Reoperative surgery requires an entirely different approach from any other kind of surgical care. The implication that the first or prior effort had failed or that the disease recurred is the essence of the problem and creates another sequence of pain, anxiety, and recovery that must be directly addressed. There are always multiple parties with an interest in the reasons for failure, the prospects of lasting recovery, and other therapeutic options. When the surgeon proposing reoperation differs from the earlier operator, there will always be the wish that younger/older, wiser or more or less aggressive, better facilities, or other aspects of the change of characters on the surgical team will lead to a better outcome. When any surgeon faces reoperation on his own patient, the psychological milieu is different in that there should always be a sense of fault or constructive self-blame, even when no error has been made:
- Could I have used different techniques?
- Better timing?
- More overall support, such as nutrition or anesthetics?
- Different antibiotics and shorter or longer use?
- An endless list of questions about materials, strategies, and devices:
- Minimal versus maximal access?
- Absorbable or nonabsorbable sutures?
- Staged operations as opposed to a single coup?
- Alimentary diversion or not?
- More or less utilization of image-dependent adjunctive therapy?
- Had I done something differently, would the outcome have been better?
Before proceeding, I rightly should recognize some specific efforts of now senior and respected protégés in keeping me focused upon the goals of surgical education; the patient is best served by the curative and innovative surgeon who is also totally honest! Gaar, Mitchell, Fry, Bland, Edwards, Evers, Voyles, and McMasters: these former residents’ books and articles on reoperation and surgical infection have hugely influenced this 2013 version of Reoperative Surgery.
Given a reoperation by the same surgeon, a conscious initial assessment, including formal or informal consultation with colleagues, must be made and plans for alternate strategies and techniques set forth with the patient and immediate family. What will lead to a more satisfactory outcome this time? In all cases, the approach to the operation should be undertaken with specific but often different goals, assured that preoperative total patient preparation and optimum imaging will have been done. The most certain predictor of failure is ‘let's see what we find and go from there.’
Again assuming the same surgeon or team is going to do the reoperative procedure, expectations must be finite and carefully laid out for the patient and family. Although preoperative consultation is given, intraoperative consultation may be even more important; a peer in the field should always be available – even if by telephone – to discuss unanticipated discoveries or diseases.
It is a psychologically easier scenario when reoperation is undertaken by a different surgeon; it is never too early to remind the reader–surgeon that many professional liability lawsuits are spawned by overt or even subtle inferences that the first operation was less than ideally done. A personal conversation between the two surgeons is not always done but is most desirable.
Senior surgeons always savor judgment and wisdom, and younger ones are fascinated by new technologies and devices. In the last decade's obsession with quality and outcomes (has it not always been so?), a study of major abdominal operations done by fully trained surgeons in a Midwestern state showed that among sequenced age groups of surgeons, only recent (<5 years of experience) graduate surgeons had a higher than expected operative mortality rate (Billeter et al. 2012, Galandiuk et al. 2004, Prystowsky et al. 2002). Regardless of the situation, two heads are often better than one! In that same vein, the surgeon's evening preceding a reoperation should dwell on details of the case ahead: think and rethink! Reoperative surgery is seldom pretty and virtually never easy.
A good example for many of these principles is the re-repair of ventral or incisional hernia; increasingly, it is agreed that nearly half such operations fail and fail again. This scenario is familiar to all general surgeons. Often in North America the predisposing cause is overt abdominal obesity. Pleas for weight reduction are seldom heeded, but the optimistic second surgeon is easily seduced. When the hernia is very large or ‘massive,’ pneumoperitoneum preoperatively in the doctor's office is an advantageous maneuver, virtually always overlooked and historically ignored. If the patient is obese, excision of the omentum as a battering ram to a new repair as well as the previous one is useful and regularly forgotten. Tension is the producer of failure and one of the advantages of component release as a technique is its de facto requirement for wide dissection (Kanaan et al. 2011). Although the sundry, innumerable meshes, or combinations thereof are regularly placed by their seriously conflicted surgeon advocates, combinations of the technically demanding component release bridged with permanent mesh are increasingly the fashion among the most experienced abdominal surgeons. Again communication failure sets the stage for disappointment; ‘do not lift anything over 4 kg (10 lbs) until the 100th days after operation’ is the most important pre- and postoperative admonition, to be repeated at every follow-up visit!
If there is any nontechnical common thread to the requirement for reoperation, it is the failure to understand and, to the extent possible, eliminate predisposing causes. Here, an alimentary fistula is a highly representative case. While the litany is known to all, distal obstruction and foreign bodies, such as mesh, and cancer lead the list. All the prescribed medications in the world will not close a fistula due to any of the unholy trinity – all of which must be systematically corrected or eliminated at reoperation.2
Safety issues apply to all operations, but reoperation is the ideal scenario in which to practice the surgical time-out (Altpeter et al. 2007). Preoperative description of the plan and goals should be followed by the postoperative ‘huddle’ – what did we achieve and what are the necessary adjuncts to postoperative care? Drains and other devices must be appreciated for what they are: early for blood, late for intestinal discharge, and removal accordingly but always with the consent of the senior surgeon.
The postoperative report to the family and the next day to the patient must emphasize essential aspects of the reoperation:
- We found no cancerOrWe found some recurrent cancer, removed it, and believe we can slow the progress of the disease to some degree with further therapy
- We found a blockage and were able to remove itOrBypass it, which often works as well
- We found a tack or suture of the mesh underneath and corrected itOrWe removed all of the mesh and used your own tissue for repair
Surgeon, patient, team, family need to enter the reoperative arena with understanding, trust, and tempered optimism. Finally, if at all possible, reoperation should be undertaken as the first case of an uncrowded day. So be it.
REFERENCES
- Altpeter T, Luckhardt K, Lewis JN, et al. Expanded surgical time out: a key to real-time data collection and quality improvement. J Am Coll Surg 2007; 204: 527–532. PubMed PMID: 17382210.
- Billeter AT, Polk HC Jr, Hohmann SF, et al. Mortality after elective colon resection: the search for outcomes that define quality in surgical practice. J Am Coll Surg 2012; 214: 436–443; discussion 443–444. PubMed PMID: 22397975.
- Galandiuk S, Rao MK, Heine MF, Scherm MJ, Polk HC. Mutual reporting of process and outcomes enhances quality outcomes for colon and rectal resections. Surgery 2004; 136: 833–841. PubMed PMID: 15467669.
- Kanaan Z, Hicks N, Weller C, et al. Abdominal wall component release is a sensible choice for patients requiring complicated closure of abdominal defects. Langenbecks Arch Surg 2011; 396: 1263–1270. PubMed PMID: 21870175.
- Prystowsky JB, Bordage G, Feinglass JM. Patients outcomes for segmental colon resection according to surgeon's training, certification, and experience. Surgery 2002; 132: 663–670.
FURTHER READING
- Bland KI, Sarr RG, eds. The practice of general surgery. PA: WB Saunders, Philadelphia 2002.
- Edwards MJ, Heniford BT, Klar EA, Doak KW, Miller FN. Pentoxifylline inhibits interleukin-2 induced toxicity in C57BL/6 mice but preserves antitumor efficacy. J Clin Invest 1992; 90: 637–641.
- Evers BM, Cryer HM, Miller FB. Pelvic fracture hemorrhage. Priorities in management. Arch Surg 1989; 124: 422–424. PubMed PMID: 2930351.
- Fry DE, ed. Reoperative surgery of the abdomen. Marcel Dekker, New York: 1986.
- Gaar EE, ed. E-General Surgery Review [Kindle version]. Louisville, KY: Earl Gaar, 2102. Available from: http://www.amazon.com/General-Surgery-Review-Earl-Gaar-ebook/dp/B00B6FH4VG (accessed 31 Mar 2014).
- Garrison RN. The Association for Academic Surgery: what a concept! J Surg Res 1992; 52: 287–292. PubMed PMID: 1593865.
- McMasters KM, Vauthey JN, eds. Hepatocellular carcinoma: targeted therapy and multidisciplinary care. Springer, New York: 2011.
- Townsend C, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston textbook of surgery, 19th edn. Saunders, New York: 2012.
- Voyles CR, Petro AB, Meena AL, Haick AJ, Koury AM. A practical approach to laparoscopic cholecystectomy. Am J Surg 1991; 161: 365–370. PubMed PMID: 1825759.
- Voyles CR, Richardson JD, Bland KI, et al. Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 1981; 194: 219–223. PubMed PMID: 6455099; PubMed Central PMCID: PMC1345243.