Take What’s Given to You

I attended the WNY vascular surgery symposium this weekend, and something Dr. Bower, chair of vascular surgery at Mayo Clinic said really resonated with me. He told the young surgeons and trainees in the audience to “take what’s given to you”.

Let me give this a little more context. Dr. Bower was talking about the slick open IVC reconstruction that they perform for primary and secondary thrombosis of IVC, and he was saying that one really has to look hard at feeding branches of these big vessels and control them as much as possible to prevent hemorrhage. I believe this notion can be applied to all surgeries, and to life. Not everyone is made the same way, just look at the variants of the aortic arch. Therefore, if life hands you a lemon, or take one away from you, you should be able to take advantage of the situation and change on the fly.

Image result for ivc reconstruction

Us medical students spend years learning about basic and clinical science. We learn about pathognomonic findings and evidence based guidelines. These information serve to steer us to the right clinical decision. To be able to adapt, however, we need to master these basic knowledge, go through rigorous training, and collect immense amount of experience. Eventually, when life hands you a lemon (you expose the IVC and find aberrant renal vein), you slice it and put it in a Corona (vessel loop, ligate, re-implant, etc).

Don’t blindly stick to any “rules”. Rules are there to guide you, but not define you. Be able to adapt to the situation, and do what’s best in each individual situation. Take what’s given to you, and milk the heck out of it.

Infra-popliteal bypass – longest case by far

Below is a short and sweet version of the longest surgical case thus far in my short and sweet medical career:

Patient is a 47 years old Caucasian male with IDDM, past stroke, past DVT, PVD, and HTN. He has a dry gangrenous ulcer in the plantar aspect of his right first metatarsal, and occlusion of anterior tibial artery. He is scheduled to undergo femoral to peroneal artery bypass with great saphenous vein.

Image result for popliteal to peroneal bypass

Common femoral artery cut down was performed first for pre-op angiogram; this was partially due to the uncertainty of where exactly the occlusion is and patient’s vascular anatomy. We saw completely occlusion of the anterior tibial artery and distal portion of the posterior tibial artery after the takeoff of peroneal artery. The popliteal artery and peroneal artery were patent. Next, the deep compartment of the mid calf was dissected from the medial leg to skeletonize the peroneal artery. We also skeletonized the popliteal artery because we decided convert the procedure to popliteal to peroneal bypass. Afterwards, we proceeded to looko for the GSV in the medial malleolus, but the vein was too small (lower threshold is 3mm in diameter, but ours was much less). Therefore, we retrieved the GSV from up to, following the sephaneous-femoral-junction. Finally, we heparinized, dilated and anastomosed the venous conduit. Due to the difficult, delicate dissection of the deep compartment of the leg, difficulty exposing the GSV, the changing of procedural planning intra-op, and not having the imaging study pre-op made the whole case around 10 hours. Luckily, the goal of re-perfusing the foot as accomplished, with biphasic pulse on doppler post-op.

The take away from this case is for me is the importance of being prepared before diving in. The fascinating part about vascular surgery for me is the options of choosing your strategies for the battle – like a tactician – may it be open, endovascular, medical, or expectant management. The choices branch out further with each category of treatment. However, in this case since we didn’t have a strong plan going in, we were not able to change our plan smoothly on the fly. The result? 10 hours of anesthesia for patient instead of 6. On a good note, there were lots of dissections and anatomy structures that I learned, rather serendipitously I would say though…

Finally, I learned the luxury of having a stool in a marathon case.