Dr. Dev (Fictional Name) was a senior resident at AIIMS, New Delhi. While working as a senior resident he had gained some experience in doing the operation of laparoscopic cholecystectomy or the removal of the gallbladder containing stone by laparoscopic/endoscopic method. He thought of take his laparoscopic surgery experience to the next level and do a laparoscopic (lap in short) appendectomy or removal of the infected appendix for appendicitis.
For Nonmedicos: In the open method, the surgeon makes a direct cut (incision) in the abdomen skin and muscles, exposing the appendix and then removes it. In the laparoscopic method, after making small tiny incisions or holes, the surgeon introduces thin instruments including a telescope with a camera attached to it, view the internal organs on a monitor screen and perform the surgery while indirectly watching it on the screen. Due to the 2-dimensional view, difficulty in depth perception, the restricted motion of the instruments inside the closed abdominal cavity, lack of touch sensation, etc., laparoscopic surgery is generally difficult as compared to open surgery and requires a longer time to learning.
At that time laparoscopic method for appendix removal was new even in AIIMS and was not being done routinely. The open method was the preferred method and was done in the emergency usually by the junior residents under the supervision and guidance of the senior residents.
Dr. Dev started reading about how to do laparoscopic appendix operations from the various books available in the AIIMS library. Most of the books were in black and white with line diagrams, with few color photographs. This was the time when YouTube was not there to watch and learn from the various educational surgical videos available on the internet. So, Dr. Dev began mental visualization on how to do the operation.
As he had not even seen a laparoscopic appendectomy, Dr. Dev approached the consultant in his unit to please do and demonstrate the procedure. The consultant refused, saying, ‘Dev, open appendectomy is one of the few operations being done by the junior residents. If I start doing it by the laparoscopic method, they will not get to do it and their training and job satisfaction will suffer.’ ‘In addition, as the facility for laparoscopic surgery is not available in the emergency operation theatre, the operation will need to be done in the main operation theatre (OT), which will lead to cancellation of other routine planned operations.’
Many months passed with Dr. Dev waiting to do or at least assist in the operation of lap appendectomy. Meanwhile, Dev kept on reading and mentally practicing the steps of the operation.
Unexpectedly, a chain of events started. Dr. Dev’s consultant had to suddenly go outstation for some personal work just a day before the routine operation day. The operations planned to be done by him had to be canceled. A female patient suffering from acute appendicitis got admitted late in the night in the emergency ward in their unit. By the time her ultrasonography and other blood test reports came, it was around 4.00 am in the morning. Doing an operation then would mean the surgical team will be free by 5.30 am and they will not get any rest at all as they would have to start working for the morning rounds at 5.30 am. Dr. Dev decided to defer the operation for a few hours and do it in the main operation theatre and added her name to the OT list which was having space as few cases had been canceled.
Just before the operations were to start, Dr. Dev explained the situation to Dr. Anurag Srivastava, then Associate Professor and unit head, presently Head of Department of Surgery, in AIIMS, New Delhi. He expressed his desire to do a diagnostic laparoscopy and then proceed with laparoscopic appendectomy if the patient was found to be suffering from appendicitis. Dr. Anurag readily agreed as it was the internationally recommended guideline in female patients of this age group and will be beneficial for the patient.
For Nonmedicos: In diagnostic laparoscopy, the surgeon makes small holes/cuts, insert the telescope and inspect the abdominal organs to detect/diagnose any disease. The diagnosis of appendicitis may be wrong in 15 to 30% of patients especially in females of child bearing age groups as many diseases of uterus and ovary may mimic appendicitis in their signs and symptoms. If on inspection the appendix is found to be normal, then it may not be removed in the laparoscopic method.
After taking informed consent from the patient and her relatives, Dr. Dev announced in the OT that they will be doing the case by laparoscopic method. Lots of sound of dismay was heard in the OT. The junior resident got dismayed that he will not be getting the opportunity to do the open appendix operation, the anesthetist and the nursing assistant got dismayed that they will not be free early today, even when the cases were initially canceled in the OT as for a novice doing appendectomy by the laparoscopic method will take 3-4 times the normal 20 – 30 minutes taken in open method. All of them started saying, ‘Why do you want to do it by the laparoscopic method? Please do the operation by the conventional open method.’
Dr. Dev placated the junior resident by saying, ‘Look I have not done or even seen a laparoscopic appendix operation in my life. What makes you think I will be able to do it in the first attempt? We will do the diagnostic lap, make a show of attempt to remove the appendix and then quickly convert the procedure to open one and only you will do the open appendix operation.’ The junior resident got pacified and started getting the case ready for operation.
Dr. Dev told the anesthetist, ‘I am convinced that the patient is not suffering from acute appendicitis. We will do a diagnostic lap, see the appendix and when confirmed to be normal we will just come out without doing any operation, taking very minimal time and save the patient an unnecessary operation.’ The anesthesia team got satisfied and started the process of anesthetizing the patient.
With a stern look, Dr. Dev told the nursing staff, ‘Sister, you are posted till 3.30 pm in the OT and it just 10.00 am. Please, just do your jobs without dictating what should be done to the surgeon.’ The nursing staff started arranging the various instruments and drapes for the operation.
The operation started. On inspection of the appendix, it was found to be infected and slowly Dr. Dev proceeded with the operation and successfully completed the operation of laparoscopic appendectomy. Once the procedure started Dr. Dev turned a deaf year to the misgivings from the junior residents and the anesthetist that you had promised a quick diagnostic lap but now you are doing the full laparoscopic procedure.
Whew! Finally over! It is longer than most of my posts but there are multiple points involved which were not apparent to even Dr. Dev at that time.
Tip: Sometimes you have to proceed to the next level without waiting for complete mastery of the present level, as this may come very late or may not be practically achievable. If Dr. Dev would have waited to completely master the basic procedure of laparoscopic operation of gallbladder before attempting the appendix operation, his tenure as a senior resident would have over before doing the laparoscopic appendix operation.
Tip: Keep on preparing, training yourself for the next level, the next difficult task, greater responsibilities, even if there does not appear to be any hope of you doing it, as opportunity may come unexpectedly without giving you any preparation time. Imagine, Dr. Dev, going to the library, reading the method to do the laparoscopic operation after Dr. Anurag gave the go-ahead to proceed with it while the patient and the operation team is waiting in the operation theater.
Tip: During the waiting period, keep your hope high and do not get depressed as a suitable opportunity may not present itself even for months and sometimes years.
Tip: Even a complex thing like laparoscopic surgery may be learned by self- study and creative mental visualization. Do not under-estimate the power of self-study and do not get dependant on direct mentorship.
Tip: Skills learned in different things may be combined to achieve new results. Dr. Dev combined the skills of laparoscopic surgery while doing gallbladder surgery with the knowledge of appendix operation by the open method to do the laparoscopic appendectomy.
Tip: Even if it is for the betterment, there may be resistance from the people around you when doing something different or new. Everyone has their own agenda. Learn to deal with them. Do not expect cooperation from everyone for achieving your own goals.
Tip: Different people may need to be dealt in different manner/approach, eg. the junior resident, the anesthetist, and the nursing staff.
Tip: The support of your boss/unit head/supervisor/chief is very important. Just the support from the top may be enough to give you the strength to overcome the resistance of those around you. The lap appendix operation could only be done because the unit head, Dr. Anurag Srivastava supported Dr. Dev.
(Based on an allegedly true incident)
— ND
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DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost.
DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use the information herein is at your one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Education should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost and according to MCI and other Board’s norms.
