Saturday, September 15, 2007

Sleeve (Up)

[This is another post that's been sitting around in draft form for a while. It might be obvious why I hadn't posted it. More cleaning of the attic -- or in this case, maybe the basement. It's conceivable that some day one person might find one thing useful.]

In no particular order, and for no special reason, here's a few surgical "tricks." Most are amalgams of observations, teachings, and trial and error. Surgeons will shrug, non-medical types (and non-surgical medical types) will say "who cares." Credulous and ingenuous students might make note and tuck them away, against the possibility -- remote as it might be -- that they'd prove useful in a future life. Whatever.

1: In thyroidectomy, "walking" to the outer parts of the poles by sequentially placing suture-ligatures provides excellent traction for exposure -- much more wieldy than Leahy clamps, the sutures can be pulled any which-way as you work.

2: The same technique facilitates the removal of a breast fibroadenoma.

3: The biggest mistake people make in open appendectomy is placing the incision too far medial. Go lateral to the rectus muscle, come down on the cecum, and you won't have to wave your finger all over the place to find the appendix.

4: At the base of the appendix there's almost always a clear window through the mesoappendix. Poke a clamp through, pull back a tie, have your assistant tie it while you snip the mesoappendix.

5: Developing flaps in thyroidectomy doesn't accomplish much more than increasing post-op swelling.

6: Use marcaine in all incisions: generously, up to 1 cc/kilo of 1/4%. Get the peritoneum. Use it all around the pectoralis muscles for mastectomy. Use lidocaine when infiltrating the sac in inguinal hernia, in case you flood the femoral nerve.

7: Sweeping a finger circumferentially around the surface of the peritoneum and behind the fascia in open appy, before entering it, greatly facilitates closure later.

8: In the proper plane, sweeping a finger in front and behind a thyroid lobe allows it to be flipped forward and out of the wound.

9: There are two ways to handle the laryngeal nerve: be sure you see it, or be sure you don't. I prefer the latter.

10: Squirting marcaine into the gallbladder fossa reduces the chance of "phantom" biliary pain in the recovery room.

11: Nearly any umbilical hernia can be repaired using a curved incision within the umbilicus.

12: Nearly any adult umbilical hernia is best repaired with mesh.

13: To make a nice mastectomy scar, draw one side of the elliptical incision, then "measure" it with a tie, placing it in the jaw of a clamp at one end of the incision, laying it onto the marked arc, and clamping it at the other end. Then use it to lay out the other arc: each will be the exact same length, eliminating bunching on closure.

14: Use curved Mayo scissors to develop the flaps in mastectomy; grab bleeders with a Debakey forceps and cauterize them.

15: For tracheotomy, place 2-0 silk sutures vertically on either side of the first tracheal ring before dividing it vertically. Use them for traction when inserting the tube, leave them for several days in case the tube needs replacing before the tract is firm.

16: Non-inflamed/infected sebaceous cysts can be removed through a tiny hole by poking them with a 15 blade, squeezing the gunk out, and continuing the squeeze to expel the sac.

17: Don't shave around a scalp cyst. Tape the hair apart with paper tape.

18: When draining an abscess under local, keep injecting with one hand and make the incision with the other, into the blanched area.

19: When operating on the chronically ill, if not giving TPN, add multivitamins to the IV; and use post-op nasal oxygen for healing.

20: Make rounds at least twice a day. Sit down in the patient's room (on the bed is OK.) Read the nurses' notes, preferably before seeing the patient.

20a: Sit down when seeing a patient in your exam room, too.

20a, i: Don't make the patient undress any more than absolutely necessary.

21: If, after many years in practice, you can only come up with this many items, you probably should have kept your mouth shut (hands in your pockets). I think there were more, but it's been a long time...


girl_in_greenwood said...

I saw a rerun of "Scrubs" the other night where they poked fun at the propensity doctors have for making patients get undressed for everything. They showed a doc telling a patient to take off his pants before looking in his ear. :)

JenL said...

For scalp cysts, I like surgilube to slick the hair back out of my way. I also like dermabond for the closure, because good luck trying to secure a bandage. The patient will have to wash the surgilube out later, but it's water soluble, so that's OK.

make mine trauma said...

In an unrelated story...My word verification is w-e-i-r-d .

Don't really have a comment, just couldn't let anything weird go to waste.

P.S. Okay, guess I do have a comment. I like the technique for non-dog-eared closure of mastectomy incisions. I may pass this on ~ not that anyone listens to me!

Dr. Rob Oliver Jr. said...

In re. to rule 15 about sebaceous cysts. I think that technique of trying to drain and express the sac piecemeal leads to lots of recurrent cysts. In most instances I'll trade a little longer access incision for getting the cyst out en-bloc or at least long enough to directly disect the cyst wall out (rather then squeeze as that can make those shells fragment)

Sid Schwab said...

Rob: I don't entirely disagree; however, done right you can express and tease the entire cyst wall intact. When you don't, you can tell, and can find the pieces. But mainly, if it's not been infected, I rarely had any trouble getting the whole thing. Looks cute, like a little leather bag.

Sid Schwab said...

j1lane: I like that lube idea! I never used a bandage; generally a single subcuticular stitch and told them they could shower whenever.

rlbates said...

Here's my best tip--
When sewing up lacerations, start with "key" landmarks--anatomical (vermillion border) or acquired (tatoos). The "puzzle" becomes much clearer then.

justme said...

In 30 years of working in hospitals, being an inpatient, and sitting with postoperative relatives, I have never seen a doctor round more than once a day. (some didn't make that). One of my favorite things about you is the way you took care of your patients before, during, and after surgery. ....if only that were the standard.

Anonymous said...

After my cancer surgery, I didn't see the surgeon until the 2nd day of my hospital stay. And that was when I accidentally bumped into him in the hall when he was exiting another patient's room. When I greeted him, he looked at me quizzically. I realized then he didn't recognize me. I said my name, then asked how my operation went. He had to look in my chart.

Sid Schwab said...

a patient: In my book, that's totally inexcusable, and I hate hearing stories like that. It's hard to think of any acceptable explanation.

Anonymous said...

Excellent list. I'm a current general surgery resident and I use many of these daily as they've been passed from generation to generation of surgeon (mostly by word of mouth). Great to see pearls like these recorded. Thanks! -RB

Lisa said...

20a, i: Don't make the patient undress any more than absolutely necessary.*

* If further undressing is required during an examination, say you'd like to visualize the legion of lentigines in the labial region of said patient, being of the same gender does not make it ok to request the patient drop trou on the spot.


Anonymous said...

The surgeon who fixed my broke hip was in my room that evening after surgery in the morning, morning and evening the second day and morning of the third day. I went home in that afternoon. No one else touched the wound. He was the best!

Anonymous said...

I'd like to see more posts like this, specifically in how doctors deals with patients and hearing more about your end of the stick.

Jo said...

I was reading an article on your preferred method of removing sebaceous cysts and came across this line:

"Care must be taken not to splatter nursing personnel with cyst contents."

Uh, yeah. Thanks for that.

Jeffrey Parks MD FACS said...

I love the one about the Mayo scissors for Mastectomies. The guy who taught me used those ultra sharp black handled mayos. I made my hospital order them special. You can't beat the uniformity of the flap, compared to bovie. Even the scrub nurses are impressed.


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