Useless general surgical interventions that should no longer be done

England’s National Health Service (NHS) could save €153 million [$178 million USD] per year by scrapping 71 low-value general surgery practices says a recently published paper in the British Journal of Surgery.

The authors, from Imperial College London, extensively reviewed the literature and Choosing Wisely recommendations from a number of countries.

I agree with many of the 71 including performing a cholecystectomy during the first admission for a patient with symptomatic gallstones instead of waiting for another admission (saving more than €54 million) and not repairing minimally symptomatic inguinal hernias, which they estimate would save over €32 million.

The Telegraph reported, “The team also discovered that robotic surgery has ‘little or no advantage’ when compared with traditional keyhole operations and said it must be ‘considered a candidate for disinvestment.’” This probably wouldn’t fly here in the US, because—like guns—too many robots are already in the hands of users.

Review of TV show "The Good Doctor"

Just when you thought there could not be another bad medical show, ABC TV presents “The Good Doctor.” It’s about an autistic young man going to California to become a surgical resident.

Just after he lands at the airport in San Jose, an overhead sign breaks and causes the unluckiest 8-year-old boy on earth to suffer three life-threatening injuries. The Good Doctor gives a bystander, who sort of sounds like a doctor but is not too confident, an anatomy lesson about where to hold pressure on a bleeding internal jugular vein. He then notices bulging of the left arm veins and diagnoses a tension pneumothorax.

He looks for a knife “with a seven-inch blade” at a TSA checkpoint, grabs a lesser knife, makes a chest tube and underwater seal from various supplies he finds in the airport, dumps half a bottle of whiskey on the kid’s chest, and inserts the makeshift tube. All of this happens on the floor of the airport concourse.

Of course the kid wakes up and starts breathing normally.

Meanwhile the board of directors of the hospital is debating the hiring of an autistic surgical resident. In this hospital, its president, who met The Good Doctor when he was 14, hires the residents, and the chief of surgery has no input. [Matching? What matching?]

Some general surgery residency graduates may not be competent to operate

A new study says 84% of general surgery residents in their last six months of training were rated as competent to perform the five most common general surgery core procedures—appendectomy, cholecystectomy, ventral hernia repair, groin hernia repair, and partial colectomy. However the percentage of those judged competent varied from a high of 96% for appendectomy to a low of 71% for partial colectomy.

When analyzing the other 127 core operations of general surgery, the investigators found that 26% of residents in their last six months of training were felt to not be competent to perform at least some of those procedures.

The study was presented at the annual meeting of the American Surgical Association in April 2017 and reported in ACS Surgery News.

Data were compiled from ratings of 522 residents by 437 faculty yielding 8526 different observations.

For all of the procedures rated, maximum resident autonomy was observed for 33% of cases, and the more complex the case, the less ready the residents were to perform it on their own.

The lead author of the study, Dr. Brian George of the University of Michigan, was asked whether the duration of surgery training should be increased. He answered, “The 20,000 hours of surgical residency should be enough to train a general surgeon to competence—it's up to us to figure out how.”

Will robots eliminate the need for surgeons?

A medical student from Germany emailed me saying he had always wanted to be a surgeon, but someone told him that by 2030 surgeons would no longer be needed because robots would be doing all the operations. He worried that after years of studying and hard work, he might lose his job to “R2-D2.”

He mentioned IBM’s Watson and a recent paper that appeared in the journal Science Translational Medicine about a robot that can handle and suture bowel.

He asks, “What do you think about the future of surgery?”

Thank you for your email and the link to the paper.

I read the paper and was amused by its title "Supervised autonomous robotic soft-tissue surgery" which is an oxymoron. The definition of autonomous is "acting independently or having the freedom to do so." This “supervised” robot is not really autonomous.

The robot is capable of performing a nearly technically perfect intestinal anastomosis but still needs a human surgeon to open the abdomen, prepare the bowel for the procedure, tidy up, and close. I'm not sure that this is any different than when surgical staplers were introduced. This robot is simply making the operation easier and possibly more precise.

Surgeons will still be needed in case the robot makes a mistake like causing bleeding while placing a suture near the mesentery. If bleeding in that area is not promptly controlled, a large hematoma can develop and possibly compromise the blood supply to the anastomosis. And will the robot be able to decide who needs an operation and when to do it?

One worrisome byproduct of surgical stapling is that many graduates of residency programs within the last 15 or 20 years have little experience in performing a hand sewn bowel anastomosis. What will they do if the hospital runs out of staplers? Soon, I guess they could consult the (somewhat) autonomous robot.

I have written about automation and the erosion of surgical skills. This problem also affects pilots. I have also addressed the concept of  robots operating alone. I don't see it happening any time soon.

I think there will always be a need for surgeons. Even the smartest robot is going to have some trouble dealing with a trauma patient who is hypotensive.

The future will take care of itself. In the 1980s, people were concerned about the demise of general surgery. Opinion pieces with titles like “Will the general surgeon become extinct?” and “Is general surgery a dying specialty?” appeared in major journals like JAMA and the World Journal of Surgery.

Then in 1990, laparoscopic cholecystectomy opened the door to a whole new area of general surgery that no one had ever dreamed of.

Good luck with your studies and your surgical career.

My response to a misguided opinion piece about surgery

"There is no place for the surgeon myth in modern medicine" says writer Alexis Sobel Fitts in Aeon Magazine.

Having a sister in medical school apparently qualifies Ms. Fitts to critique the specialty of surgery.

She starts with an old joke "An internist can figure out what’s wrong with you, but he can’t fix it. A surgeon has no idea what’s wrong with you, but he’s happy to fix it." If you read it carefully, you should note that it’s not that funny, and it’s wrong on both counts. No surgeon would ever fix something unless she knew why, and internists have these things called pills which can successfully treat a number of diseases.

She goes on, "After all, fixing problems is corporeal, often removed from the more intellectually nimble task of diagnosis." Apparently she is unaware that surgeons often make diagnoses—occasionally even correct ones, and I’ve written before about the misconception that doing an operation doesn’t require thinking [here and here].

"Surgeons are descended from the barber or the butcher," she says. That was hundreds of years ago. Nowadays, surgeons complete four years of medical school just like her sister and all the other doctors.

"Any missteps might incite devastating consequences, as the surgeon navigates around the vagus nerve, which dictates facial response…" I hope her sister didn’t give her that information. The vagus innervates many structures, but the face isn't one of them.

"Before anaesthesia and antibacterials, a patient undergoing surgery could be assured of two things: immense pain and the likelihood of infection and death." That’s actually three things. Of course without surgery, patients experienced immense pain, infections, and death anyway.

"Since the 1950s, laboratory science has increasingly been the origin of medical innovation. Which is why, over the past four decades, merely a 10th of the articles published in The New England Journal of Medicine have covered surgical innovation." Or maybe it's because The New England Journal is a medically, not surgically, oriented journal.

Here’s the winner. "Surgery’s place at the bottom of the medical hierarchy can be attributed to the crude cruelty of early surgical procedures." Other than Ms. Fitts, who has placed surgery at the bottom of the medical hierarchy? It’s certainly not US medical students who make the surgical specialties among the most competitive of all.

In the 2015 resident match, surgical specialties filled their first-year positions with 80% or more US medical school graduates. In fact, orthopedics matched with 94.3% US grads. Compare those numbers to internal medicine and family medicine, which filled their first-year positions with 49% and 44% US graduates, respectively.

Here's what Wikipedia has to say about its Aeon Magazine entry:

This article has multiple issues. Please help improve it or discuss these issues on the talk page.

The neutrality of this article is disputed.

This article contains content that is written like an advertisement.

This article contains weasel words: vague phrasing that often accompanies biased or unverifiable information.

That pretty much describes the Aeon essay about surgeons too.

A curious trend in appendectomies by residents

Some experts are worried that laparoscopic cholecystectomy is so prevalent that future surgeons may have difficulty doing open cases. I was going to blog about the possibility that open appendectomy would become the next operation that next generation surgeon might have trouble with. But while looking at some data [link added 12/4/15] collected by the RRC for Surgery, I was struck by something else.

Since 1999, the total number of appendectomies (open and laparoscopic) performed by surgical residents who completed 5 years of training has risen by 65.1% compared to the total number of appendectomies done in the US, which has increased only 16.4%. Here are the numbers:

Except for the academic year ending in 2006, the average total appendectomy rate per resident has risen every year since 2000. The chart below displays that change and the changes in the numbers of open and laparoscopic appendectomies.

Click on chart to enlarge

The difference in the average combined number of appendectomies between the two academic years ending 2000 and 2014 is significant, p < 0.0001.

What comes after the Heimlich maneuver?

At the end of an otherwise informative article about the nuances of performing a Heimlich maneuver, New York Times science reporter Jane E. Brody recommends that if all else fails, a cricothyrotomy should be attempted.

She goes on to briefly explain how the procedure is done. In the right hands, a cricothyrotomy is safer and easier to perform than a formal tracheostomy. However, for a layperson who has never seen either procedure done, does not know the relevant anatomy, and has never put a knife to anyone's skin, it is highly unlikely to be successful.

Ms. Brody includes a link to website with some static drawings of the procedure. The site is called Aaron's Tracheostomy Page and it bills itself as "The Internet's leading tracheostomy resource since 1996."

Here's an excerpt from that description of the operation:

"3. Take the razor blade or knife and make a half-inch horizontal incision. The cut should be about half an inch deep. There should not be too much blood." Yes, there should not be too much blood, but sometimes there is.

Both the Times article and the reference repeat the medical urban legend that the barrel of a ballpoint pen can be used as a breathing tube.

A 2010 paper found that due to high resistance to airflow, most ballpoint pens are not adequate airways, and the two that were acceptable (the Baron retractable ballpoint and the BIC Soft Feel Jumbo) are unlikely to be on hand. An earlier paper also reported similar high airflow resistance with ballpoint pens.

A small study involving inexperienced junior doctors and medical students found that they were able to successfully perform cricothyrotomies in only 8 of 14 cadavers. Injuries to the thyroid and cricoid cartilages were common.

Remember these important points—cadavers don't need an airway in a hurry and they don't bleed.

Evidence of successful cricothyrotomy by bystanders is lacking. A 2010 review of American soldiers killed in Iraq between 2003 and 2006 noted that five of those who died appeared to have had attempts at cricothyrotomy, all of which failed.

I once was asked to see a patient whose "cricothyrotomy" done in an ED by an experienced emergency physician and a resident turned out to be a laryngotomy. The tube was inserted directly into the larynx.

To the uninitiated, surgery looks easy. Last year I blogged about Malcolm Gladwell's outrageous claim that just about any college graduate could become a cardiac surgeon.

I suppose one might say "What have you got to lose? The patient is dying. Try the cricothyrotomy." I can’t stop you. But be certain it is necessary, and realize your chances of success are extremely low.

If you’re considering it, at least look at some of the many instructional videos available online.

Warning: Graphic. There is some blood. Here’s one by an ED doc. In a non-hospital setting, you would not have all the help and equipment he had. Here’s another, this time by a surgeon—with lots of help and equipment. Both patients were relatively thin.

Now imagine doing it with a pocket knife and a ballpoint pen on an obese person. Still think it’s easy?

Medicare is changing the way it pays surgeons

Starting in 2017, Medicare will end global payments for operations. The current payment scheme combines preoperative, operative, and postoperative care into one fee. When the change occurs, each of those events will have to be billed separately—otherwise known as “unbundling.”

I missed this news when it first appeared late last year and thank one of my blog followers who calls himself Artiger for bringing it to my attention. An Advisory Board piece summarized the situation.

After analyzing a number of claims, Medicare came to the conclusion that it was paying for duplicate services. What a revelation! I could have told them that without a claims analysis.

For many years, certain surgical specialists have been delegating preoperative evaluations for “medical clearance” and postoperative management of everything but the incision to internists and hospitalists. Since the global fee was meant to include pre-and postop care, Medicare was indeed paying twice for the same service.

Representatives of the American College of Surgeons expressed concern that sicker patients would need more in-hospital postoperative visits thereby incurring more bills. [If they receive more care, maybe they should pay more.] They also worried that since postoperative care was covered under the global fee, patients might forgo office visits after surgery because of increased costs.

The unbundling of the global fee may have other unintended consequences. Since preoperative and postoperative care reimbursement will be separated from the fee for the operation itself, surgeons will be paid less for performing surgery.

Most surgeons would rather operate than make rounds and may look to perform more surgery to make up for the loss of income. This could end up costing Medicare more money.

With global payments, there is no incentive for a surgeon to keep a patient in the hospital longer than absolutely necessary. When the payment method changes, the exact opposite will exist. And surgeons who aren’t very busy might schedule more postoperative office visits to make up the difference caused by the reduction in the surgical fee.

This might all become moot anyway because Health and Human Services Secretary Sylvia Matthews Burwell has proposed that 30% of Medicare payments be converted to a non-fee-for-service model by the end of next year rising to 50% by the end of 2018.

According to a news@JAMA article, doctors may be given incentives to join Accountable Care Organizations. Quality indicators such as readmissions and infections currently applied to hospital fees might be imposed on doctors too. More bundled payments for acute care illnesses may be created. [This of course is the exact opposite of the plan to unbundle global surgery fees. I'm getting confused].

One thing I'm sure of is that none of this is making me regret that I retired.

Can Google Glass make you a better surgeon?

Advocates of Google Glass in surgery are apparently desperate to find some use for the device.

An article headlined "Google Glass makes doctors better surgeons, Stanford study shows" concluded that the study offered "compelling preliminary evidence that the head-mounted display can be used in a clinical setting to enhance situational awareness and patient safety."

Using an app capable of displaying vital signs on Google Glass in real time, 7 surgical residents recognized critical desaturation in simulated patients having procedures under conscious sedation 8.8 seconds faster than a control group of 7 residents relying on standard monitors. Glass-wearing residents also became aware of hypotension 10.5 seconds before the control group.

Not mentioned in the article but present in a linked abstract of the paper not yet submitted for peer review was this pearl—neither difference was statistically significant.

This evidence is not that convincing. Even if the difference had been statistically significant, it is surely not clinically important.

How seeing vital signs on Google Glass is better than relying on the simple alarms that are built in to every monitor is not clear. Either way, you must stop the operation and look up to see the vital signs.

In a brief video accompanying the article, a surgeon can be seen rather clumsily activating and resetting the app on his Google Glass. The time required to perform these maneuvers apparently was not discussed.

The article, probably written directly from a press release, took a comedic turn with this sentence, "One test demanded that the resident perform a bronchoscopy, in which the surgeon makes an incision in the patient’s throat to access a blocked airway." But bronchoscopy does not involve making an incision in the throat or anywhere else.

If you would like to hear a different side of the Google Glass story, check out this video review from GeekBeatTV entitled "Google Glass is the worst product of all time." You can forward to the 3:45 mark to get past the woes of wearing prescription glasses with Google Glass and hear about the poor battery life, the balky commands, the system crashes, and more.

Are sutures better than staples for closing skin for C-sections?

According to a recent randomized trial of 746 women having cesarean sections, closing skin incisions with staples resulted in a 10.6% incidence of wound complications, compared to 4.9% of the women closed with sutures. Put another way, suturing was associated with a 57% reduced risk of wound complications.

As usual, naive media, including The New York Times, accepted the study's findings without reservations. Also as usual, I did not.

Here's why.

Surgery in space: I foresee problems.

The astronauts are halfway to Mars when suddenly one of them develops abdominal pain and requires surgery. What will they do?

According to NASA, a miniature robot capable of assisting in surgery has been developed, tested in pigs, and is soon to be trialed in a weightless environment. The robot, which weighs less than 1 pound, can be inserted into the abdomen via the umbilicus and controlled remotely.

The press release from NASA said types of operations that the robot would be capable of performing were "emergency appendectomies, emergency cholecystectomies, emergency perforation of gastric ulcers [sic], and intra-abdominal bleeding due to trauma." NASA meant to say "repair of perforated gastric ulcers." Not surprisingly, many science reporters for media outlets, for example, SFGate and WiredUK, did not notice the error. New Scientist also missed it, but at least published a later correction.

However, even the famous da Vinci robot is incapable of performing surgery on its own.

The original idea was that a surgeon on the ground would direct the robot's movements, but that will not be possible for two reasons. In deep space, the time lag between the earthbound surgeon's actions and the robot's response would be too long, and a recent article about remote-controlled drone crashes highlighted the problems that can occur when links are lost or computers malfunction.

The plan is to train the astronauts to perform minimally invasive robotic surgery on each other. What could go wrong?

A lot.

Antibiotics instead of surgery for appendicitis? I'm still not convinced

Two recent papers have added more fuel to the debate about whether appendicitis can be managed without surgery.

The first paper is a prospective observational study from Italy involving 159 patients over the age of 14 who were thought to have uncomplicated appendicitis. Nonoperative management with oral antibiotics was planned for all of the patients.

Nonoperative management failed within 7 days in 19 (11.9%) patients, all of whom underwent immediate surgery. Appendicitis was found in 17 patients, and 2 had tubo-ovarian abscesses

The abstract says "After 2 years, the overall recurrence rate was 13.8% (22/159)." This is blatantly misleading. The overall recurrence rate was 19 recurrences within 7 days plus 22 more recurrences between 7 days and 2 years for a total of 41 (25.8%) recurrences with 27/159 (17%) of the patients requiring surgery.

If you look at this paper more carefully, you will find the following from Table 3:

Did a "botched" vasectomy cause a man to shoot his doctors?"

Last week, I blogged about a Forbes post criticizing surgeons for making too many errors. I pointed out that all complications are not caused by errors, and some complications cannot be prevented. My plea was that if one is going to criticize, at least one should get the facts straight.

The day after I posted that on Physician's Weekly, a man with a shotgun walked into a urology office in Reno, Nevada fatally shooting one doctor and critically wounded another before taking his own life.

Nearly every tweet and media headline about this incident stated that the shooter was upset about "botched" surgery that had been performed on him three years before.

Fox News: "Neighbors say Nevada gunman had botched vasectomy"

CBS News: "Neighbors: Hospital shooter in pain from botched vasectomy"

Huffington Post: "Botched vasectomy might have prompted shooting in Nevada urologist's office"

The Australian: "Gunman had botched vasectomy: Neighbors"

Even after I tried to correct people, they continued to tweet these headlines for a week.

USAToday reported that the shooter's friend said "complications from a vasectomy left the man so sick and weak that he could barely move" and that he "was dying from this."

The last paragraph of the story quoted a professor of urology from the University of California, San Francisco, who said that "many very large studies … show that a vasectomy is not a risk factor for any longer-term health problems, and that's very clear."

The American Urologic Association says that 1 to 2% of vasectomy patients may have chronic pain.

There is no evidence whatsoever that symptoms like being weak and sick were the result of a vasectomy, botched or not. Since chronic pain can occur after surgery that was done correctly, the use of the term "botched" in this case is inappropriate.

And only a couple of stories mentioned the fact that the shooter had a history of depression since the 1990s for which he had been taking Prozac on and off and had also been talked out of committing suicide well before before he had the vasectomy.

Not only are the headlines misleading, but they insult the competence of both of the unfortunate urologists who were victims of a senseless crime.

But I guess the article gets more clicks if "botched" surgery is involved.

As Mark Twain said, "Never let the truth get in the way of a good story."

Despite checklists, wrong-site surgery still occurs. Why?

Not long ago, two California hospitals were cited by the state for wrong site surgery.

At one hospital, a skin incision was made in the right groin of a patient who was to have had a left orchiectomy. Fortunately the error was discovered, and the skin was closed. The correct testicle was removed. To his credit, the surgeon told the patient and his wife what happened immediately after the operation.

An investigation found that the patient's groin had not been marked. The time out did not prevent the error because the OR team did not verify the operative site as the protocol mandates. In other words, they had gone through the motions.

The hospital was fined $75,000.

The other California case did not turn out as well. Instead of removing a cancerous left kidney, surgeons did a right nephrectomy. The error was not discovered until the pathology report was reviewed. A number of assumptions and misunderstandings contributed to this error for which the hospital was fined $100,000.

Are "safety scalpels" safer than standard scalpels?

A Twitter follower wrote me this: "hospital making me use 'safety scalpel' w/retractable sheath. I've almost cut myself x 2. Do you know of any data about it?"

That got me interested because I like to question things. Was this going to be yet another rule without evidence?

I thought I would have to do an exhaustive search to see if anyone had ever studied the question of whether so-called 'safety scalpels' really are safer than standard scalpels.

I was pleasantly surprised to find a 2013 paper in the Canadian Journal of Surgery which reviewed the literature on the subject. The authors, from the University of British Columbia, found no studies that addressed harm reduction and the use of safety scalpels. A previous paper from Australia in 2009 also found no randomized trials of safety scalpel use.

In their discussion, the authors point out that the introduction of safety scalpels might have the opposite effect on safety due to factors such as personnel not being familiar with how they work and that safety scalpels have never been subjected to rigorous evaluation by failure mode and effects analysis. And they noted that injuries related to the use of safety scalpels have been reported.

Since there is no proof that safety scalpels are effective in reducing injuries, there seems to be no rationale for regulatory agencies or hospitals to mandate their use.

The paper noted that at least 24 different safety scalpels have been developed and approved for use in the United States. An Internet search confirmed that there are at least that many types of safety scalpels on the market.

I attempted to find a specific mandate about scalpels in the Needlestick Safety and Prevention Act of 2001 but was unable to do so. If the act says anything about scalpels, perhaps someone could let me know.

Among the issues with safety scalpels are that surgeons complain that they do not have the correct feel, quality or precision of standard scalpels.

The use of devices that allow for safer removal and replacement of scalpel blades may be a better alternative than using safety scalpels.

In 2011, the magazine Outpatient Surgery and the International Sharps Injury Prevention Society surveyed 186 operating room clinicians and found that 60% of respondents were not using safety scalpels at their hospitals. OSHA is not fining many institutions since 95% of those who answered said they had never been fined.

Meanwhile, safety scalpel use is far less than expected. The use of safety scalpels appears to have been based on an unwarranted assumption that safety scalpels are safer.

It is certainly possible that safety scalpels do reduce the incidence of injuries, but it is equally possible that the rate of injuries in the same or even worse with the use of safety scalpels.

As a byproduct of their investigation, the authors mention that the use of hands free passing techniques for sharps, double-gloving and avoidance of using hands as retractors have been shown to be effective in reducing sharps-related injuries.

But not safety scalpels. So why are they being used at all?

Do more hospital resources equal better care?

For surgical patients, the answer is "Yes."

A recent study from England found that mortality rates for patients admitted with high-risk general surgery diagnoses were significantly lower in National Health Service Trust hospitals that used more CT scans and ultrasounds and had more ICU beds.

During the first decade of this century, nearly 368,000 patients were admitted as emergencies to English hospitals with surgical diagnoses carrying mortality rates in excess of 5%.

The diseases were bowel obstruction, liver/biliary conditions, hernias with obstruction or gangrene, peritonitis, gastrointestinal ulcers, perforated diverticulitis, bowel ischemia and miscellaneous diagnoses.

The 30-day risk-adjusted in-hospital mortality rate for the eight illnesses was 15.5% with a range of 9.2% in low-mortality hospital trusts (LMHTs) to 18.2% in high mortality hospital trusts (HMHTs). An operation was performed in 37.4% of patients, and 14.9% were readmitted within 28 days.

Three factors significantly differentiated LMHTs from HMHTs:

LMHTs had 20 ICU beds per 1000 beds vs. 14 for HMHTs, p = 0.017.

LMHTs performed 24.6 CT scans per bed per year vs. 17.2 for HMHTs, p < 0.001.

LMHTs performed 42.5 ultrasounds per bed per year vs. 30 for HMHTs, p < 0.001.

Some limitations of the study included the fact that it was based on administrative data. There was no way to determine if the increased use of imaging or availability of ICU beds had a direct effect on patients admitted with emergency surgical diagnoses. Also, variables such as delays in surgery or competence of surgeons could not be investigated.

Despite its limitations, this study is provocative.

No doubt the HMHT hospitals, which have fewer ICU beds and perform fewer imaging studies, are not as expensive.

But the study suggests that if you have the misfortune to arrive at an HMHT hospital with one of the surgical diagnoses listed above, you may have twice the chance of dying than if you had gone to an LMHT hospital that utilizes more resources.

This study is supported by a Viewpoint article in October's JAMA Surgery which looked at two studies of postoperative care in the UK and Europe. In both papers, many seriously ill postoperative patients did not receive appropriate levels of critical care. "Among patients who died during hospitalization after major surgical procedures in the United Kingdom in 2001, approximately 8.5% were admitted to an ICU at some point in their hospital stay. During the same period in the United States, this figure was 7 times greater, 61%."

In the European study, only 5% of surgery patients had planned admissions to intensive care, and 75% of those who died postop did not spend any time in an ICU.

The authors added, "in efforts to achieve good surgical outcomes, there really may be no free lunch: tradeoffs between cost and quality are inherent to the contemporary delivery of intraoperative and postoperative care."

What do you think?