All surgery, including vitreoretinal surgery, is a landscape not for the faint-hearted or thin-skinned. As Abraham Verghese reminds us with the quote above, the degree of difficulty is massive. I don’t consider it to be a difficulty only a genius can comprehend, but more like a fighter pilot with the ability to sustain periods of extreme intensity and the skill to respond with proficiency and equanimity. Those who have seen me in surgery or discussed it with me know that I love to try new techniques and approaches, always looking for opportunities to solve problems with insight and intrepidness, while being cognizant of never putting a patient at risk. This article, aimed at early-career vitreoretinal surgeons, will address pearls and tips to ensure success in the retina operating room (OR).
Chess can be divided into an opening, middlegame, and endgame. I am going to borrow this conceptual construct to break down and analyze the steps to help ensure success in the OR. Think of the opening as everything that happens before you actually get to the OR. Be aware of all relevant logistical aspects that will impact your performance: how cases are booked, turnover times, type of paper or electronic medical record used in the surgery center, preferred practices (e.g., surgical timeouts, patient identification), and so on. Familiarize yourself with the equipment available to you — microscope, vitrectomy machine, and available instruments. Don’t assume that everything will be available at a moment’s notice! If special equipment is required — for example, small-gauge subretinal cannula — or if samples will be sent for analysis (e.g., endophthalmitis, diagnostic vitrectomy for lymphoma), ensure you have the necessary tools, and that you and your team are aware of the process for submitting samples. When operating, especially when first starting out after fellowship, focus on the surgery at hand and don’t be hindered by logistical cognitive fatigue.
There are three issues I commonly see in this opening: surgeon-staff interactions, surgeon preference cards, and surgical templates.
First, be courteous to and respectful of your surgical team. I’m dumbfounded by the type of behavior I sometimes see from surgeons. You don’t have to be everyone’s best friend, nor it is necessary to ask everyone about their weekend plans; do say “please” and “thank you.” Everyone realizes that surgery is stressful; however, it’s important to acknowledge those who are working to support you and respect their place in the operating room. These human dynamic basics you learned some time ago ensure the surgical team has high morale and is ready to tackle anything — and believe me, anything can and will happen — that transpires over the course of an OR day.
Second, with respect to surgeon preference cards, make sure your preference cards are updated and reflect what you actually want. What type of suture do you commonly use? Belt-loops or sutures for buckles? Straight or widefield light pipe? Make the OR team aware of this by using preference cards.
Finally, and in line with the latter, you should have thorough surgical templates, whether dictated or typed, that you can deploy efficiently. As I mentioned previously, especially when you’re starting out, minimize logistical cognitive fatigue and focus on the surgery, not on writing a novel from scratch after a case is completed.
In chess, the middlegame follows the opening. There is no clear line between the opening and the middlegame. For surgeons, the middle game is the actual surgery. Once you start the surgery, there’s no going back. You can suture close a sclerotomy, but you can’t undo it! Consequently, the most important part of surgical success is your plan. This is, without a doubt, the most important pearl for surgical success I have learned. A famous quote attributed to Abraham Lincoln states: “Give me six hours to chop down a tree and I will spend the first four sharpening the axe.” Surgical success is very much aligned with this sentiment. Ask a senior surgeon or mentor how their OR day went, and you will commonly hear, “No surprises.” This is what you want. “No surprises” doesn’t mean that you performed a perfect surgery, but rather that you had a game plan to account for the myriad of issues that may arise.
Although we could easily put this thesis of surgical preparation in the opening, I believe it to be of such crucial nature to the actual surgery that it should be the cornerstone of your surgery. Be ready! Spend the majority of your time planning so that your execution is smooth, efficient, and free of surprises.
By the endgame, you have completed the task at hand and you’re ready to close. I’m not dogmatic about any one approach or technique, because the preferred technique should be the one that — in your hands — achieves the best outcomes. Be cognizant of difficulties you encountered, and track your cases. Be aware of your outcomes and complications as they compare to your peers and the literature.
In discussing cases with fellows and colleagues, we can see that, most of the time, complications follow Hanlon’s Razor: “Never attribute to malice that which is adequately explained by stupidity.” Failing to address a surgical complexity — whether by denial or assumption — usually leads to larger issues than the initial bump in the road. Manage complex cases or difficult surgical maneuvers with measured and reasoned decisions. These are not the times to throw caution to the wind and hope for the best. Make every effort to be accountable for every move you make while operating.
Of course, no matter how prepared you are, complications will arise. If you’re like me, I guarantee that you won’t remember the 99 successful retinal detachments you repaired but will instead be haunted by the one or two that failed. This is fine as long as it doesn’t impair our ability to succeed in the next case. Learn with a constant goal of improving and progressing. What you cannot do is carry over impairment to the next patient —they deserve better.
Finally, part of the endgame is what happens to your patients after they leave the operating room. Be clear with postoperative instructions (positioning, drops, follow-up appointment, and so on). The goal is twofold: First, it will avoid numerous calls from perioperative staff about patients; second, it allows patients to go home feeling confident and trusting in the care they received. ■