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Something interesting I learnt in the operating room…all heart surgery is a risk.

Authors: Alifa Sabir; Resident Cardiac Surgery; Rawalpindi Institute of Cardiology; Rawalpindi; Pakistan. @alifa_sabir;

The operating theatre is a world of controlled chaos, where surgeons, anaesthetists and other team members navigate through the intricacies of human anatomy to alleviate misery and save lives. Despite meticulous planning and preparation, the unpredictability of surgery often throws unexpected challenges that require quick decision making, adaptability, and teamwork. While surgeons strive for successful outcomes in every procedure, the reality is that complications and failures can occur despite their best efforts. Dealing with failure on the operating table is an arduous challenge that requires resilience, introspection, and a commitment to growth. This is something I learned during the initial few months of my training as a cardio thoracic surgeon.

I got to scrub in a case of a young lad with a large anterior mediastinal mass, compressing heart, great vessels and trachea. The operation required meticulous planning, collaboration among various specialists, and the use of cutting-edge techniques. We planned to go in through a mini right anterior thoracotomy to get a biopsy of the mass, as it was suspected to be either a lymphoma or a tuberculous mass which may respond to chemotherapy without further need for surgery. Endotracheal intubation posed a challenge for the anesthetists as the patient started developing stridor as soon as he was put on operation table in supine position. But our experienced anesthetists succeeded in rapid, successful intubation.

As soon as the first incision was given, we noticed a massive gush of blood, leaving everyone spellbound except the very experienced operating surgeon, who with his complete equanimity and unmatched expertise, uttered: “SVC syndrome”(superior vena cava syndrome). The tumour had compressed the superior vena cava of the patient leading to increased blood flow in collateral blood vessels leading to massive bleeding on even skin incision. However, it was tackled, the tumour accessed and a biopsy taken. The patient was shifted to ICU and put on a ventilator. But the ventilator showed very high peak airway pressures showing severe obstruction of the airway tract by the tumour due to relaxation of tracheal muscles during intubation. He was started on manual ambulatory support but this also failed to oxygenate the patient.

The patient had to be rushed back to the OT for emergency debulking surgery. The attending surgeon remained calm under this high stakes situation, drawing upon his extensive training and experience to navigate through the intricacies of the procedure.

Femoral arterial and venous access was taken and the patient put on cardiopulmonary bypass as a bail out. A Median sternotomy was done and a large mass compressing heart, great vessels and trachea was seen. Debulking of the tumour started. A large portion of the tumour was removed from the surface of the heart and trachea. But the prolonged compression of the heart resulted in left ventricular dysfunction. Furthermore, the tumour had invaded the major vessels of the heart, which were then reconstructed using a tube graft. Now came the tricky part; haemostasis of a very vascular tumour bed after prolonged cardiopulmonary bypass. Despite the utmost efforts of anaesthetists, perfusionists and cardiothoracic surgeon, we failed to correct the coagulopathy associated with prolonged pump time, and there remained bleeding from raw tumour bed. The decision was made to pack the chest cavity as damage control and do re-look surgery after stabilization. However, despite the team’s expertise, dedication and commitment, the patient succumed to death on the operating table. This was a very challenging case trying us all to our maximum capacity. But as Steve Westaby said, ” All heart surgery is a risk. Those of us who make it as surgeons don’t look back. We move on to the next patient, always expecting the outcome to be better, never doubting it”

This incident taught me that no matter how well-prepared the surgical team may be, complications can arise during any procedure. Unexpected bleeding, adverse reactions to anaesthesia, or unforeseen anatomical abnormalities can present challenges that require rapid decision making, strong nerves and a dedicated team. However, there are instances when despite the collective efforts of the surgical team, a patient may succumb to their condition during the surgical procedure, leaving healthcare providers grappling with feelings of grief, guilt and self-doubt.

Stephen Westaby wrote in the opening sentence of his memoir, “The finest of margins separates life from death, triumph from defeat, hope from despair – a few more dead muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. The Grim Reaper perches on every surgeon’s shoulder and death is always definitive. There are no second chances”.

It is important to realize in these situations that mortality is an inherent part of our experience as doctors. It can help us cope with the loss and find solace in knowing we did everything within our power to save the patient.


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