Saturday, June 02, 2007

Operation; Epilogue: post op ergo propter op


A reader suggested that after finishing my long-winded description of an operation, it would be interesting to see how it all would look in a typical operative report ("op note.") I like it!

It is said -- and I happen to agree wholeheartedly -- that op notes ought to be dictated immediately, else the content stales likes a bagel. I was pretty fanatical about doing so; nothing bugs me more (OK, lots of things bug me more) than being told by medical records that I'm delinquent on a dictation. ANY dictation; but particularly op reports, because I always did them instantly. Usually I'd write with a flourish that I HAD dictated and give the date. It was not entirely rare that they insisted it wasn't anywhere, so I'd go to my office and find the copy that I'd already received, and tell them if they'd send me a self-addressed stamped envelope and a dime, I'd copy and send it. But that's neither here nor there. (Usually, though, it WAS there.)

To me a good op note is succinct and stripped of irrelevant data. Surgeons read lots of them, because we like to know what went on inside someone who's fallen into our care after prior surgery. It's amazing. Some people tell you their shoe size, what soap they used on their hands, every sort of instrument they used. "Metzenbaum scissors were used to cut... Sutures were tagged with Kelley clamps..." Who cares? I want to know what was found, what was done in enough detail to predict what I'm likely to find. "The patient was brought into the operating room... (check that.... the operating suite!)" As opposed to what? Operating in the hall?

I sit at a desk in recovery; or if the patient is taking a while to awaken, I grab the phone in the OR and bend it into the corridor, punch in the numbers for the dictation system, the campus, an op note. There are numbers for start/stop, repeat, back up, etc; I never learned them. Blast on through fast as I think someone can transcribe, giving spelling when necessary, and punctuation. I heard a lecture once given by a guy who'd just finished dictating a bunch of charts. He kept saying to the audience things like "Hello comma I'm Dr Jones period. I'd like to talk to you today comma and I'll leave time at the end for questions period.... Sorry exclamation point."

This is Doctor Sidney Schwab dictating operative report on Blah (bee ell ay aich) Blah (bee ell ay aich).
Date 5/14/07 to 6/1/07.
Assistant: Joanie.
Preop diagnosis: diverticulitis.
Postop diagnosis: same.
Operation: Sigmoid Colectomy.
Indication: recurring episodes of diverticulitis.

Findings: The mid-sigmoid was indurated and thickened and contained multiple diverticula. It was stuck laterally to the pelvic sidewall. A couple of loops of small bowel were stuck to it medially. There was no evidence of perforation or abscess. The uterus and ovaries were normal.

Description: After induction of general anesthesia the abdomen was prepped with one-percent iodine and draped sterilely. A lower midline incision was made and the peritoneal cavity was entered without difficulty. Wound edges were covered with moist laps and a retractor was placed. The sigmoid was mobilized off the pelvic sidewall with blunt and sharp dissection, and the small bowel was mobilized sharply without enterotomy. A portion of tissue remaining on the pelvic wall was removed sharply and sent for frozen section. Bleeding was controlled with cautery. Packs were placed to expose the operative field. Sites for division were selected and cleared of fat. The peritoneal reflection was incised laterally and within the pelvis to achieve adequate mobility. Mesentery was divided using clips and vicryl ties. The field was covered with betadine-soaked pads. Bowel clamps were placed and the bowel was divided sharply and the specimen was removed. Bowel ends were wiped with betadine. An open end-to-end anastomosis was accomplished using interrupted 4-0 silk and running 3-0 vicryl. There was excellent circulation to both sides of the anastomosis, absence of tension, and wide patency to palpation. Mesentery was closed with running 3-0 vicryl. Packs were removed and the field was copiously irrigated with dilute betadine solution. After final inspection for bleeding, peritoneum was closed with 0-vicryl, wound was further irrigated with betadine solution, infiltrated with quarter percent marcaine plain.
[note: I used to use it with epinephrine, which lasts a bit longer; but I use so much that I don't want any confusion: if the patient has tachycardia, I want to know it's not from the local] Fascia was closed with number one vicryl running. Skin was closed with a few interrupted subcuticular 4-0 vicryl followed by steri-strips. Sterile bandage was applied and the patient was brought to the recovery room in stable condition.

Complications: none

Estimated blood loss: negligible

Specimen to pathology: sigmoid colon and biopsy of pelvic sidewall. Endofdictationthankyou.

25 comments:

Emily T said...

Dr. Schwab, if this operation were done in a teaching hospital, and certain parts, most or all of the operation were performed by a resident, would this have to be indicated in the report? If not, how does the resident get credit or recognition for his contribution?

And thank you so much for such an enlightening series, made so easy for the layperson to follow.

I'll be waiting for your post on adhesions.

Anonymous said...

Interesting blurb on op reports, since I saw quite a number of examples of such as a HIT student and got to know what was really "necessary" and what was superfluous information irrelevant to the content that would actually be coded for reimbursement. Some docs are better than others at it, or so I heard from the experienced HIM people from my internships. I would think dictation would be better than handwriting, however.

Greg P said...

May all of your estimated blood loss be negligible.

buckeye surgeon said...

why not a laparoscopic approach?

Sid Schwab said...

buck: for all the reasons I've mentioned in previous posts: I see no advantage whatsoever when I can do the operation via a small incision, taking 40 or so minutes, having the patient go home in two days. Not to mention I happen to enjoy sewing bowel (which, if it were worse in some way, would not be justified.) By comparison to lap colectomy, my approach saves thousands of dollars; I know of no lap series in which the average patient goes home any faster, returns to work any quicker. I've done three colon resections in a four-hour block: I doubt that can be said by surgeons doing it laparoscopically.

Anonymous said...

A running anastomosis with 3-0 or 4-0 nylon would work just fine, and would save you a little time. And, what's with all the Betadine? It's injurious to tissue, even at the one per cent or less concentration at which it's effective.

Sid Schwab said...

anon: all I can say is my wound infection rate was so low as to be nearly non-existent; likewise leaks. I'm too lazy to look them up, but I know of studies that have confirmed efficacy of dilute betadine in wound irrigation. If it's injurious in the lab, I had no evidence of it in practice. I realize my anecdotal experience isn't exactly scientific. But I found what I did to be highly effective. The sum total of it was that in the brief period when a local large insurance company collected data on total costs per operation type and distributed to surgeons, my costs for colectomy were among the least in the entire state; I can't recall if I was first or second: it was one or the other for colon, and the other or one for mastectomy, as it turns out. I only used betadine for open bowel cases. It might well be true that water alone, or other antibiotic solution would have done as well, but I had no reason to find out! I'm just a country doc, after all.

Bruce said...

Your comments on the essential elements of an op note are right on target. On occasion, I have done surgical quality reviews for a cooperative group and I have seen some horrendously bad op notes. I once reviewed a case that included a one paragraph op note (from a well-known teaching hospital, no less) that "described" a total laryngectomy and radical neck dissection...not a single finding was mentioned, although I learned that it described a six hour procedure.

Anonymous said...

(Blogsnooper here -- I've given up trying to post under that name, just won't work -- hence I shall identify myself among all the other 'anonymouses'!)

Love your writing. The links are most interesting too -- sometimes they are the real thing and sometimes a hilarious gag, you never can be sure which. ("Dr. Scwab's links are like a box o' choklits, ya never know what you're gonna get")

Sid Schwab said...

Bruce: when I was in training there was an emeritus professor who still came around once in a while. Very famous guy, had a nerve named after him. I used to see his op notes. They went like this:

"A radical mastectomy was performed in the usual manner. H. Glenn Bell."


anon: finally!! I enjoy my "gag" links. No one has ever commented on them, so I'm glad there's at least one person out there who likes them, too.

emily t said...

You forgot to answer my qeustion. :'-(

emily t said...

(corr)*question*

Sid Schwab said...

emily: you get "credit" for those cases in which you are first assistant. In applying for certification, you list your cases you did, and, separately, those in which you were first assistant. If it's a case for which the attending is primary surgeon, even if he/she lets you do parts, that's how it's listed. When the resident does the case -- ie when it's a "clinic" case, as it were -- he/she is listed as the primary surgeon, and the attending as the assistant. Usually.

midwest fp said...

"...ergo propter op." Hahahaha. You could do a post on weird postop complaints that patients blame on the surgery. "Doc! could you give me some Viagra? ever since you took my colon out, the second time just ain't what it used to be!"

W8nTables said...

Hmmm...I wonder if "all sponge, needle and instrument counts were 'reported' to be correct."? This "all important phrase" to be included in the op note is near and dear to my heart

Sid Schwab said...

W8Tn: I never dictated that. My reason is, I thought it obvious, just like I never dictated that I washed my hands and put on gloves. No operation is finished until that phrase is uttered; it's written in the record as well, in the nursing notes. And, as you may be implying, the saying of it doesn't make it so. Whereas no surgeon would finish until s/he's told the counts are correct, and none would ignore an incorrect count, it has happened -- and still does -- that a count is announced as correct, only to find later that something was left in. Rare. But real.

JP said...

*Sigh* Dr. Schwab,

I read the whole thing at once, one through ten. How very, very cool. Scientifically gripping, and also elucidating (the humanity of the surgical team). Thanks for opening yourself up to critique like this for the sake of sharing. That cannot be easy - semi-retired or no.

Anonymous said...

Great blog doc! - I have to agree with you on the pour betadine- I use the hand assist for lap colons and used to have wound infections at the umbilicus where the hand port was placed - Betadine works great! - I also paint incisions with it and it "anecdotally" works great in my practice. Thanks.

A!ice said...

Hi again Dr. Schwab,

Would you happen to be slightly myopic, enough to require glasses? If so, do you leave them on in the OR in order to better see the surroundings, or do you take them off to better see what you are doing close up - or do you peek just under the edge???

Would glasses need to be sterilized in order for one to have them on in the OR?

And what if the glasses were not sterilized and started sliding down your nose during the procedure: would the non-sterile person be able to slide them back up again for you? I mean, nowadays (when "operating" on rats and frogs), I simply prop them back up with the back of my wrist... but then again, sterility isn't an issue in this case.

A question about headlamps, now: is there sometimes "glare" from moist/wet surfaces resulting from the lamp? I couldn't stand it when I once tried one on (a very big one, rather like a cave explorer's headlamp), and am wondering if those used in surgeries are perhaps different, in some way.

What about the lighting in the OR? Is it always from lamps? Are there any windows? Is the lighting sometimes a strain on the eyes???

About masks: do they provide any protection whatsoever against arresting odours?

And the cauterizing tool - can it actually burn your finger like a lighter???

When performing an operation, is it at all possible to sit down?

Do you always dictate a summary of the operation? Do you ever write it up yourself? Who is the person to whom it is dictated? - Is this person specially there to write up things for surgeons???

Is there a rule about not excising any structures which were not meant to be excised as the goal of the surgery? I am referring to fat, here. I mean, if there is a glob of fat somewhere that is decidedly in the way, can you simply cut it out? (And I don't mean anything larger than, say, a finger... I know that adipose tissue plays a role in hormone secretion and regulation, at least some of it...).

Also, speaking of fat... if there is a patient with a large amount of fat in the belly area, and you split it to get to the intestines (I guess I'm talking about subcutaneous fat here - because the omentum can be lifted out of the way, right?), will it later somehow re-fuse together at the split-line? Or might the next surgeon have an easier task to separate it again (after, say, a year)???

And I'm not sure I understood this correctly... but you said that when you stitch together the two ends of intestine, you puncture only the outer layer? Why? I know you don't want to puncture the entire structure, but don't you stitch both the inside and outside layers of the intestine together???

And say you have to go back inside to get something left behind in the belly, would you try to re-use the previous needle holes when re-stitching it up again? I mean, would you necessarily avoid hitting them? Or are they deemed irrelevant???

Erm, this comment wasn't supposed to be this long, but I had many pent-up questions. We once had a neurosurgeon give a "motivational" talk at the university to us aspiring pre-meders, and he didn't talk about anything at all of such interest: he kept going on about number of years and evaluations and what a CT scan is, and I kept looking at the time and wondering when he would ACTUALLY start his REAL presentation; he never did, because that was it. I hope you can at least very briefly address most of them... if not all in one reply, I can wait... I am just so very curious. And you are, after all, trying to bring the reader into the OR, aren't you?

A!ice

Sid Schwab said...

Yikes. Well, okay, I'll try to be helpful, if brief.

Would you happen to be slightly myopic, enough to require glasses? If so, do you leave them on in the OR in order to better see the surroundings, or do you take them off to better see what you are doing close up - or do you peek just under the edge???

Some glasses, eg loupes, are left in the OR. There are, you know, glasses of varying refractive power: bi/trifocals, or varilux.

Would glasses need to be sterilized in order for one to have them on in the OR?

No. Nor your hat nor eyes or ears.

And what if the glasses were not sterilized and started sliding down your nose during the procedure: would the non-sterile person be able to slide them back up again for you? I mean, nowadays (when "operating" on rats and frogs), I simply prop them back up with the back of my wrist... but then again, sterility isn't an issue in this case.

People prone to sweating and sliding can wear athletic-type straps on the earpieces, or ones that loop over the ears. In a pinch, the circulating nurse can push them back.

Sid Schwab said...

Sheesh! Blogger's restrictions are gonna make me post three times to get this in.

A question about headlamps, now: is there sometimes "glare" from moist/wet surfaces resulting from the lamp? I couldn't stand it when I once tried one on (a very big one, rather like a cave explorer's headlamp), and am wondering if those used in surgeries are perhaps different, in some way.

Glare can be a problem. All lights, overhead and head, can be adjusted. I've asked that they be turned down at times. Or up.

What about the lighting in the OR? Is it always from lamps? Are there any windows? Is the lighting sometimes a strain on the eyes???

Ambient light is rarely enough except for minor office stuff. Many ORs have windows. Some have shades that are pulled during various procedures, eg laparoscopy.

About masks: do they provide any protection whatsoever against arresting odours?

No. As I wrote somewhere else in this blog, when it gets bad enough, some people put benzoin on their masks.

Sid Schwab said...

And the cauterizing tool - can it actually burn your finger like a lighter???

The tip can get hot enough to burn. The worst, though, is when there's a hole in a glove and the current arcs through it.

When performing an operation, is it at all possible to sit down?

Sometimes, eg, some hand surgery, eye surgery, neurosurgery. Can't sit and reach into a belly.

Do you always dictate a summary of the operation? Do you ever write it up yourself? Who is the person to whom it is dictated? - Is this person specially there to write up things for surgeons???

Always dictate, but write a brief note to be in the chart immediately. Most hospitals and clinics have a steno staff to whom the dictations are directed, either by sending tapes there (old style) or by dictating directly into a phone system which stores it for retrieval.

Is there a rule about not excising any structures which were not meant to be excised as the goal of the surgery? I am referring to fat, here. I mean, if there is a glob of fat somewhere that is decidedly in the way, can you simply cut it out? (And I don't mean anything larger than, say, a finger... I know that adipose tissue plays a role in hormone secretion and regulation, at least some of it...).

A matter of degree, and judgment. Generally operative permits acknowledge that unforeseen things may come up which necessitates doing things not covered specifically in the permit. There's no way to remove so much fat as to affect hormone storage; maybe in really extensive liposuction, but in that case it would have been the point of the operation.

Also, speaking of fat... if there is a patient with a large amount of fat in the belly area, and you split it to get to the intestines (I guess I'm talking about subcutaneous fat here - because the omentum can be lifted out of the way, right?), will it later somehow re-fuse together at the split-line? Or might the next surgeon have an easier task to separate it again (after, say, a year)???

Most reoperations, through fat, through muscle, through anything are harder than going through "virgin" tissues. Scar tissue forms and can be tough sledding.

And I'm not sure I understood this correctly... but you said that when you stitch together the two ends of intestine, you puncture only the outer layer? Why? I know you don't want to puncture the entire structure, but don't you stitch both the inside and outside layers of the intestine together???

There are many ways to do it, as I've said in other posts here. I like to sew the inner and outer layers separately. It can be done in a single layer, or with staplers. As long as you don't tie things too tight, cutting off circulation, and as long as you have preserved the necessary blood supply to the area, it'll heal.

And say you have to go back inside to get something left behind in the belly, would you try to re-use the previous needle holes when re-stitching it up again? I mean, would you necessarily avoid hitting them? Or are they deemed irrelevant???

Generally not an issue.

Erm, this comment wasn't supposed to be this long, but I had many pent-up questions. We once had a neurosurgeon give a "motivational" talk at the university to us aspiring pre-meders, and he didn't talk about anything at all of such interest: he kept going on about number of years and evaluations and what a CT scan is, and I kept looking at the time and wondering when he would ACTUALLY start his REAL presentation; he never did, because that was it. I hope you can at least very briefly address most of them... if not all in one reply, I can wait... I am just so very curious. And you are, after all, trying to bring the reader into the OR, aren't you?

Yes, I am. And I was hoping to be able to do it the first time around.

A!ice said...

Oh. Thanks for answering, and so promptly! Yes, I suppose I can be difficult at times. That neurosurgeon-dude ought to be glad that I spared him from my intense cross-examination. He looked a little... delicate. ;)

You were not so lucky.

I'm glad to hear that the ears do not have to be sterilized. I am not partial to having them wet in the first place.

Cool.

As a surgeon, what was your work schedule like in terms of free time and time off work? I mean, for family life? (Not that I want one - yet. But you never know.) How long were your vacations, if you had any? Does that depend on the hospital at which you work? (If you already wrote about this elsewhere, please direct me to that location... I only happened across your blog yesterday, during my break from studying for molecular bio. It has been bookmarked. The study break was a long one.)

A!ice said...

Oh... so adipose tissue DOES somehow fuse back together (the subcutaneous one). I just wasn't sure if that would be the case, somehow.

What if you accidentally detach a hunk of adipose tissue and leave it in there instead of taking it out??? Is it likely to fuse itself to something and undergo angiogenesis, or to die and cause problems??? Couldn't the cells survive by temporary diffusion of - of things from the interstitial/interorgan(?) fluid??? (Note my fascination with adipose tissue. It is just so gross and interesting. I know it has spare vasculature, hence why I am wondering about all this.)

Um, for comparison's sake, if you left a piece of totally detached gut in the wound (speculatively, of course), might it be possible for it to somehow survive? (I know it would no longer function as itself, but might it??? I think it would die faster as it might require more blood...)

A!ice said...

I meant to say "sparse" vasculature instead of "spare". Omit one letter, and you end up with the opposite meaning. Oh, joy.