Monday, September 21, 2015

"Are you sure"

     This happened yesterday. Our professor who has an experience of more than 25 years in surgical practice was doing a laparoscopic cholecystectomy. As I have mentioned so many times before he is a very friendly person and easily approachable for residents. Now my Junior who is in his second year of residency recently did a laparoscopic training course. There they taught him basic laparoscopy techniques and cholecystectomy on porcine specimens. Our professor dissected the Calot's triangle and clipped the cystic duct. Unlike we usually do he was in a little hurry and didn't mind to explain each step. Then my junior who was really enthusiastic after all that one week training   questioned him, 'Are you sure?!!' (that you are clipping the cystic duct and not the common bile duct!!). Professor started laughing. Even I, who was holding the scope, could not prevent myself shaking the scope due to laughter.

          Surgery and any other medical professions has got this peculiarity. Once we pass the degree, we are legally equal to our teachers. Now this is a reality, but it depends on individuals how he or she assimilates that fact. Even though senior resident has the same educational qualification as the professor, his clinical examination and treatment modality may not be the one the Professor wish. In this profession the thing that matters most is experience. Allthough it may considered class 3 or C evidence in context of evidence based medicine, it is the most important factor.

         It is also another effect of this profession. You are at a position with ten years of experience and then a youngster who just passed out, come and question your decisions. Often you may not have an evidence based explanation for what you do, but based on a 'gut' feeling. Most of the time the youngster believes what he learned in books, but each patient is different and each one needs treatment or surgery, tailored to his or her need which an experienced practitioner can understand.

Saturday, September 5, 2015

Robotic surgery and some thoughts

             Robotic cholecystectomy was going on. Surgeon was uncomfortable because he was not able to use the Maryland dissector the way he wanted to. Using the Bipolar cautery he was not able to adequately separate the tissue. My junior scrubbed and assisting by the patient side suggested that we should use scissors to cut the tissue. Then the Urology professor watching the procedure replied, “we can, but we will have to open a new instrument and that will add cost to the surgery”. We were doing robotic cholecystectomy as a part of getting used to the robot before going on to do major surgeries.

              Definitely robotic cholecystectomy does not offer any advantage over laparoscopic surgery. But in fact, add cost and effort. The machine itself costs hefty and the accessories also come at a high cost. Each surgery needs costly drapes and the instruments get auto-locked after ten uses. The Da Vinci system has got the monopoly over robotic surgery all over the world. 


             The day before the surgery I went to the patient to take consent for the surgery. Earlier she was posted for Laparoscopic cholecystectomy, but the surgery was cancelled since the previous cases on the list got delayed and the OT time was over. I explained to her that we were planning for a robotic surgery and if there was any problem, we will convert it into a normal laparoscopic procedure and again if we find difficulty, we may have to convert it to an open surgery. The poor patient coming from a village hundreds of kilometers away nodded her head for what ever I explained to her. Finally her only question was “Do I have to stay fasting (NPO), tomorrow also?”