of discrimination against the elderly, with
to the staff or the department; disclosure to the this preventing the states from passing age-
patients of the surgeon’s health, among others. related driving reforms. Age-based criteria come
The proliferation of outcomes data will make it into play in many other public policies: Social
likely that hospitals and patients will want to Security, Medicare, housing programs, and tax
receive assurances that an aging surgeon’s per- benefits. Similarly, driving is legally not permit-
formance is up to the standard. Comparisons ted until 16–18 years of age. Furthermore, pur-
such as these are indeed difficult, complex, and chasing or consuming alcoholic beverages is not
very dependent on the level of patient risk that legally permitted until age 21. State administra-
the surgeon accepts. A similar paradigm exists tors have been subjected to liability for failing to
with regard to driving age: It is difficult nowa- identify the disabilities of drivers who subse-
days to determine who should drive and who quently cause death or damages. Thus, some
should not. Data confirm that the cohort of driv- similarities exist to the responsibilities faced
ers over age 65 do not represent a hazard to the when credentialing of older surgeons. Why is it
public since their crash rate per mile is increased appropriate to require older drivers to be recerti-
only slightly until they reach age 75. On the other fied but not surgeons? We monitor for adverse
hand, such older drivers are more vulnerable to outcomes, but then the question arises as to why
injury once a crash has occurred. In a survey of it is necessary for an adverse outcome to occur
15,336 two-car fatal crashes, drivers over age 64 before something is done in the surgical profes-
were five times more likely to die when com- sion? Acting on a single adverse outcome would
pared with drivers less than 20 years of age [3, precipitate legal challenges, but multiple adverse
14]. Drivers are required to undergo reexamina- outcomes would spur the plaintiff’s attorney to
tion at least every 4 years: knowledge and vision include the Chief of Surgery and others in the
tests are also administered; deficiencies and limi- legal actions. Calculated risk is certainly not
tations must be documented; remedial measures acceptable when group risk exists, as in the case
must be taken if required; finally, driving licenses of passengers in a commercial aircraft. The
can be terminated if necessary. How the states Federal Aviation Administration has successfully
handle this responsibility differs considerably: defended legal challenges to its requirement that
most require vision testing at some age, and only commercial pilots flying larger planes retire at
some require knowledge or road testing. age 60. On the other hand, pilots flying smaller
Suggestions have been made that vision include commuter and private aircraft are not subject to
both acuity under reduced illumination and this restriction. Moreover, no data exists suggest-
dynamic visual acuity [15]. Data suggest that the ing that older commercial pilots are subject to
frequency of examinations be increased to every more accidents. The defense of the age 65 retire-
ment rule has been that the older pilots challeng-
ing the rule must demonstrate that their
2
Used with permission from Greenfield LJ. “Farewell to performance is as good as that of any other older
Surgery.” Presented as the Presidential Address at the pilot. But there is a Catch 22, since no other older
Forty-first Scientific Meeting of the International Society pilots are available for comparison. A research
for Cardiovascular Surgery, North American Chapter,
Washington, D.C., June 7–8, 1993. J Vasc Surg project that would study the relationship between
1994;19:6–14. aging and accidents and would lead to tests to
244 S.J. Dudrick

select individuals capable of flying safely and Greenfield [3] cited interesting results: 33 %
competently after 60 is in progress, commis- of physicians over 65 reported word-name block-
sioned by the Office of Aviation Medicine within age; only 10–20 % under age 55 admitted to hav-
the FAA. Pilots have a much higher death rate ing this problem; 40 % of physicians age 65 or
than the general population (peaking between older indicated problems with short-term recall;
ages 55 and 59 for reasons that have not been only 22 % under age 55 years had this problem.
identified to date), so this study may be hampered Coping strategies for memory loss such as keep-
somewhat. But it is interesting to note that pilots ing notes or making lists were reported by most
who retire early seem to enjoy a longer life physicians. If it is assumed that most physicians
expectancy [3]. will or should recognize the signs of mental and
After this sidebar discussion of driving and physical aging, the logical outcome should fol-
piloting, Greenfield [3] returns to the subject at low that they will change workloads accordingly
hand. New information on changes in cognitive and perhaps conclude that retirement is a better
functions of older physicians is presented due to a option than losing one’s reputation. However, it
new computerized neuropsychological screening is not unusual for some surgeons to ignore the
battery entitled the Assessment of Cognitive signals and signs of diminished performance
Functions [16]. This screening tests mental func- quality and/or capability and to keep operating
tions that use the limbic system to learn, store, and well beyond the obvious decline of their skills.
retrieve information. Impairment of the limbic All of us have experienced such situations and
system results in memory deficits similar to the usually have been unable or unwilling to do much
dementia of the Alzheimer disorder. Attention, about them. Perhaps the most famous is the story
language, calculations, visuospatial operations, of the last years of Ferdinand Sauerbruch, as
and reasoning by 21 subtests sampling 16 cogni- described in the book The Dismissal by Thorwald
tive domains are also evaluated by this series of [3, 17].
tests. This test was administered to 1002 physi- Why and how is it that otherwise gifted sur-
cians in Florida, Texas, and Massachusetts, who geons have little or no insight into their deteriora-
ranged in age from 25 to over 75. It was validated tion or can be so unwilling to give up operating?
by concurrent testing of control individuals who Three physician traits have been identified that
were normal or mildly impaired; emotional state, can account for this behavior [18]. The first trait
medication, sleep deprivation, and intellectual is poor self-esteem. This is surprising at first
ability were not shown to influence the results. glance, but it refers to the tendency for physicians
During the first three decades, a gentle downward to identify themselves with what they do rather
slope occurs for both physicians and normal con- than who they are as persons. As an example, he
trol subjects. Following that, a more rapid decline relates the comment of a 70-year-old surgeon
occurs after age 65. Great variability exists among who said, “I know I have no business doing sur-
individuals at advanced age; many will continue gery anymore, but what good is a surgeon who
to function at levels comparable to those of doesn’t operate?” The second trait is ignorance or
younger individuals: four of five physicians aged rejection of death, which seems even more
70 to 74 functioned as well intellectually as those unusual because physicians deal with death
in the allegedly prime age range of 45 to 64. One everyday. He points out that physicians deal with
must keep in mind that, since these studies are other people’s deaths and as a group are extremely
cross-sectional versus longitudinal, they are vul- afraid of disease and death. Studies show that
nerable to Darwinian law, which dictates that only most people come to the realization that life is
the fit survive to be tested. When 445 physicians finite and death is real in their forties, whereas
were asked whether or not they had become aware physicians do not adjust to this reality until their
of signs of diminished personal cognition, it was sixties. The third trait is resistance to change,
found that the admission of cognitive problems which characterizes physicians reluctant to
was also directly proportional to age [3, 16]. accept the need to adjust to advancing age and
23 When Should Surgeons Quit Operating? 245

who boast, “I’ll never retire!” This is easy to tennis game and others in the same age group
understand because it requires facing the previ- who cannot even walk to the mailbox. The same
ous issue of loss of self-worth and confronting can be said for surgeons: many still do great work
one’s own death [3]. in their 70s, but others should not even be allowed
Obvious to all is that better longitudinal data into the operating room [27].
on the performance of aging surgeons is abso- Recently, the American Medical Association
lutely necessary. Cognitive and functional test took the initiative in this situation, convening a
results need to be evaluated under controlled cir- group of physician members to recommend
cumstances designed to produce objective data in guidelines for assessing the skills and the abili-
preference to subjective criteria, in order for ties of physicians late in their careers. However,
credible performance evaluation to be estab- no definitive action had been announced by July
lished. It is of paramount importance that the 2015, nor has any indication been made as to who
stigma associated with retirement must be obvi- would be charged with conducting such assess-
ated. Of equal importance is that the means for ments of competency. In the United States, one of
productive surgeons to continue to retain their every four licensed physicians is older than age
self-esteem must be devised, implemented, sup- 65, with 40 % of them actively practicing, accord-
ported, and encouraged as they enter the final ing to the AMA statistics. Their goal in creating
stages of their chosen profession [3]. guidelines is to head-off calls for a mandatory
Specific problems, examples, and studies retirement age, especially for surgeons, while
related to aging surgeons—including their profi- still safeguarding patients. A thoracic surgeon at
ciency, operative mortality, cognitive changes, Sinai Hospital in Baltimore in his seventh decade
neuropsychological tests, decay of skills, surgical of age was not involved in generating the AMA
risk factors, surgeon fatigue, time to leave active report, but has been a strong proponent of guide-
practice, and other less specific estimates of com- lines tied to competency, particularly for sur-
petence and safety—have not been yielding uni- geons [28]. He published his work on “The Aging
formly unequivocal data or information which is Surgeon” in the Annals of Surgery in 2014 and
as conclusive as had been anticipated regarding reported several disquieting anecdotes that he
definitive resolution of some of the study objec- had heard regarding excellent surgeons with
tives originally hypothesized [19–26]. exemplary reputation and respect who ran into
More recently, Whitehead [27], in a short trouble as they got older. One requested a col-
communication on the internet entitled, “When league to lead him back to his office after an
Should Surgeons Stop Operating,” highlighted a operation because he wasn’t sure that he could
two-day series of assessments for older surgeons find it. Another ordinarily meticulous surgeon
to evaluate physical and cognitive function, a began to show up to work appearing sloppy and
program offered at Sinai Hospital in Baltimore. unclean. Yet another surgeon actually fell asleep
She noted that some of the declines that accom- while performing a surgical procedure in the
pany aging include increasing fatigue, forgetful- operating room! To dramatize his message, he
ness, and reduced eyesight. She then pointed out abstracted the tragic and heartbreaking late years
that other professions maintain a close watch for of Ferdinand Sauerbruch (1875–1951), one of the
such changes in order to protect the public, and world’s greatest surgeons, who for decades was a
some even have a firm age cut-off. For example, brilliant diagnostician and exquisite technician in
airline pilots are required to retire at age 65, and his clinic and operating theaters in Berlin.
some firefighters must step down by age 57; how- However, in his late 60s, his colleagues noted that
ever, no nationwide age-related cut-offs, required Sauerbruch would be subject to sudden mood
assessments, or guidelines currently exist to swings, would strike others in the operating the-
ensure that physicians provide their services ater with instruments, and became sloppy and
safely and competently. She added that we all clumsy, among other complaints. In part because
know octogenarians who can play a respectable of the success related to his international fame
246 S.J. Dudrick

and generation of financial resources, the Faculty in 2014, the program invites surgeons from around
and Administration failed to intervene, and indi- the world to come to Baltimore to take a two-day
test that rates their physical and cognitive abilities.
vidual efforts by his friends suggesting his retire- Among the many skills and attributes examined,
ment were flatly rejected. After a prominent actor the tests evaluate hearing, vision, and hand-eye
succumbed to bleeding during a simple hernior- coordination. Surgeons who are concerned about
rhaphy and a child died after a stomach resection their health can opt to take the tests, but hospitals
can also request evaluations of their surgeons. The
because Sauerbruch failed to restore gastrointes- results and recommendations—good or bad—are
tinal continuity, he finally acceded to demands to entirely confidential and are supplied solely to the
retire in 1949 at age 74 when threatened with a individual who requested the evaluation.” [27]4
humiliating public dismissal. Despite this, he had
While it may sound like a good option for
little insight and continued to operate in his home
senior surgeons, the program has had its difficul-
with disastrous results. His 1953 autobiography
ties. For one, not a single doctor has stepped for-
is entitled “Master Surgeon.” Sixty years since
ward voluntarily to date to take the test as of July
then, there are overwhelming anecdotes and
2015 [27]. Katlic has indicated that a number of
some published evidence that the aging surgeon
physicians would retire voluntarily rather than go
remains a problem, which has piqued Katlic’s
through this screening [27, 28].
interest and efforts [28].
Whitehead [27] continues:
He believes and says:
“Stanford Health took a similar approach in 2012
“I think the general public would be very interested when it created the Late Career Practitioner Policy
to know that surgeons don’t police themselves well requiring physicians over the age of 75 years to be
as a profession. It often takes a bad complication screened every 2 years. The policy has faced oppo-
that hurts a patient before something serious is sition among Stanford Faculty members with some
done. Surgery requires solid mental and physical arguing that there is research proving that older
capabilities that some older surgeons may be lack- physicians are more likely to make mistakes than
ing. Fine motor skills are needed to wield sharp younger physicians. Some critics of these sorts of
scalpels; endurance is essential for long proce- tests and guidelines say that they are needlessly
dures, and quick reaction times are a must, too. If a discriminatory and should focus on competency,
problem arises in the operating room, surgeons not age. Others point out that physicians, of all
need to analyze the situation swiftly and make people, have the training and experience to evalu-
decisions on the fly.”[28]3 ate their own health and shouldn’t need outside
oversight. But that’s not good enough, Katlic and
A surgical oncologist at Eastern Virginia Perry say. Doctors are human too. Most people,
Medical School has reported that the concept of regardless of the field they fall into, fail to recog-
“fluid intelligence” is an essential factor in prob- nize that they are not doing as well as they used to,
lem solving, and that this ability can and does Perry said. We all know people in our families who
are driving that shouldn’t be—but if you speak to
degrade with age. But surgeons need to continue them, they think that they are perfectly fine.” [27]5
to think on their feet, so to speak, and figure things
out on the go, not just by formula, and find cre- Perry’s [29] analysis is that, while it will take
ative alternatives instantly, despite age [27, 29]. time, doctors will eventually see the need for
How can we determine whether and when a competency tests and will, in the end, accept
surgeon can no longer be trusted wielding a scal- them. The hopeful forecast would be that doctors
pel during a major operative procedure? would also then agree to participation in the
Whitehead [27] states: Aging Surgeon Program [27]. Katlic [28] con-
cludes that such a confidential assessment is
“The key is creating a series of tests and guidelines
that check capabilities instead of chronological
age. The Aging Surgeon Program at Sinai Hospital 4
Used with permission from Whitehead N. http://www.
is one example of this initiative. Created by Katlic
npr.org/sections/health-shots/2015/06/18/414912417/
when-should-surgeons-stop-operating.
3 5
Used with permission from Katlic MR, Coleman J. The Used with permission from Whitehead N. http://www.
Aging Surgeon. Annals of Surgery 2014;260 npr.org/sections/health-shots/2015/06/18/414912417/
(2):199–201. when-should-surgeons-stop-operating.
23 When Should Surgeons Quit Operating? 247

essential to protecting the patient while at the ior, and rational, logical, moral, and ethical deci-
same time recognizing the dignity and value of sions must prevail. Until the definitive
the doctor to the overall good of society. adjudication of the time for surgeons to quit oper-
“When should we quit operating” has been a ating occurs, we will continue to be dependent
difficult question to answer for surgeons through- upon the innate insight, judgment, wisdom,
out the centuries; and it has become ever more integrity, character, competence, strength, skills,
trying, demanding, formidable, and controversial ethics, health, finances, and other personal fac-
as our patients and surgeons age and live longer, tors of the individual surgeons to make this often
and as our society has become more complex and distressing decision and to “do the right thing.”
demanding. No uniformly recognized, accepted, On a personal note, at the time of this writing,
enforced laws, rules, regulations, standards, prac- the author is 80 years old and has refrained from
tices, or guidelines have been established, and primary responsibility for major operative sur-
little progress has been made in defining and gery and acute patient management for 5 years
managing this onerous problem. Prior to the Age since his 75th birthday in 2010. It was not easy or
Discrimination in Employment Act (ADEA) in pleasing to do, and there has not been a day since
1986 in the United States, the mandatory retire- then that I have not missed doing what I loved
ment age of 65 years served as a generally, though most, but I have maintained my long-standing
not entirely, accepted landmark or milestone for modified, prospective decision, and I have only
surgeons to use to relinquish their leadership returned to the operating theater on a few occa-
positions of authority, and concurrently to surren- sions since then to provide requested consulta-
der their major operative privileges and complex tions or assistance to my younger staff colleagues
patient management activities and responsibili- or trainees who sought the benefits of my more
ties. This was somewhat helpful in avoiding and extensive experience. To be candid and honest, I
ameliorating the problem of the aging surgeon. have greatly enjoyed those occasional sojourns to
However, the mandate against age discrimination the operating suite, and I have cherished the grat-
has had a significant impact on surgical practice, ifying opportunity to continue to be useful in
both positive and negative, and many of the sharing my accrued experience, judgment, and
resulting consequences have been noted, wisdom.
described, and/or discussed throughout this chap- On the other hand, I have not really retired
ter, together with what relatively little relevant or from life or from the microcosm of academic
representative literature has been published to medicine and surgery. I have been occupied
date. Moreover, in addition to the studies and pre- 40–80 h a week (sometimes more), lecturing,
sentations of some of our most intellectual, philo- teaching, and mentoring medical students, physi-
sophical, responsible, and concerned individual cian assistant (PA) students, residents, fellows,
surgeon colleagues, some of our most respected other members of the healthcare community;
and honorable professional societies and govern- supervising history-taking, physical examina-
ing bodies have undertaken the challenges to elu- tions, surgical skills sessions, simulation exer-
cidate and resolve this “Gordian knot” problem, cises; advising and counseling; writing reference
including the American College of Surgeons, the letters; making personal telephone calls and
American Board of Surgery, the American cyber contacts to advocate for students, residents,
Medical Association, and others. To date, no and fellows; presenting lectures, conferences,
definitive conclusions or recommendations have seminars throughout the country; writing papers,
been forthcoming, although it is inevitable that chapters, books, usually with younger co-authors
the greater healthcare community and the patient at all levels; giving mock oral examinations; trav-
population will demand and expect the resolution elling throughout the world lecturing at major
of this problem in the near future. It is highly professional meetings and learning; spending
unlikely that any resolution will be acceptable to more time with my wife of 57 years and family of
everyone, but such is the nature of human behav- six children, 16 grandchildren, and one great
248 S.J. Dudrick

grandchild; and enjoying more time with them, longer. I persuaded my closest professional and
especially in our beloved New Hampshire lake personal surgical friends to promise me that they
house. There are so many other wonderful, chal- would not allow me to embarrass myself or to
lenging, and exciting things for me to do and perform below my own high expectations from
enjoy that I don’t have time or desire to reflect other surgeons, and that they would discretely
upon the past “glory days” of surgery because I inform me when it was “time to hang up the
am trying to help promote the future greatness of cleats,” and “turn in the uniform.” Indeed, I regu-
surgery via my associations and interactive larly checked with them as to whether I was still
opportunities with the brightest generation of doing “OK.”
young aspirants to our specialty that I have ever As I approached age 75, became an Emeritus
known. Professor, Emeritus Chairman of Surgery, and
To conclude my tale, I had made the decision Emeritus Program Director of Surgery, I rea-
when I was completing my Chief Residency in soned that it was time to become an emeritus
Surgery at The Hospital of The University of operative and practicing surgeon. All of the wind
Pennsylvania in 1967 that if I lived and enjoyed socks were blowing in the same direction.
good, functional mental, emotional, and physical Moreover, at age 74, I underwent a successful
health I would quit operating at age 65, not really triple coronary artery bypass procedure which
expecting to reach that age. I did not want to be temporarily took a little wind out of my sails,
the failing “old man” who was “losing it” in the and, although I returned to the operating room a
operating room and thereby endangering the few months postoperatively, I knew deep within
patient, distressing the nurses and house staff, my body and soul that it was time to close the
and compromising a reputation which I would curtain, and I did so without histrionics, fanfare,
have worked hard to achieve and maintain as a or regrets, definitively and without recourse at
safe, competent, and perhaps even an excep- age 75, which was 10 years longer than I had
tional, surgeon. I wanted to quit surgery while I originally planned. I am greatly blessed to have
still could play an acceptable, safe, efficacious, had the opportunity to help my fellow human
non-embarrassing, no-fumbles surgical game and beings with my clinical surgical efforts for 43
walk away with my head held high in the knowl- years as a board-certified surgeon, and for a total
edge that I had had a gratifying, effective, distin- of 49 years, including my internship, surgical
guished surgical career. residency, and fellowship. Since then, I have been
As I approached my 65th year, it became enjoying life as a surgical educator, scientist,
apparent to me that I still had the strength, energy, mentor, writer, lecturer, husband, parent, and
endurance, cognitive ability, eye–hand coordina- grandparent, for almost six additional, wonder-
tion, competence, and other skills, together with ful, and gratifying years, and cherishing the
a rich experience and successful record of com- opportunities to continue to be as useful as I can
plex surgical management of countless critically be for as long as I am able. Who would want or
ill patients, and that I might extend my original ask for anything more?
planned operative exit from age 65 to age 70,
while spending more time sharing my patient
load with my younger surgical colleagues and References
residents in order to reduce my work-load and to
1. Pogo KW. Daily comic strip. Earth day. New York:
increase theirs, to the benefit of their experience
Post-Hall Syndicate, Simon & Schuster; 1971.
and expertise and to my extended operative lon- 2. Bradley R, Nehra M, Nehra A, Folkes J. The Gambler.
gevity. I enjoyed that period, and when I talked of Sony/ATV Music Publishing, LLC; 1978.
quitting operating at age 70, my colleagues at all 3. Greenfield LJ. “Farewell to surgery”. Presented as the
presidential address at the forty-first scientific meet-
levels assured me that I still could “handle the
ing of the international society for cardiovascular sur-
toughest cases” with ease, safety, and compe- gery, North American Chapter, Washington, DC, june
tence, and they convinced me to continue a bit 7–8, 1993. J Vasc Surg. 1994;19:6–14.
23 When Should Surgeons Quit Operating? 249

4. Stauger R. Boredom on the assembly line: age and 18. Deckert GH. How to retire happy. Med Econ.
personality variables. Industr Geront. 1975;30:23–43. 1992;69:73–80.
5. Benson R. Management perceptions of older employ- 19. Neumayer LA, Gawande AA, Wang J, Giobbie-
ees. Mon Labor Rev. 1978;101:33–5. Hurder MS, Itani KMF, Fitzgibbons Jr RJ. Proficiency
6. Hauon engineering guide to equipment design. of surgeons in inguinal hernia repair: effect of experi-
New York: McGraw Hill; 1963. ence and age. Ann Surg. 2005;242:344–8. discussion
7. Garg A, Funke S, Janisch D. One-handed dynamic 348–352.
pulling strength with special applications to lawn 20. Waljee JF, Greenfield LJ, Dimick JB, Birkmeyer
mowers. Ergonomics. 1988;31:1139–53. JD. Surgeon age and operative mortality in the United
8. Astrand PO, Rodahl K. Textbook of work physiology. States. Ann Surg. 2006;244:353–62.
New York: McGraw Hill; 1977. 21. Bieliauskas LA, Langenecker S, Graver C, Jin Lee H,
9. Tzankoff SP. Age-related differences in lactase distri- O’Neill J, Greenfield LJ. Cognitive changes and
bution kinetics following maximal exercise. Eur retirement among senior surgeons (CCRASS): results
J Appl Physiol. 1979;42:35–40. from the CCRASS Study. J Am Coll Surg.
10. Karnes EW, Freeman A, Whalen J. Engineering work 2008;207:69–78. discussion 78–79.
standards for warehouse operations: effects of perfor- 22. Boom-Saad Z, Langenecker SA, Bieliauskas LA,
mance ratings, age, gender and neglected variables. Graver CJ, O’Neill J, Caveney AF. Surgeons outper-
In: Trends in ergonomics/human factors III (part A). form normative controls on neuropsychologic tests,
New York: Elsevier Science/North Holland; 1986. but age-related decay of skills persist. Am J Surg.
p. 535–43. 2008;195:205–9.
11. Welford AT. Changes of performance with age: an 23. Blasier RB. The problem of the aging surgeon. Clin
overview. In: Aging and human performance. Orthop Relat Res. 2009;467:402–11.
New York: Wiley; 1985. p. 333–65. 24. Tuwairqi K, Selter JH, Sikder S. Assessment of sur-
12. Required quantity and quality of light committee. geon fatigue by surgical simulators. Open Access
Selection of illuminance values for interior lighting Surg. 2015;8:43–50.
design (RQQ report 6). J Illum Eng Soc. 1980;9: 25. Garrett K, Kaups KL. The aging surgeon: when is it
188–90. time to leave active practice? American College of
13. Garg A. Ergonomics and the older worker: an over- Surgeons: Bulletin; 2014.
view. Exp Aging Res. 1971;17:143–55. 26. Drag LL, Bieliauskas LA, Langenecker SA,
14. Partyka S. Comparison by age of drivers in two-car Greenfield LJ. Cognitive functioning, retirement sta-
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16. Powell DH, Whitla D. Profiles in cognitive aging. 2014;260(2):199–201.
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Sauerbruch. New York: Pantheon; 1962. Surgeons. May 2013.
 Part IV
The Final Word
 Final Thoughts on Surgical
Decision-Making 24
Rifat Latifi and Fortesa Latifi

“In a surgeon there is no quality of mind more to be desired than that of judgment. It is
judgment even more than skill that makes him truly a successful surgeon.”

Hugh Devine, 194311

1
Foreword to: Marx Thorek. Surgical Errors and Safeguards, Fourth edition, Philadelphia:
J.B. Lippincott Company; 1943.

If you thought for one moment that by the end of decided to revisit Modern Surgery [1) by Max
this book, you would understand entirely how we Thorek published in late 1939 as a second edition.
surgeons make decisions, I am afraid that you may In the first chapter of this book, “The Surgeon
not be fully satisfied. While we have explained a and his Art,” Professor Thorek quotes the
number of aspects of this complex issue, much famous English surgeon, Lord Moynihan [2, 3]
remains unknown, and further research is required. as saying:
This research should be done by surgeons and in “Surgery is not only a matter of operating skill-
collaboration with those specifically trained to fully. It must engage in its service qualities of mind
understand the mind, how the brain works, and and heart that raise it to the very highest pinnacle
how the brain can be directed or trained. of human endeavor. A patient can offer you no
higher tribute than to entrust you with his life and
After 2 years of an intensive labor of love, I was his health, and by implication, with the happiness
finishing the final touches on this work and of all his family. To be worthy of this trust we must
submit for a lifetime to the constant discipline of
unwearied effort in the search of knowledge, and
most reverent devotion to every detail in every
R. Latifi, M.D., F.A.C.S. (*) operation that we perform” [1].
Department of Surgery, Westchester Medical
Center, New York Medical College, 100 Woods Professor Thorek continues his chapter with:
Road, Valhalla, NY 10595, USA
“There is no human calling which demands from
Department of Surgery, University of Arizona,
those who follow it a greater endowment of the
Tucson, AZ, USA
best human qualities and the highest developments
e-mail: rifat.latifi@gmail.com
of technical knowledge and skill than art of sur-
F. Latifi, B.S. gery.” Further, he writes “On the other hand, the
Department of Surgery, University of Arizona, surgeon’s judgment, knowledge and skill may save
Tucson, AZ, USA a life otherwise doomed; Erroneous or careless
e-mail: Fortesa.latifi@gmail.com surgical procedures may and often do bring either

© Springer International Publishing Switzerland 2016 253

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5_24
254 R. Latifi and F. Latifi

death or life-long misery to a patient who has had tory test, radiologic study, policy, administrative
a comparatively easily corrected condition” [1].
rule will substitute for the surgeon’s decision-
making and what goes into this decision.
There may be no need for anything more to be Despite all the factors explored in this book,
said here as Professor Thorek seems to have said the final decisions of whether or not to operate,
it all. Yet, in rereading each chapter again and when to operate, and what approach to use are
again, I have come to realize how complex and still a matter of complicated interaction of experi-
important surgery is and why it was called as ence, gut feelings, education, training, exposure,
“one of the noblest arts.”1 and the continuous strive to provide the best care
Throughout these chapters, the complexity of possible for the patient.
surgical decision-making is clearly reflected. When considering the entire spectrum of tech-
Reading the surgical books of the early twentieth nological advances, it is clear that we have become
century and comparing them with today’s litera- better surgeons by the definition of surgical
ture, one recognizes major changes. However, outcomes of operative procedures, which have
there are many things which have not changed: lowered morbidity and mortality rates and pro-
respect and dedication for the patient; respect for duced a better quality of life for patients.
the disease; respect for the procedure; and the At its core, surgical decision-making comes
desire to change and improve the management of down to more than can be explained by evidence.
every disease. Most importantly, the respect for It is the core of being a surgeon. We are humans
the complexity of surgical decision-making has with technical skills, ongoing enthusiasm to save
remained the same and is embedded in the souls our patients, and minds that question ourselves
of surgeons the world over. constantly. The day we stop questioning why we
The manner in which the surgeons of the second are doing what we are doing and what we could
decade of the twenty-first century make decision is have possibly done better is the day we should
different compared with the surgeons of the first stop being a surgeon. In fact, we probably have
decade of the twenty-first century. Technological stopped being a surgeon already, if we do not
advances have changed the way we practice medi- question ourselves.
cine and surgery and thus we have experienced an Not all decisions that we surgeons make will
unprecedented surgical metamorphosis. The intu- be the right decision, and we should be able to
itiveness, ingenuity, and courage of the surgeon acknowledge and admit when such a thing occurs.
have combined with advancing medical technolo- To quote again Professor Max Thorek:
gies to transform the surgical climate. Laparoscopy, “To fail to admit one’s mistakes is to block prog-
nanotechnologies, genetics, and bioengineering are ress; an honest declaration of error is the first step
all industries that would have been unfathomable toward its correction. In this age of cooperation in
just a few decades ago. This metamorphosis in the the science of healing, the surgeon who fears loss
of prestige through acknowledgment of fault vio-
surgical industry has allowed patients to become lates not only faith to himself, but also unjust to his
more engaged, better educated, and more involved calling” [5].
with their own health and in doing so, have experi-
enced better outcomes. As a result of these changes, Recognizing the possible error in decision-
hospitals have undergone major transformations making will no doubt teach us potentially new
to be capable of supporting such technology. ways of approaching the next patient.
To this end, we surgeons have become patient- Finally, it is our hope that this collective work
centered, disease-focused, technology-driven, will inspire others to dedicate their research
and team-oriented [4], and no machine, labora- efforts to this topic. The senior surgeons, in par-
ticular, should try to better explain how they make
1 decisions. Perhaps it should be part of every sur-
Foreword to: Marx Thorek. Surgical Errors and
Safeguards, Fourth edition, Philadelphia: J.B. Lippincott geon’s planning for surgery as well as debriefing
Company; 1943. with the team, as the senior author of this chapter
24 Final Thoughts on Surgical Decision-Making 255

(RL) does routinely. That will add tremendous 2. Groves EW. The life and work of Moynihan. Br Med
J. 1940;1(4136):601–6.
knowledge and cohesiveness to the team and
3. Groves EW. The life and work of Moynihan: Part II.
teach the decision-making process. Br Med J. 1940;1(4137):649–51.
4. Latifi R, Dudrick SJ, Merrell CR. The New surgeon:
patient-centered, disease-focused, technology-driven, and
team-oriented. In: Latifi R et al., editors. Technological
References advances in surgery, trauma and critical care. New York:
Springer Science + Business Media; 2015.
1. Thorek M. Modern surgery. Philadelphia: J. P. 5. Thorek M. Surgical errors and safeguards. 4th ed.
Lippincott; 1939. Philadelphia: J.B. Lippincott; 1943.
Index

A Acute traumatic coagulopathy, 96

Abbreviated laparotomy Acute tubular necrosis (ATN), 149
intra-abdominal infection, 72 Advanced Trauma Life Support (ATLS), 134
preoperative optimization, 73 Age and heart rate, 242
Abdominal compartment syndrome, 96 Age and public policies, 243
Abdominal sepsis, 99 Age discrimination, 241, 247
Abdominal surgery Age Discrimination in Employment Act (ADEA), 247
artificial heart, 130 Age issue, 243
colectomy, 127 Aging surgeons
CT scan, 128 cognitive and functional test, 245
super obese patient, 129 performance, 245
Abdominal wall reconstruction program, 246
abdominal wall complex defects, 113 Alcohol consumption, 22–23
component separation, 113 Alloderm®, 193
ECF diagnosis, 112 AlloDerm® (LifeCell, Bridgewater, NJ) reconstruction,
patient management, 111 116
“pinch sign” indicator, 113 Alzheimer disorder, 244
plastic surgeons, 113 The American College of Chest Physicians and the
postoperative care, 112 Society of Critical Care Medicine (ACCP/
strategies, 111 SCCM), 60
surgical approach, 112–113 American Medical Association, 245
Acceptance, death, 235 American society of anesthesiologists physical status
Acute cardiogenic shock, 167, 169, 172–173 (ASA-PS), 44, 48
ACS, 166 Analytical decision making, 179
acute heart failure, 165 Anastomosis, 146
cardiorenal and cardiohepatic syndromes, 166 Anatomy of surgical decision
definition, 165 Checklist Manifesto, 9
ECMO (see Extracorporeal membrane oxygenation decision-tree diagrams, 10
(ECMO)) master surgeons, 10
hospital case fatality rates in patients, 167, 168 (see mechanistic and cognitive processes, 9–10
also Intra-aortic balloon pump (IABP)) operating room, 9
MCS (see Mechanical circulatory support (MCS) physical and personality factors, 10–12
therapy) rational process/immediate cognition, 10
medical and surgical emergency, 165 role of intuition, 10
non-ischemic causes, 166 and situational awareness
pVADs (see Percutaneous ventricular assist devices ACC, 14
(pVADs)) analytical decision-making, 13
randomized, large-scale studies, 167 assessing and diagnosing, 13
SIRS and sepsis, 166 brain damage, 14
trans-thoracic echocardiography, 165 cognitive task survey, 14
treatment algorithm, 166, 167, 169 creative decision-making, 13
TRIUMPH and SHOCK trial, 167 description, 13
Acute mesenteric ischemia (AMI), 126 FFS, 14
Acute mitral regurgitation (MR), 169 intuitive recognition, 13
Acute Respiratory Distress Syndrome (ARDS), 21, 74, 185 look–detect–scan, 13

© Springer International Publishing Switzerland 2016 257

R. Latifi, Surgical Decision Making, DOI 10.1007/978-3-319-29824-5
258 Index

Anatomy of surgical decision (cont.) causes, 229

memories and knowledge, 14, 15 depersonalization, 227
military strategists, 13 description, 227, 228
non-technical skills, 14 helplessness, 227
operating room, 12 measuring tools, 229
patient’s physiologic status, 14 population at risk, 228
preoperative preparations, 14 prevention in surgeons, 230–231
“real-time” data, 13 problems, 227
RP, 14 recovering, 231
rule-based, 13 self-worth, 227
scan–look–detect, 13 signs and symptoms, 230
situational factors, 10–12 vs. stress, 228–229
Anesthesia, 45 in surgeons, 229
Anesthesiologist physical status classification, 44 symptoms and diagnosis, 230, 231
Anger, 234 Burn patients
Anterior cingulate cortex (ACC), 14, 22 admission criteria, 184
Anterior resection for cancer ambulation, 195
LAR, 54 antibiotics and infections, 187–188
technical choices, 54, 55 chronic renal failure, 184
Antimicrobial dressings decision-making process, 185
bacitracin ointment, 186 hyperglycemia, 184
nystatin-silvadene, 186, 187 ICU admission, 184
silver nitrate Solution, 186 infection, 195
SSD, 186 pain control, 194
wound cellulitis, 185 resuscitation formulae, 184
Arterial base deficit, 85–87 Ringer’s lactate, 183
Assessment of Cognitive Functions, 244 size and depth, 183
Australasian Resuscitation in Sepsis Evaluation social issues, 195
(ARISE), 75 treatment, 184
Aviation Selection Test Battery (ASTB), 27 wound care, 195
Burn sepsis, 187, 188
Burn surgery
B bacteremia, 191
Bargaining, 234 grafts, 191–192
Bariatric surgery, 3 granulation tissue, 190
Bayesian probability (BP), 135 neo-epithelium, 191
Bereavement, 234 partial thickness, 190
Bile duct complications, 146 platelet count, 191
Biliopancreatic injuries, 96
Blood cortisol measurements, 27
Brachioradialis muscle, 219 C
Breast reconstruction Cardiac-related morbidity, 42–43
acellular dermal matrix, 207 Cardiovascular disease, 45, 46
autologous, 204 Central venous pressure (CVP), 65
bilateral nipple sparing mastectomy, 207 Cerebrovascular disease, 46
DIEP flaps, 207, 208 Checklist Manifesto, 9
fat graft, 208 Checklists, 3–4, 26, 30
latissimus dorsi flaps, 207 Chemical burns, 189–190
mastectomy flaps, 207 Chest X-ray, 37
pectoralis muscle, 208 Chief Residency in Surgery, 248
right-sided hematoma, 208 Child-Pugh (CP) class, 47
saline implants, 208 Cholecystectomy, 3
submuscular placement, 208 Colloids Versus Crystalloids for the Resuscitation of the
tissue expanders, 207, 208 Critically Ill (CRISTAL) trial, 65
transverse rectus abdominus myocutaneous flaps, 207 Common bile duct stone extraction (CBDSE), 50
wound complications, 207 Communication and mental model, 5
Bridge mesh placement, 116 Communication within surgical action teams
Broad-spectrum antimicrobial therapy, 70 briefing–debriefing model, 32, 33
B-type natriuretic peptide (BNP), 68 debriefing/after-action review, 32
Burnout implementation of new practices, 32
Index 259

leader communication, 32 complications, 233

mental model development, 32 coping mechanisms, 236–237
post-action debriefing, 33 depression, 234
quality of information, 32 emotional distress, 233
real-time communication, 32 expected vs. unexpected, 235
shared characteristic, 32 fear of litigation, 236
Complex abdominal wall defect, 111, 112, 117 grief, 234
Complicated skin and soft tissue infections (cSSTIs), 123 guilt, 234
Complications: A Surgeon’s Note on an Imperfect medical contract, 233
Science, 234, 236 outcomes of surgery, 233
Component separation technique (CST) palliative surgery, 233
abdominal defect after underlay mesh placement and patient factors, 235–236
bilateral component release, 114 performance issues, 236
description, 113 symptoms of disease, 233
seromas reduction, 114 types of surgeons, 234
surgical expertise and patient selection, 115 Decision-making process, 6, 158–161, 239
underlay mesh placement, 114, 115 anastomosis, 52
vascularized flaps, 114 cardiac-related morbidity, 50
Computerized tomography (CT) scan, 120, 128 clinical research, 135
Congenital agenesis, 144 corticosteroids therapy, 52
Controlled continuous veno-venous hemodialysis CT technology, 136
(CVVH), 142 diagnostic medical technology, 136
Coping mechanisms, 236–237 error rates, 138
Coping strategies, 235, 244 intraoperative segment, 52
Corticosteroid Therapy of Septic Shock (CORTICUS) nonrational cognitive factors, 137
trial, 69 nontherapeutic laparotomies, 136
Creative decision making, 179 NSQIP study, 52
CST. See Component separation technique (CST) pattern recognition, 133, 134
perioperative events, 50
probabilities and gravity, 50
D set preferences, 158
Damage control (DC) “status quo”, 158
abdominal sepsis, 99 surgical oncology
definitive abdominal closure, 97–99 appeal to consequences, 161
definitive (injury repair) operation, 96–97 appeal to justice and equality, 161
description, 95 appeal to virtues, 161
hemostatic resuscitation, 96 cancer service delivery, 160
indications, 95 contextual features, 161
laparotomy, 95 end-of-life issues, 158
management, 95 eventual recurrences, sarch of, 158
open abdomen technique, 95 evidence-based surgery, 159
open abdominal wound, 97–99 informed decision-making model, 159
operation, trauma, 96 intraoperative period, 158, 160
orthopedic interventions, 99–100 medical indications, 161
timing, 95 in oncologic patient care, 161
vascular interventions, 99 operating room (OR), 160
Damage control laparotomy paternalistic model, 159
coagulopathy, acidosis and hypothermia, 104 patient-centered care, 159
description, 104 patient preferences, 161
loss of domain, 104 postoperative course, 158
soft tissue infections, 104 power and authority issues, 161
Damage control orthopedics (DCO), 99 preoperative period, 158
Damage control resuscitation (DCR), 96 professional, agent model, 159
Darwinian law, 244 quality of life, 159, 161
Death surgeon, concept of, 160
acceptance, 235 surgeon’s level of experience, 159
anger, 234 trauma surgery, 133
bargaining, 234 uncertainty, 158
bereavement, 234 well-defined alternatives, 158
burnout, 237 Deep Inferior Epigastric Artery Perforator (DIEP) flaps, 207
260 Index

Dehiscence allograft, 215

fascial, 119 auto graft, 215
intra-abdominal infection, 119 bone reconstruction and stabilization, 215
open vs. laparoscopic techniques, 125 duplex Doppler, 213
suture failure, 120 false negative/positive sensory feedback, 213
Depression, 228, 230, 234 flexion and extension, 221
Dermagraft®, 193 free fibula bone graft, 215, 216
Detachment, 228, 230 inspection, 213
Diabetes, 47–48 K wires, 215, 217
The Dismissal, 244 left hand volar view, 213, 214
Disrupted surgical symphony, 18 lower extremity reconstructions, 217–218
Donor site, 194 Newton’s third law, 215
Duodenal atresia repair, 177 non-injured extremity, 221
Duodeno-cystostomy, 152 open distal femur fracture, bone defect, 215, 216
Duodeno-jejunostomy, 152 peripheral circulation, 213
Duplex Doppler, 213 reconstruction, acute trauma, 214
right elbow motorcycle accident, 215, 216
right hand gunshot wound, 217
E soft tissue problem, 215
Ear burns, 188 SPY angiography, 213
Early bowel obstruction, 106–108 two-point discrimination test, 213, 214
Early goal-directed therapy (EGDT), 61, 75 upper extremity reconstructions, 218–221
Early postoperative period, reoperative surgery, 103–104 X-ray, 214
ECMO. See Extracorporeal membrane oxygenation Eye–hand coordination, 248
(ECMO)
Electrical burns, 188–189
Electrocardiograms (ECG), 5, 13 F
Emergency department (ED), 138 Farewell to Surgery, 243
Emergency general surgery, 96, 99 Fasciocutaneous flaps, 204
Endoscopic retrograde cholangio-pancreatography Federal Aviation Administration (FAA), 26, 243
(ERCP), 50 Feed-forward sweep (FFS), 14
Enterocutaneous fistulas (ECF) First-line therapy, 67, 68
fascial integrity, 121 Flexor carpi radialis tendon (FCR), 222
identification and diagnosis, 120–121 Fluid intelligence concept, 246
nutritional status, 121 Fluid resuscitation, 65–66
postoperative complications, 119 Forearm flap, 205
provision and optimization, 121 Formalized pattern matching (FMP), 135
radiological investigation, 122 Forty-first Scientific Meeting of the International Society
SOWATS guideline, 120 for Cardiovascular Surgery, 243
tissue coverage, 121 Forty-first Scientific Meeting of the North American, 241
treatment strategy, 121 Free flaps, 208, 210
vacuum-compaction devices, 122 Frozen in glycerol, 192
wound care and reduction, 121 Functional magnetic resonance imaging (fMRI) methods,
Escharotomies, 185 22
Evidence-based decision tree
gut-feeling, 41
physiological conditions, 41 G
surgical risk, 41–42 The Gambler, 240
Expected utility (EU) model, 135 Generalized psychological distress, 227
Expected vs. unexpected death, 235 Goal-directed therapy, 62, 87, 88
Extensor carpi radialis brevis (ECRB), 223 Gordian knot problem, 247
Extensor carpi radialis longus (ECRL), 221 Grief, 234
Extensor carpi ulnaris (ECU), 221 Guilt, 234
Extensor digiti minimi (EDM), 221
Extracorporeal membrane oxygenation (ECMO)
cardiopulmonary bypass machine, 172 H
heparin-coated catheters, 173 Hand-sewn technique, 4
veno-arterial, 172, 173 Hartmann’s procedure (HP), 52
Extremity surgery Helplessness, 227, 228
acute table saw injury, 213, 214 Hematologic diseases, 47
Index 261

Hemodynamic parameters, 65 training and education, 4

Hemostatic resuscitation, 96 Intraoperative resuscitation
Hepatic artery flow, 145 dynamic fluid exchange, 83
Hepatic artery thrombosis (HAT), 145 global cellular failure, 82
Hepatic diseases, 46–47 hemodynamic monitoring, 82
Hepatic vein bleeding, 144–145 morbidity and mortality, 81
Hepaticojejunostomy, 146 mortality, 81
Heuristics, 135 patient’s preoperative condition, 82
Hopelessness, 228 surgical procedures, 81
Hospital of the University of Pennsylvania, 248 Intravenous (IV) access, 63–65
Hydrofluoric acid (HF) Isolation, 230
concentration symptoms and systemic toxicity,
189–190
hand burns, 190 K
Hydroxyethyl starch (HES), 66 Kerlex®, 193
Hypoperfusion, 69 Kidney transplantation
Hypothalamic–pituitary–adrenal (HPA), 20 arterial challenges, 148–149
intraoperative inoperability, 148
ureteral anastomoses, 149
I venous anastomosis, 149
Impella® system, 171 Kirscher wires (K wires), 215
Imperial Stress Assessment Tool (ISAT), 20
Infection, 69–70
Inferior mesenteric artery (IMA), 127 L
Informed decision-making model, 159 Laboratory Risk Indicator for Necrotizing Fasciitis
Institute of Medicine (IOM), 19 (LRINEC), 72, 125
Integra®, 192 Lactate metabolism, 87–88
Intensive Care Units (ICUs), 59 Laparoscopic cholecystectomy (LC), 12
International Society for Cardiovascular Surgery, 241 Laparotomy, 95
Interpersonal conflict, 33–34 Latissimus flaps, 206, 207
Intestinal ischemia, 127, 128 Leadership
Intestinal transplantation, 147–148 communication within surgical action teams, 32–33
Intra-abdominal infections, 72–74 decision-making
Intra-aortic balloon pump (IABP) developing expertise in, 36–37
cardiogenic shock with mechanical complications, expertise in, 36
168–169 dynamic team, 31
illustration of, 168, 170 handle bar injuries, 37
technology advancements, 168 interpersonal conflict, 33–34
Intracardiac thromboembol, 146 static tasks, 31
Intraoperative complications, 143, 146 surgical crisis, 34–35
Intraoperative decision types of action teams, 31
checklists, 3–4 uncertainty, 35–36
clinical experience, 6 Left colic artery (LCA), 54
creativity, 6 Left upper extremity reconstructions
decision-making process, 3, 6 active finger extensions after tendon transfer, 224
flexibility and open-minded approach, 6 donor site, 223, 224
hand-sewn technique, 4 ECRB, 223
high-risk professionals, 3 ECRL, 222, 223
intestinal anastomosis, 4 ECU, 222
leadership ability, 6 EDM, 222
mental state, 6 extensor tendons and muscles, 221
physiology, 6 FCR, 222, 223
pilots, 3 flexor muscle/tendon injury, 222
situation assessment, 6 patient’s problems, 221, 222
standardization, 4–5 PL, 222, 223
stapler techniques, 4 postoperative image, 223, 224
surgeons and pilots, 3 preoperative image, 221, 222
surgeon’s education, 6 scar tissue, 222
taxonomy of surgeon’s leadership inventory, 6 tendon graft, 223
and technological advances, 5–6 Lethal triad, 95, 96
262 Index

Liver injuries, 96 gas-forming bacteria, 122

Liver transplantation hyperbaric oxygen therapy, 125
donor surgeon, 144 laparotomy, 73
extrahepatic metastases, 143 life-saving treatment, 125
hepatic failure, 144 operative procedure and repeat assessment, 73
hilum, 143 patient, 122
instrument failure, 145, 146 resuscitation and surgical debridement, 123
intrahepatic bile duct cancer, 143 scoring systems, 124
porta hepatis, 143 surgical intervention, 123
Lower extremity reconstructions treatment, 72
denervated muscle, 217 type I and II, 71
free flap, 217 Newton’s third law, 215
intraoperative anterior view, 217, 218 Norepinephrine, 67
open ankle fracture, 215, 217
reconstructive ladder, 217
sensitive sole, 217 O
sural flap coverage, 217, 218 Office of Aviation Medicine, 244
traumatic lower extremity amputation, 217, 218 Onlay placement, 115
Lumbar spine, 242 Open abdominal wound
appropriate reconstruction, 97
debridement of devitalized tissue, 97
M gauze, 97, 98
Mafenide Acetate, 186 intestines, 97
Magnetic resonance imaging (MRI), 120 intra-abdominal pathology, 97
Maslach Burnout Inventory, 229 poor man VAC, 97
Mastectomy flaps, 207 postoperative, 99
Master surgeon, 246 skin graft, with delayed reconstruction, 97, 98
MCS. See Mechanical circulatory support (MCS) therapy TAC, 97
Mechanical circulatory support (MCS) therapy temporary vicryl mesh, 97
acute setting, 167 washout to reduce contamination, 97
less-invasive devices, 167 wound VAC, 97, 98
Medical error, 136 Open coronary artery bypass, 3
Memory loss, coping strategies, 244 Operating skill, 253
Metabolic equivalents (METs), 44 Operative surgery, 241
Metacarpophalangeal joint, 222 Opsite®, 194
Metamorphosis in surgical industry, 254 Orthopedic interventions, 99–100
Model for end-stage liver disease (MELD) score, 142 Orthopedic procedure, 38
Modern surgery, 253 Oxygen delivery and consumption
Modular Egress Training Simulator (METS), 27 alpha agonist agents, 85
Morbidity and mortality conference, 179 arterial oxygen content, 84
MR. See Acute mitral regurgitation (MR) blood transfusion, 84
Multi-institutional survey of surgical residents, 26 fluid shift and blood loss, 83
Multiple organ dysfunction syndrome (MODS), 60 heart rate, 84
Multiple organ failure (MOF), 82 hemoglobin concentration, 84
Multivisceral transplantation, 147–148 oxygen utilization, 85
Musculocutaneous flaps, 206 pressure–volume relationship, 84
Myocardial infarction (MI), 150 regulatory mechanisms, 83
tissue perfusion, 84

N
Nasogastric (NG) tube, 121 P
National Practitioner Bank (NPDB), 18 Palliative surgery, 233
National Surgical Quality Improvement Program Palmaris longus (PL), 222
(NSQIP), 48, 59 Pancreas after kidney transplant (PAK), 150
Necrotizing fasciitis (NF) patients, 125 Pancreas transplant alone (PTA), 150
Necrotizing soft tissue infections (NSTIs) Pancreas transplantation
antibiotic therapy, 123 arterial challenges, 150–151
clinical presentation, 123 bleeding, 152
diagnostic considerations, 71 distal pancreatectomy, 150
enterotomies, 73 early vs. late graft pancreatectomy, 153
Index 263

exocrine pancreatic secretion, 152 intervention

intraoperative inoperability, 150 decision, 200
postoperative complications, 150 timing, 200
retransplantation, 153 multiple surgeries and modalities, 208, 209
SPK category, 150 patient considerations
suboptimal graft, 152 anatomy, 197
venous anastomosis, 151 chronic steroid and wounds, 201
Pancreaticoduodenectomy (PD), 28, 128 comorbidities, 201, 202
Paternalistic model, 159 deficient/missing, 197
Pediatric surgery desires of patient, 202
and adult surgery, 178 diabetes, 201
analytical decision making, 179 FRIENDS pneumonic, 200, 201
creative decision making, 179 heart disease, 201
excessive deliberation, 179 outcomes, 197, 199
expert without experience, 180 patient nutrition, 201
incorrect identification, 179 reconstructive defects, 197
long hospital stays, 177 smoking and nicotine, 201
morbidity and mortality conference, 179 surgical trainees, 200
personality and coping styles, 178 tenets, 197, 198
plan-continuation errors, 179 procedure(s)
providers and health care organizations, 178 factors, 202
risk management, 179 interventions, 202
RPD, 179 method of reconstruction, 202
rule-based decision making, 179 needs and desires of the patient, 203
single organ system, 177 optimize outcomes, 202
stay out of trouble, 180 planning surgery, 202
trainees, 178 rotation flap, 202
VACTERL association, 177, 178 rungs, reconstructive ladder, 202
Pedicled flap, 209 serial debridement, 202
Pelvic X-ray, 37 skill and experience, 207
Percutaneous ventricular assist devices (pVADs) surgeon considerations, 206
complications, 171, 172 tissues, 203–204
early RV failure, 172 wound reconstruction, 209–212
Impella® system, 171 Poor man VAC, 97
PCWP, 170 Portal vein absence, 145
severe LV dysfunction, 172 Posterior interosseous artery flap, 205
small mechanical pumps, 169 Posterior sagittal anorectoplasty (PSARP), 177
TandemHeart® system, 170 Postoperative anastomotic leaks, 125–126
ventricular tachycardia (VT) ablation, 172 Postoperative hemorrhage
Performance in stressful situations embolization therapy, 106
alcohol consumption and surgeons, 22–23 lumen and bowel obstructions, 106
sleep, 21–22 nonselective angio-embolization, 106
Peripheral vascular disease, 46 treatment factors, 106
Permissive hypotension, 96 venous bleeding/oozing, raw operative
Personality factors, 10–12 surfaces, 106
Phenol burns, 190 Posttransplant complications, 153–154
Phenylephrine, 67 Post-traumatic stress disorder (PTSD), 228
Physical factors, 10–12, 95 Pretransplant complications, 141–143
Pilot Primary resection with anastomosis (PRA), 52
future, 27 Principalization of Plastic Surgery, 197
risk, 27–28 Prospective Recombinant Human Activated Protein C
SA, 28–29 Worldwide Evaluation in Severe Sepsis
sense-making, 28–29 (PROWESS), 74
training, 25–27 Prothrombin complex concentrates (PCCs), 96
Plan-continuation errors, 179 Protocolised Management in Sepsis (ProMISe), 76
Plastic surgery Protocolized Care for Early Septic Shock (ProCESS)
breast reconstruction, 207–209 trial, 75
comorbidities, 207 Proximal defunctioning stoma (PRADS), 52
desires of patient, 207 PSARP. See Posterior sagittal anorectoplasty (PSARP)
donor site considerations, 204–206 Pulmonary disease, 46
264 Index

Pulmonary thromboembolism, 146 Steroids, 68–69

pVADs. See Percutaneous ventricular assist devices Stress, 21–23, 227, 228, 230
(pVADs) ARDS, 21
brain structures, 20
vs. burnout, 228–229
R catecholamines, 20
Reanastomosis, 144 coordination, 20
Recognition primed decision-making (RPD), 5, 179 definition, 19
Recurrent processing (RP), 14 emotional, 19
Reductionist biological methods, 27 glucocorticoids, 20
Renal diseases, 47 hormones, 21
Reoperative surgery HPA axis, 20
after abdominal surgery, 106 hypothalamic–pituitary–adrenal stress, 20
anastomotic failures, 105 ISAT, 20
bariatric surgery, 105 learning and memory, 20
characteristics, 103 performance, 19 (see also Performance in stressful
complications, 105 situations)
damage control laparotomy, 104, (see also Early physical and psychological challenges, 20
bowel obstruction) physiological effects, 19
early hemorrhage/profound abdominal sepsis, 103 psychological stressors, 21
early postoperative period, 103–104 SNS, 19
enterotomies/intestinal perforation, 105 surgeons, 20
immediate source control, 105 task and time pressure, 20
management, 105 validation studies, 20
perioperative optimization, infectious complications, Yerkes–Dodson law, 20
104 (see also Postoperative hemorrhage) Stroke volume variation (SVV), 65
reoperation, 108 Stuivenberg Hospital Acute Renal Failure (SHARF), 65
resection, 108 Sub-arachnoid hemorrhage (SAH), 133
Resuscitative endovascular balloon occlusion of the aorta Suboptimal graft, 146–147
(REBOA), 99 Suboptimal kidney graft, 149, 150
Retransplantation, 147 Superior mesenteric artery (SMA), 127, 151
Routine surgeons, 240 Superior mesenteric vein (SMV), 145
RPD. See Recognition primed decision (RPD) making The Surgeon and his Art, 253
Rule-based decision making, 179 Surgeons
ingenuity and courage, 254
judgment, 253
S risk, 27–28
Saline versus Albumin Fluid Evaluation (SAFE) study, 66 SA, 28–29
Sepsis, 60, 62–63 sense-making, 28–29
Septic patient surgical resident selection, 27
implementation, 61 training, 25–27
septic shock, 62–74 Surgeon’s mind, 19–21
Silvadene, 194 anesthesia, 18
Sinai Hospital, 245, 246 catastrophic consequences, 17
Situational awareness (SA) complications, 18
comprehension, 29 disrupted surgical symphony, 18
perception, 29 never events, 18, 19
projection, 29 operating theater, 17
and sense-making, 28–29 orchestrated set, 17
Situational factors, 10–12 patient’s condition and physiologic state, 17
Situational sense-making, 28–29 performing surgery, 17
Situation assessment, 6 stress (see Stress)
Skeletal muscle strength, 242 tragedies, 17
Sleep deprivation, 21, 22 Surgery, training and board certification, 241
Splenectomy, 133 Surgical action teams
Spontaneous bacterial peritonitis (SBP), 143 communication, 32–33
SPY angiography, 213 surgical crisis, 34–35
Stapler techniques, 4 uncertainty, 35–36
Sternotomy, 144 Surgical crisis, 34–35
Index 265

Surgical decision-making, 3, 9, 197, 254 Tranexamic acid (TXA), 96

anatomy of surgical decision (see Anatomy of Trans-esophageal echocardiography, 166
surgical decision) Transplant surgery, 141
intraoperative (see Intraoperative decision) Trans-thoracic echocardiography, 165, 166
in plastic surgery (see Plastic surgery) Transverse Rectus Abdominus myocutaneous flaps, 207
Surgical ethics Trauma, DC operation, 96, . See also Decision-making
cancer, cause of death and sufferings, 157
characteristics, 157, 158
decision making, elements, 158, (see also Decision- U
making process) U.S. Food and Drug Administration (FDA), 123
personalized/tailor-made treatments, 157 Underlay placement, 115–116
technical, moral and ethical considerations, 157 Upper extremity reconstructions
“value” concept, 157 amputation, 218
Surgical food chain, 241 left, 221–224
Surgical management failures, 240 and metacarpals, 219
Surgical metamorphosis, 254 nerve repairs and transfers, 219
Surgical oncologist, 246 occupational therapy, 219
Surgical outcomes of operative procedures, 254 postoperative, 219, 220
Surgical planning rotational muscle flap, 219, 221
decision-making process, 50–52 sensation, 219
laparoscopic vs. open, 49–50 severe crush injury, 219, 220
morbidity, 48–49 severe left hand, wrist injury, 218, 219
mortality, 48–49 soft tissue reconstructions, 219
Surgical residency, 26 tendon grafts to tendon transfers, 219
Surgical standards, 4–5 Upper gastrointestinal (UGI), 120
Swan-Ganz catheter, 142 Urine output, 65
Sympathetic nervous system (SNS), 19
Systemic inflammatory response syndrome (SIRS)
goal, 60 V
lexicon, 60 Vacuum-assisted closure (VAC), 121
and sepsis, 60–61 Vascular injuries, 96
septic shock, 61 Vascular interventions, 99
Vasopressin and Septic Shock Trial (VASST), 67
Vasopressors, 66
T Venous oxygen saturation (SvO2), 88–90
TandemHeart® system, 166, 170 Venous-to-arterial CO2 difference, 90
Tar burns, 188 Ventricular septal defect (VSD), 169
Task visualization, 5 Viscus injuries, 96
Technical complications, 141, 148, 150 VSD. See Ventricular septal defect (VSD)
Technical decisions, 52–54
Technological advances, 5–6
Telfa® Clear, 192 W
Temporal abdominal closure (TAC), 97, 99 White blood cell (WBC), 65
Temporary intravascular shunt (TIVS), 99 White phosphorus burns, 190
Temporary vicryl mesh, 97 Wound infection, 119, 121, 122
Thoracic surgeon, 245 Wound reconstruction, 209–212
Thoracotomy, 144
Thrombolysis, 146
Thumb interphangeal joint flexion, 214 X
To Err Is Human: Building a Safer Health System, 136 Xeroform®, 194
Toll-like receptors (TLRs), 83
Total parenteral nutrition (TPN), 120
Training Y
pilot, 25–27 Yerkes–Dodson law, 20
surgeons, 25–27 Y-graft, 151