Thursday, June 4, 2015

Can a surgeon who is sitting perform abdominal operations?

A loyal reader alerted me to news of a lawsuit brought by an obstetrician in South Carolina who is suing a hospital for suspending his privileges. He had performed a cesarean section while sitting on a stool because he had a foot fracture secondary to diabetes. Several witnesses said that the doctor "had been unable to properly view the surgical field, unable to properly handle the baby and unable to address hemorrhaging." The patient later developed a serious infection.

A seated surgeon can operate on the hand and arm. In fact, that's the way everyone does it. The surgeon's knees easily fit under the small table holding the outstretched arm. Certain anorectal operations and gynecologic procedures done through the vagina can be done by a surgeon who is sitting, but abdominal and pelvic operations done via laparotomy can't be safely done that way.

The problem is that when a surgeon is sitting, she can't get close enough to the OR table and the patient to see way down into the abdomen and pelvis. If bleeding occurs deep in the wound, controlling it would be challenging to a surgeon who is sitting. Tying a secure knot in the pelvis while sitting might even be impossible.

With the exception of robot-assisted surgery where the surgeon sits a console remote from the operating table, a seated surgeon would have trouble doing both open and laparoscopic procedures. Even with a robotic operation, there can be problems. If the surgeon can't stand, an assistant would have to help insert the robotic ports. What if something went wrong and the abdomen had to be opened?

In a laparoscopic case, the video monitor could be seen by a sitting surgeon, but manipulating the rigid instruments would be difficult because of the angles created by the locations of the ports through which the instruments are passed.

As a retired surgeon, I sympathize with anyone who might be forced to quit operating because of illness or disability, but the safety of the patient comes first.

I hope that the suit is resolved quickly and we learn what the outcome is.

22 comments:

Korhomme said...

I have seen it done in mainland Europe, though the surgeon had to move between sitting and standing at times. It's possible with a Kifa table which used a fixed pillar to which a 'table' or platform is attached. The attachment can be eccentric, with the support at, say, the head end; there is plenty of room for the surgeon's knees under the platform.

It did strike me as odd, seeing this, but practical in many ways, though the disadvantage is the fixed position of the post. The tables were expensive, so of course not available on the NHS.

The assistant in a laparoscope cholecystectomy can sit during the procedure, though the operator can't.

Skeptical Scalpel said...

Korhomme, thank you for your comment. I was unaware of the existence of such a table. I still think it would be difficult to see into the pelvis while sitting, particularly when operating on a very obese patient.

I wonder if it would be practical to buy this for a single surgeon. Also, if you only had one of these tables, you would have to allow others to use it to optimize the utilization of the operating room that it was in. This means if the surgeon who had to sit had an emergency and the room was being used by someone else, the table might not be available. It doesn't seem like a foolproof solution to the problem.

I agree that the assistant in a laparoscopic cholecystectomy could sit for a good part of the case. But opening, inserting ports, and closing might require standing.

Korhomme said...

I saw these tables at the University Hospital in Basel, Switzerland; the main operating block had 12 theatres, all so equipped. In the continental system, the chief surgeon—Chefarzt—could and did say how things were going to be.

Patients there were almost always lean. For a highly selective vagotomy (it was all a while ago) they used a ring type retractor with large blades to hold the abdominal wall open. They could use a Rochard retractor, a curved blade to fit the substernal area, to widen the costal margin and hold it up. This gives amazing access to the upper abdomen. They had a system of adjustable arms used to hold retractors which were used to hold organs away. The use of such mechanical means allowed the assistant to assist, rather than just retracting.

The surgeons all used much longer instruments than are common in UK; they kept their hands outside the abdomen. That took some getting used to, but works quite well.

They would sit, at times, on stools more like bar stools in height, though they would hop on and off at times; not all surgeons used stools. They didn't sit for intra-pelvic dissections.

The base of the Kifa table needs to be built into the floor structure, so only suitable for major renovations or a new build. I didn't see to much of other hospitals, but IIRC they used conventional tables.

As you say, the fixed base is a little problematic; but the advantages include various tops or platforms, not just for abdominal surgery, but also fractures (which general surgeons did in Basel). The tops are radiolucent, so easy to do an operating cholangiogram—there are no obstructions under the platform. There were multiple tops for each table.

I'm not sure if Kifa tables are still available; a web search brought up only some pictures.

As you say, inserting the ports in a lap cholecystectomy is done standing. We were taught the 'American' 4-port method with 2 assistants. Later NHS cutbacks meant that there was usually only one assistant, and when doing this I found it easier and more comfortable to sit rather than stand.

artiger said...

It said "...essentially asked Dr. Robinson to take a permanent leave of absence." That would be a bit different than a suspension, which would have more ramifications. Suspension seems a bit harsh just for exercising poor judgment on a single case. If he's going to go the ADA route, what's next? Allowing a blind surgeon to operate with a an assistant to tell him/her where to cut?

As for standing or sitting, I think there might be a lot of things that could be done seated, but not a C section. Too much need for manipulation and maneuvering and controlling blood loss.

Skeptical Scalpel said...

Korhomme, thanks for the explanation. It doesn't work that way here in the US. The days of surgical chairmen getting whatever they want are long gone.

Artiger, if you read the case that is linked to in the Outpatient Surgery article, it says, "Plaintiff took a six week medical leave of absence, and has since been involved in various attempts to regain his ability to practice medicine at both hospitals." That sounds like a suspension of privileges to me.

Unknown said...

My guess would be that if he thought it was appropriate to perform a C-section while seated then this is not his first lapse in judgement. This was probably the last straw for the hospital.

OldfoolRN said...

Years ago I worked with some visiting German surgeons that had many complaints about positioning patients in American operating rooms. They were appalled by the fact anesthesia controlled the position of the table. This was the domain of the surgeon. Another deficit in their opinion was the patient was not sufficiently secured to the table for fine movements. The tables they used were infinitely adjustable and were controlled by surgeon operated foot pedals. The table be moved in any direction.

Skeptical Scalpel said...

Unknown, you may be right. He probably had done many C sections before the one that went bad.

Old, thanks for commenting. Once I had anesthesia get the table where I wanted it, I rarely asked for it to be adjusted again. I don't think I ever needed an infinitely adjustable table.

Korhomme said...

OldfoolRN and SS: in the UK, the anaesthetists taught us as students that they were in charge of the operation, that the surgeon did as he (it was always a he then) was told.

In the Germanic culture, anaesthesia was a sort of minor division of surgery; anaesthetists were there to do the surgeons' bidding, they were little more than handmaidens. Where I was, the intensive care was very much a surgical domain, with anaesthetists there for the technical details. (There was an entirely separate medical ICU.)

A very different climate.

artiger said...

Scalpel, you're right, I initially did not see the link to the case. It sounded like the medical leave was recommended initially, and yeah, when I read the part about attempting to regain privileges it sounded like a suspension. I believe he even referred to his privileges being "jerked". If I'm not mistaken that has to be reported to the state medical board, possibly even the Data Bank. So even though suspension is serious business, maybe it was indeed appropriate. If I'm a pregnant patient I wouldn't want this guy doing my section.

Skeptical Scalpel said...

Korhomme, ah the good old days. I think it was more like Germany than England back in day here in the US.

Artiger, if I recall correctly, any suspension or modification of privileges if it occurs even if voluntary while a doctor is under investigation must be reported to the data bank.

Korhomme said...

SS, I'm sure you are correct. Back in the day, American surgeons travelled extensively in Europe—think of the Mayo brothers. Although I've never worked in the US, the working pattern there, as I've heard, was similar to the Germanic one. A very early start, with a morning conference discussing all the admissions of the previous 24 hours. A very long day, with operations proceeding much more slowly than in England. Whereas in England, Sir arrived at say 9am, descending from his chauffeur driven limo to be greeted by his 'firm', a ward sister and a few doctors—not the entire surgical staff of the hospital. I'm convinced that the visiting US surgeons preferred German efficiency to the rather amateurish attitudes of the English. And in those days, German was a major international scientific language.

Anonymous said...

Anonymous Europe: Where I work you are allowed to operate as you wish as long as you get the job done. I for one usually alternate between sitting and standing depending on what the actual situation requires and what the operation is. The guy in the article should not have gone into the OR if he could not stand.... If you are unfit to do this job, then maybe you should wait till you heal...

Skeptical Scalpel said...

I agree.

Anonymous said...

There is a scoliosis surgeon in Baltimore who is an achondroplasic dwarf. Even when standing on stools his arms are to short to reach anything, so he has to lie on patient. Thanks ADA & Political Correctness.

Anonymous said...

I know of surgeons who have gone into fields such as Ophthalmology, Hand & ENT just so they could sit for surgery.

Skeptical Scalpel said...

First anonymous, I don't know whether to believe you or not. I have never heard of this before. I only allowed the comment to see if anyone else knows anything about this.

Second anonymous, I have no doubt that some surgeons have chosen their specialties based on the amenities such as sitting.

frankbill said...

The surgeon's name is Dr. Michael Ain. He is at Johns Hopkins. http://www.shortsupport.org/News/0238.html

Skeptical Scalpel said...

Frank, thanks for the info and the link. Very interesting.

frankbill said...

There is also a surgeon who lost his fingers in an earthquake1985. Had his toes transplanted to his hands.

http://www.apnewsarchive.com/1986/Mexican-Surgeon-Operates-After-Losing-Four-Fingers-In-Earthquake/id-980419cbe74430170f7e0061f3cf4bd7

Skeptical Scalpel said...

I guess when he's clumsy he has to say, "I'm all toes today." But wait, he's all toes every day.

artiger said...

I don't have a problem with someone such as Dr. Ain if the outcomes are acceptable.

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