In the past four weeks in my surgery clerkship, I’ve seen several different surgeons operate in their distinct own styles. They’ve ranged from the calm and meticulous vascular surgeon to the loud profane but courteous trauma surgeon to the high-velocity efficient bariatric surgeon. Each was effective in their own methods and I admired them all. However, on Tuesday, I watched Dr. Saldinger, the Chairman of Surgery at NYP Queens, perform two masterful operations, and his surgical style was awe-inspiring. Exacting, precise, and particular. He trained in Basel, Switzerland before coming here, and he is stereotypically Swiss in the best possible way. Watching him operate was the first time I felt like I truly witnessed that mythical surgical precision.
Saldinger said this while opening: “there is no reason to work in suboptimal conditions.” That statement stuck with me. He was performing extremely elaborate surgeries: a distal gastrectomy and a hepatojejunostomy, but they seemed effortlessly reduced down to the fundamental components of any operation, big or small: setting up, retracting, dissecting, and suturing. Each fundamental was so carefully calculated. Every time he retracted, the tissue looked so plainly and cleanly presented. Not once did he trip over an excessive piece of equipment. Even footwork came into play as he rotated his torso to adjust his angle of attack or widened his stance to lower himself. Each step looked so obviously elementary: retract, dissect, anchor, dissect some more, suture. Yet, before long, he had opened the abdominal cavity, mobilized the stomach, detached the pylorus from the duodenum and antrum from the stomach, anastomosed (connected) it to the jejunum, and closed the incision. What.
Well, maybe was the difference between watching him operate and observing other surgeons was that Saldinger cared to point out details. He was teaching a chief resident (an excellent surgeon already), but Saldinger helped refine his technique by commenting on the tiniest details and the rationale for each detail. Well, some say he nitpicks, but I think it was a rare opportunity for us both. The qualities that make a good surgeon — an ability to unconsciously develop movements, confidence in improvisation, a just-do-it bravado — don’t contribute to planning effective presentations. Yes, they dictate vital instructions, but junior surgeons must learn by semi-conscious imitation because senior surgeons often don’t (or can’t?) explain precisely what they’re doing. Thus, during those few hours of watching Dr. Saldinger work, I learned so much about how to operate effectively.
My favorite aspect was his confident utilization of the system for passing instruments. The scrub tech and the instrument table were an organic extension of Saldinger’s hand. Their coordination enabled automatic, reliable, and expedient interchangeability between implements, and it was a marvel to watch. He held out his hand and said “yup” and the scrub tech slapped the next instrument into his palm. Somehow, it was always the right instrument, in the correct orientation, and in the correct position so that Saldinger could slip in his fourth finger without regripping. Obviously the scrub tech paid close attention to predict the next steps. Saldinger dictated in advance when steps were changing. (I got to play along when we were rapid-fire suturing an anastomosis). Just as importantly, Saldinger assumed that the neutral zone, a magnetic mat under the right arm, was always clear, so he could blindly drop used instruments there. He also assumed that there was a clean pad of gauze placed just off the field for cleaning (both required covert replacing by the scrub tech while Saldinger worked in the field). The result was that Saldinger almost never had to take his eyes off the field, an incalculable advantage over surgeons who habitually look around for their own instruments.
I wonder if a surgeon’s preferred operating instrument personifies the surgeon himself. Other surgeons I’ve met have favored instruments ranging from tiny Stevens scissors, or spring-loaded pickups, monster Kelly clamps, or 45-degree 10mm laparoscopes. On the other hand, Saldinger’s tray features one distinctive custom dissector that I’ve never seen before. It resembles a medium length right angle instrument, but past the joint it abruptly narrows and tapers down to an extremely fine point that’s bent at 60 degrees. I asked the scrub tech what it was. “It has an official name on the sheet, but none of us know what it is. Dr. Saldinger just calls it the ‘weirdo.’”
(Anyway, what follows are some notes I took, and they’re necessarily horrendously technical. Sorry!)
SETUP: When setting up the surgical field, Saldinger only relied on one good overhead light that was easily reachable and rarely obscured. He measured out the length of the bovie (electrocautery) and suction cables beforehand to minimize tangling later. He systematically draped the inferior, superior, and then lateral sides to avoid disordered creasing that might catch instruments later. The OR personnel knew that all communication had to be of appropriate volume to avoid confusion and all arrivals and departures had to be announced to avoid unexpected distraction or commotion.
RETRACTING: He said “your left hand makes your right hand good.” When retracting, he pulled back with his shoulder then to the side with his index and pinky fingers to apply even tension in all directions. When advancing the instrument into windows, he lowered his hand upon insertion to avoid puncturing deep structures. When tenting tissue, he lifted the instrument to apply tension near joint; he explicitly avoided prying, which would apply tension unevenly to the tip.
ELECTROCAUTERY DISSECTION: Aside from the initial skin incision, virtually all dissection was performed with the bovie. He held it perpendicular to the tissue plane to dissect straight down, sweeping quickly to avoid excess thermal damage. When the tissue plane was thick, he swept back and forth to dissect the side with tension. When there were multiple layers, he dissected the overlying soft tissue then returned to cut through the tougher fascia.
SUTURING: He made a point to execute suturing as few motions as possible, especially in running sutures. Grip tissue and retract, drive by pronation, release needle, regrip, drive further from the back, release, load needle on other side, draw out, release tissue, add required tension to the line, repeat. To tie, each throw had a unique direction to pull. First throw, he pulled along the incision line to start tension. Second throw: the reference end was pulled straight up to set tension. Third throw and beyond: he pulled to the side to avoid adding extra tension. He pushed throws down adjacent to the knot, not onto the tissue itself.
This is how I’ve always thought of surgery. This is what I used to dream of doing when I grew up. It was calculated. Beautiful. Optimized to the point of simplicity.
Well, now what?
If all goes to plan, this is Part 1 of 3…