New M.D.

A Flexible Approach to Surgery

By Lauren A Eckstein, M.D., Ph.D.

Grasping the anterior capsule flap with my utrata forceps to begin the capsulorhexis, I appreciated marked phacodonesis that had not been evidenced during the patient's preoperative evaluation.

As the patient had an advanced, dense nuclear cataract, I had originally planned to remove the cataract via divide-and-conquer; however this new development brought to mind different thoughts.

Rather than adhering to my preoperative surgical plan, I instead proceeded with horizontal chop to accomplish nuclear disassembly in an effort to minimize zonular stresses. The case proceeded without complication. The cataract was removed safely, and the intraocular lens was successfully inserted into the capsular bag.

Be Prepared to Adjust

One of the questions I am frequently asked by attending physicians before beginning a phacoemulsification is, "How do you plan to remove this cataract?" Although I have worked hard to familiarize myself with various techniques — divide and conquer, stop and chop, flip and chip — I have often found it difficult to answer this question. While I have my preferred methodology, which I try to reproduce on most cases, I have found that the single most helpful approach is not to adhere to any particular surgical technique in particular, but rather, to be flexible, allowing the case to proceed along its "natural" pathway, and adjusting to the changing surgical situation as it evolves.

As educators we are compelled to teach the numerous established clinical approaches and surgical techniques to successfully manage most cases. As students, we are compelled to acquire the knowledge and the skills to identify these individual cases and implement appropriate interventions. However, when taken to its extreme conclusion, this philosophy may lead to a "cookbook" approach to both clinical care and to surgical planning and execution. This rigid protocol has great utility in many cases but may leave the novice practitioner ill-equipped to negotiate novel or unexpected situations.

Flexibility Is Key

Indeed, we must grasp the philosophical foundation for each of the surgical approaches we might employ: not just when to use a particular technique, but why to use the technique. This rational understanding of surgical methodology enables the practitioner to anticipate complications and to successfully adapt to changing intraoperative conditions. While it may be expedient for the beginning resident to adhere to a fixed routine initially, they must also be encouraged to try new techniques — both to expand their armamentarium and to engender flexibility and confidence.

Of course, there is a natural tension here. To facilitate the acquisition of complex surgical skills such as phacoemulsification, we wish to reduce them to their indivisible elements — like wound construction or capsulorhexis – and master each individually. To do so requires a methodical approach and practiced repetition.

Unfortunately, for the resident surgeon, all such operative elements, at least initially, may not be perfectly executed, thereby necessitating a dynamic surgical approach. Flexibility enables the novice surgeon to recognize unexpected surgical opportunities as they arise intraoperatively and to exploit them to the betterment of their patient. For instance, a resident familiar with divide-and-conquer may create an unintentionally large capsulorhexis. Rather than adhering to a dogmatic, planned approach, he or she may instead be encouraged to prolapse the nucleus during hydrodissection and proceed instead with a chopping methodology for mechanical nucleus disassembly.

As we acquire greater skills, we may direct the course of surgery by our successive planned manipulations and by the execution of well-practiced maneuvers. Nevertheless, each case will proceed along a natural evolution. Although we may modify this pathway to a greater degree as our facility expands, we must remain flexible enough to adapt to a changing environment and to capitalize on unexpected opportunity. OM