A 16-year-old collie had this 6-pound benign splenic hematoma. (Photos Courtesy of Dr. Phil Zeltzman) Surgeons love quotes. In a few words, a good quote summarizes the wisdom accumulated by past generations. Sometimes borrowed from others, sometimes definitely unique, quotes are important to live by in the operating room as long as we all understand that they are tongue in cheek. 1. A chance to cut is a chance to cure Most of us live for surgery. It’s pretty simple, really: If a patient has a tumor, cut it out. If a dog has a twisted stomach, untwist it (and pexy it!). If the patient is paralyzed, remove the herniated disc. Surgeons are more open-minded than many credit them for. For example, most surgeons now realize that a perianal fistula is not a surgical condition. Because of its immune-mediated etiology, it often is best treated with drugs such as cyclosporine. Some open wounds heal quickly and cosmetically with simple hydrotherapy. Other wounds respond very well to Epsom salt soaks. Surely, there are other examples of patients who may not benefit from surgery. Our musically inclined readers may be interested in this factoid: “A Chance to Cut Is a Chance to Cure” is an album by a San Francisco duo named Matmos. They apparently added their electronic music to recordings of actual surgical procedures: a suction machine, a bone saw, plastic surgeries. Song titles include “LASIK,” “Lipostudio” and “California Rhinoplasty.” The CD is easy to spot at your favorite music store. Look for the No. 11 scalpel blade on the cover. 2. All bleeders stop, eventually This is an indisputable law of surgery and volemia. However, for the sake of the patient, the sanity of the anesthesiologist and the happiness of the technician, it is highly recommended that careful hemostasis be used to stop or prevent bleeding. Electrocautery, secure ligatures and hemostatic agents are some of the many ways to control bleeding. Symptoms typically appear when acute hemorrhage leads to 15 to 20 percent blood loss. Shock occurs after 35 to 40 percent blood loss. It is important to make sure that every surgery patient has been off aspirin for seven days before surgery. Some clients don’t seem to consider aspirin a drug and may tell you their dog is not on any drugs. In at-risk breeds such as Dobermans, it may be a good idea to test patients for von Willebrand’s disease. 3. Measure twice, cut once Borrowed from carpenters, this is definitely an expression to live by in the OR. Literally or not, this saying can apply to numerous surgeries. For example, although it is critical to obtain clean margins after excision of a large skin mass, it is imperative to be able to close the wound without tension. Careful planning and a surgical marker may help the surgeon reach an acceptable compromise. This concept also applies to thoracotomies, where it is essential to count ribs to identify the correct intercostal space. More broadly, this saying can be applied to other medically and legally tricky situations to make absolutely, positively sure that you are operating on the correct knee, amputating the correct leg or removing the correct ear canal. 4. If it’s worth taking out, it’s worth turning in This mantra was probably borrowed from pathologists, one of whom told us: “Excising a mass and not submitting it for histopathology is probably legally indefensible in 2009.” Another pathologist reminds us that “The three deadliest words in our profession, ‘Just watch it,’ will become more and more difficult to explain when what was thought to be a lipoma turns out to be a mast cell tumor. ” 5. Biopsy, biopsy Few will agree that every subcutaneous mass needs to be excised, but at the very least, it should be aspirated or biopsied. The purpose of a biopsy is two-fold: * If a skin mass is found to be benign, it could be ignored for the time being if the client chooses. The owner’s refusal should be documented in the medical record. Maybe it can be excised on an elective basis, for example when the patient is anesthetized three months later for a prophylactic dental procedure. * If a malignant process is discovered, then we can act on it by following Axiom No. 4 and take it out. Submitting the mass to the lab again is highly recommended, not necessarily for diagnostic purposes if we already have a specific diagnosis, but to determine whether clean margins were obtained. 6. Treat patients, not X-rays A classic example is hip dysplasia. Patient A has severely arthritic hips on radiographs but seems relatively comfortable. Meanwhile, Patient B shows mild signs of degenerative joint disease on X-rays but is clinically severely debilitated. Although Patient A still should receive the benefit of pain management, a total hip replacement is not urgent. Similarly, a patient may show a relatively minor spinal compression on a myelogram or an MRI, yet exhibit severe signs of pain. Likewise, not every patient with enlarged adrenal glands on ultrasound exam needs immediate adrenalectomy. Further testing and close monitoring, yes. Emergency laparotomy, no. The same idea applies to other “incidentalomas” found via various imaging techniques 7. Big surgeons make big incisions Though this adage definitely applies to standard laparotomies (see Veterinary Practice News, February 2008) and several other surgeries, the trend in some ORs is to make incisions just long enough to allow insertion of cameras and instruments. Arthroscopy, laparoscopy and thoracoscopy certainly are revolutionizing surgery. 8. There is routine surgery but no routine anesthesia The fact that some surgeries are routine may be debatable. Nevertheless, this classic saying was surely invented by an anesthesiologist. Unfortunately, when we expect it the least, the seemingly most stable patient may crash. It could be during a “routine” spay, a “routine” neuter or a “routine” anterior cruciate ligament surgery. Suddenly, your patient’s blood pressure drops and yours instantly rises. The apparently healthy 6-month-old pup with an unknown cardiac malformation unexpectedly decompensates during a spay. The “healthy otherwise” greyhound develops malignant hyperthermia after you suture a skin laceration under general anesthesia. Because of Murphy’s law, it is vital to have a well-trained technician or anesthesiologist monitoring the patient, and a well-stocked crash box in the OR. 9. Cut till you drop This isn’t really a surgeon’s saying. It’s what Chris, one of my technicians, answered one day when I asked her, “What’s a surgeon’s motto?” The answer I expected was “Measure twice, cut once” during patent ductus arteriosus surgery. But her answer was so funny, I had to mention it. Then again, Jess, another technician, replied to the same question: “The technician is always right.” Let’s not go there. I prefer Chris’ answer. Like other veterinarians, surgeons have a burning desire to help as many patients as possible and make a difference in as many families as possible. Like other veterinarians, this is why some surgeons sometimes miss dinner or occasionally wake up at 2 a.m. to save the world. Surgery is a wonderful and demanding passion. They can’t say that at the doughnut factory. 10. Age is not a disease OK, this may not be a classic saying of surgeons. But it is helpful to remember it when owners wonder if a “tie-back” surgery should be done on a 12-year-old Labrador with laryngeal paralysis, or whether a 13-year-old golden retriever should have a splenectomy, or if a 14-year-old bulldog should have a soft palate resection, laryngeal saccule excision and a rhinoplasty. By the way, these are actual recent cases. Surgery for laryngeal paralysis or brachycephalic syndrome has a very high success rate. And as for the spleen of our golden, it had a large but benign nodule. So truly, age is not a disease. These conditions are merely an unfortunate bump along the road. If the client can’t afford surgery or is not emotionally bonded to the pet, that’s a different story. But it is ethically and medically advisable to recommend surgery in such cases. In fact, we have never seen a client regret performing a splenectomy on a dog that had hemagiosarcoma. The additional three to six months the client gets to spend with the pet is typically highly appreciated. And with chemotherapy, a longer survival time may be attainable. 11. Never be first to use a new treatment and never be last This is a suggestion from my old pharmacology professor. Surely, certain procedures and treatments should have been left behind in the 20th century. This is no reason to embrace every new treatment or medication without further research. Scientific articles, colleagues and specialists are good sources of objective information. 12. When there’s a doubt, there’s no doubt This one is more powerful than it sounds. It means, for example, that if you think a patient’s sublumbar lymph nodes are enlarged, they probably are. If you wonder whether they should be ultrasounded, they probably should. 13. Dilution is the solution to pollution This little saying is not from Al Gore. It is useful to remember this when treating an open wound or a septic abdomen. Copiously flushing a wound or rinsing an abdomen is a very simple step that can make a huge difference. Let’s be realistic: No wound and no septic belly can ever be sterile after we are done treating them. However, the sheer volume of fluids can dilute bacteria to a point that the patient’s defense mechanisms should be able to control. It is not unrealistic to use two to three liters of LRS to flush an open wound, or 10 to 12 liters of warm saline to rinse a septic abdomen. <HOME> Phil Zeltzman, DVM, Dipl. ACVS, is a small-animal board-certified surgeon at Valley Central Veterinary Referral Center in Whitehall, Pa.
