New M.D.

Learning From Tough Surgical Cases

By Allen Hu, M.D.

"Two types of surgeons don't experience complications. Those who don't admit to them and those who don't operate."

I heard these words from one of my mentors during grand rounds a few months ago, but only recently have I started to acknowledge the harsh reality of that statement. As a second-year ophthalmology resident, I'm spending more time in the operating room and realizing that every case so far is "complicated" by something that could have been done slightly better.

My First Complication

I will never forget my first major surgical complication. As I held the phaco probe in my right hand, angled exactly as I had seen my mentors hold it, to carve my initial groove during cataract surgery, I could see that something was just not right as the anterior chamber started to deepen and the lens material began to sink posteriorly. I held my breath. Luckily, I also remembered to hold onto the mostly intact lens nucleus with my phaco tip before it fell in to the dark abyss of the vitreous space. With the help of my attending and eight 10-Nylon sutures later, what started out as a 4-mm scleral tunnel incision was converted into a large 12-mm incision. Though substantial amounts of vitreous were lost though a posterior capsular tear, a sulcus IOL was successfully placed.

As a newbie surgeon just beginning to grasp the fundamentals of ophthalmic surgery, I have begun to directly experience the feelings of frustration and discouragement associated with complications in the operating room. If new surgeons allow these situations to bog them down and fail to recognize them as opportunities, they may be paralyzed by self-doubt. A more positive response in the aftermath of unexpected events in surgery is to develop an effective strategy to gain insights from current errors to prevent future mistakes.

Review Your Difficult Cases

I now have several methods that help me learn from difficult cases. First, if possible, it is always best to videotape cases. Just like sports teams record their games and go over tapes in practice sessions, we as surgeons should examine our own performances to understand areas in which we can make improvements. In the heat of the moment during a complicated case, it is often impossible to remember the details of key events within the eye. It makes sense to review the videos later at a slower pace. Uday Devgan, M.D., who teaches cataract surgery to residents in the Jules Stein/UCLA ophthalmology residency program, records all of the cases he attends for his residents to review.

Second, keeping a surgical log to reflect on weaknesses and strengths at the end of the case not only forces you to actively make a mental list of specific improvements you intend to make in your next case, but allows you to organize these thoughts so that you can call upon these insights prior to your next case.

Third, always ask for advice from more experienced surgeons. Those battle-tested veterans know which mistakes beginning surgeons are apt to make and can help you overcome them because more likely than not, they faced similar challenges when they were in your shoes. It's been proven statistically that a combination of a finite number of common mistakes account for a large majority of surgical complications.

Fourth, once you can intellectually understand how you can improve your skills, practice these manual skills in the wet lab. My strategy is to start with focused sessions (e.g., learning/practicing specific steps of a procedure like anterior capsulorrhexis). You don't have to repeat the entire case. Just as a musician will focus on specific, more difficult portions of a musical composition, the beginning surgeon can focus on specific tasks he or she finds particularly difficult.

Finally, I encourage my colleagues to be aggressive and not shy away from tough cases. As my skills mature, I hope to seek out particularly challenging cases to implement and reinforce what I have learned. I cannot think of a better time than residency or fellowship training to challenge yourself, given the availability of experienced veterans at your side to guide you in these more difficult cases. OM