The Best Surgeries are the Ones We Avoid

To do or not to do, that must be the question

A lot of the work that happens on this newsletter every week is focused on the act of doing. What will we do so that disease can be removed? What can we do to restore anatomy? and so on. And important as it might be to know what to do, it’s sometimes important to also know what not to do.

Some procedures look like a cure but the moment you begin to consider their cost; they no longer look like a good option. Cost not just in terms of money but in risk, post-op recovery, and quality of life.

As surgeons, we are often so excited at the prospect of a complicated surgery, that we forget to empathise with the patient’s need of not wanting to ever see us in the first place.

At Mayflower, we believe in performing endometriosis surgeries to not only nullify disease involvement but with the bigger goal of giving the patient a better life.

Take this case for instance. The image displays an endometriosis nodule on the rectum that’s invading the serosal and subserosal layers. We needed to take a call on what procedure would be best for this patient.

It’s important to remember that the overarching target of all of our surgeries is anatomical restoration. Endometriosis significantly alters anatomy of a pelvis, and our surgical plan is always focused on restoring the same.

Note: You can watch the video of this case on our YouTube channel.

In cases of colonic involvement of endometriosis, three levels of involvement dictate three different procedures that we can carry out. The level of involvement is determined by a combination of two factors. The first being depth of infiltration, and the second being frequency of occurrence in the vicinity of a certain nodule. 

• In cases where the mucosal layer isn’t involved, rectal shaving is indicated

• In cases where the mucosa is involved, an anterior discoid resection is applied.

• However in cases where more than one nodule occur or covering more than 30% of the colonic circumference, leading to what we call an hourglass stricture, resection anastomosis is the procedure of choice.

But it should be clear from these definitions that the lines between these procedures are blurred. Especially between rectal shaving and discoid where one surgeon might be more radicle and choose discoid stating recurrence avoidance as a reason, while the other might categorise it as a client for shaving only.

At Mayflower, we’ve always taken a conservative but total approach to surgery. The closer we bring the anatomy to what previously existed, the better the surgical outcome. Hence we lean towards rectal shaving as opposed to discoid.

Of course, the procedure has a difficult curve, especially when the nodule is only slightly shy of the mucosa, but the outcomes are exceptional. One of the biggest advantages is  NO - LARS (Lower Anterior Resection Syndrome)

LAR Syndrome is likely multifactorial. Many potential pathophysiologic mechanisms for LAR syndrome have been proposed which are

1. Internal anal sphincter dysfunction

2. Decrease in anal canal sensation

3. Disappearance of recto-anal inhibitory reflex

4. Reduction in recto reservoir capacity and compliance

We also observe a constant improvement in:

1. Pain

2. Gastrointestinal scores 

3. Quality of life 

4. And infertility 

These benefits on one hand far outweigh the cost of having to learn how to perform the procedure right. In exchange, we get some excellent outcomes.

We could however, like any normal human being, be wrong in surgery when making one call vs the other. Being prepared for being wrong and being candid about the possibility is I think a great sign of surgical maturity. Since we are in the grey zone between discoid and shaving, we stay prepared for both. Another reason is also because with shaving we always run a risk of opening the mucosal layer which will then necessitate discoid. So we plan in advance, and plan two steps ahead. 

The technique of shaving begins with firmly grasping the nodule and lifting it. Staying flush to the nodule, the harmonic scalpel is used to dissect off the nodule over the mucosal layer. At every step of the way, the nodularity is first felt with the harmonic, and only then is it activated so we only shave off what it needed.

Once done, we confirm the total removal of the tissue and then proceed towards suturing. Here, we prefer using a Vicryl 3-0 suture taken in a continuous non locking fashion. There is a key aspect, one must remember while suturing over the bowel. take big bites, in order to prevent tearing of the tissue.

Remember to be very gentle with the bowel at all times. 

Once all the stitches are taken we revisit each of them, and pull. But don’t stretch too much. We only need to gather a good approximation. Once done, at the end a loop is made and the angle is secured.

It’s important to not be in a hurry with this step because the finish line is so close.

Always check your stitch-line again and if needed take a couple of reinforcement stitches if that feels right.

Once done, colonic integrity is checked with an air insufflation test and an exit is made.

At mayflower, we frequently deal with cases that are easy to categorise as discoid, but the choice to perform shaving wherever possible, stems from the core philosophy, “cut follows cause”

Every dissection we make, every vessel we ligate, the smallest change in route of surgery that we make, must always address the larger cause at hand, the cause of giving our patient a better life. Cuts made with shortsightedness are easy to justify at the moment, but they almost never stand the test of time. 

You can read more about rectal shaving, discoid, and anastomosis procedures in our edition on the Rule of M which goes into great detail about the procedure.

But for today, remember that often the question to ask is not whether a patient is the right candidate for a procedure, but if the doctor is.

Before we sign off for this week, with much excitement we would like to announce the 14th batch of CSEEMIG

You can register for the program by clicking here

And if you do, we will see you at Mayflower, in May <3

See you next week!