Deep Surgery
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In the early days of my career, appendicitis was considered a true surgical emergency. If someone was diagnosed with appendicitis, the surgeon would call and let the staff know that this case would take priority. The staff for the next case to finish would be diverted so that he could remove the offending organ.
Then, about 20 years ago, I was working with a (very good) surgeon who did his colo-rectal fellowship in Cambridge, England. He told the story of how he was called to A&E (the ER) at no-o'clock for what was suspected to be acute appendicitis. He confirmed the diagnosis, and called the OR to get the case done ASAP.
He was shocked when the OR nurse told him, "OK, Dr. Smith. We will get you going on your appendicectomy at 7:30 this morning."
"But, but...that's 6 hours from now!"
"Yes, I'm aware of the time. It can wait."
And it did.
So, over the next 10 years, it became less and less common to treat appendicitis as a true surgical emergency. It became "urgent," not "emergent." By the time I retired, most (not all) cases of acute appendicitis would be admitted, given antibiotics, and wait until staff/surgeon/time became available. We would just shoehorn it into our schedule.
A blog that I follow had a long discussion about whether surgery is even required in acute appendicitis. Some studies showed that conservative therapy with antibiotics resulted in a favorable outcome with no need for surgery. However, a significant percentage of these cases eventually did need to come to the OR at a later time.
I haven't followed this since I retired.
Perhaps @bachophile has some more current information?
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Something that caught my ear in the video...These Pharmacists Mates were not completely foreign to the OR. Apparently, they must have had a rotation during their training, especially if they had been in the Navy for awhile.
Brings up a question...For a nurse or a scrub tech who had observed or assisted in several appendectomies, what would be the confidence level of them being able to perform the surgery without screwing up?
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first of all now almost every right lower quadrant pain gets a CT. In my younger days the diagnosis was only based on physical exam and you were expected to have an 85% success rate in diagnosing. If you were getting 95% correct diagnosis, that meant your were not operating enough appys and you were missing some. If you were right 70% of the time, you were operating too many and you were too hot on the trigger to operate. 85% was the sweet spot.
Now CT’s give about 95-97% sensitivity for diagnosing appys and also see easily which ones are the bad ones, perforations, pus in the abdomen etc, and which ones are mild, can wait, and maybe easily treated with antibiotics.
So in the end our current treatment strategies and the change over the years is due for the most part because of much more accurate diagnosis by imaging.
The downside? Residents have lost the skill to accurately diagnosis an acute abdomen with their fingertips. And that’s a real shame, because in the end, the art of physical diagnosis is still what makes a physician a learned skill and not a technical one.
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To jolly’s question, today almost all appendectomies are done laparoscopically which is a different skill set than an open operation. I’m still of the age where the majority of appys I’ve done were open, but today residents have no clue how to do an open appy.
Lap appys are not something you can learn simply observing. It takes a considerable learning curve of doing them actively to get the confidence to get through an operation. Lap skills are not intuitive. They must be practiced. Today there are simulators to help train residents learn lap skills
And in the future it will shift to robotics. That’s the next generation of training.
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first of all now almost every right lower quadrant pain gets a CT. In my younger days the diagnosis was only based on physical exam and you were expected to have an 85% success rate in diagnosing. If you were getting 95% correct diagnosis, that meant your were not operating enough appys and you were missing some. If you were right 70% of the time, you were operating too many and you were too hot on the trigger to operate. 85% was the sweet spot.
Now CT’s give about 95-97% sensitivity for diagnosing appys and also see easily which ones are the bad ones, perforations, pus in the abdomen etc, and which ones are mild, can wait, and maybe easily treated with antibiotics.
So in the end our current treatment strategies and the change over the years is due for the most part because of much more accurate diagnosis by imaging.
The downside? Residents have lost the skill to accurately diagnosis an acute abdomen with their fingertips. And that’s a real shame, because in the end, the art of physical diagnosis is still what makes a physician a learned skill and not a technical one.
@bachophile said in Deep Surgery:
Residents have lost the skill to accurately diagnosis an acute abdomen with their fingertips
That extends to my experience. At the time I was retiring, there was a huge shift to imaging for just about everything: arterial lines, all kinds of nerve blocks, and internal jugular sticks.
In the thousand or so internal jugular sticks I've done I never had the availability of ultrasound for placing the needle. It was done by instinct, feel, and experience. I was about 90 - 95% successful in getting it in - blind.
Today, it's probably a breach of the standard of care to not use ultrasound when placing an IJ line.
And, to expand on @bachophile's point about laparoscopic (and robotic) surgery - there's something about the "feel" of a tissue when you're using the instrument directly. A hand-held needle driver will give you a feel that you can't get from a laparoscopic or robotic instrument. There's probably something lost in that. With epidurals, the "feel" of your Touhy needle going through all the tissue planes is something unique. THere's a push, or at least research being done, for using ultrasound for placing epidurals. DOn't know if that's a good thing or not.
