Gastrointestinal Operations and Technical Variations 1st ed. 2017 Edition PDF ebook Free
Gastrointestinal Operations and Technical Variations 1st ed. 2017 Edition PDF Download
By Michael Korenkov (Editor), Christoph-Thomas Germer (Editor), Hauke Lang (Editor)
- Hardcover:444 pages
- Publisher:Springer; 1st ed. 2017 edition (October 28, 2017)
Since the establishment of the abdominal surgery as an independent field, every operation will be performed according to the certain technical stan- dards. These standards have been appropriately adapted for the new knowledge and technical developments. However deals a practical surgeon frequently with situations, in these originally simi- lar operations can have very different develop- ment. A lot of predisposing factors can influence it: different anatomy and morphology of operational areas, different effects of the similar intraoperative steps (bleeding after tissue transection, organs injured during the abdominal opening), surgical experience, manual skill, drop out of instruments and devices, strategic problems, mental condition from every team member, as well as a quality of assistance. All these factors can make the perfor- mance of every operation difficult, especially in cases when a surgeon is “programmed” to achieve certain technical standards. Until today, there is no definition of what constitutes a difficult surgical situation, but every practical surgeon knows very well what it means and how important it is. We define the difficult surgical situation as an intraop- erative surgical problem, which increases the like- lihood of intraoperative and postoperative complications, if the initially planned surgical pro- cedure was carried out without modifications. In a difficult surgical situation, the surgeon gets into dilemma whether to continue the intended opera- tion “at all costs” or to deviate from the initially planned surgical procedure to some alternative technique. Choosing the first option can increase the risk of intra- and postoperative complications. For example, performance of a complete instead of “subtotal” cholecystectomy by severe fibrotic changes in Calot’s triangle can lead to bile duct injury. Enforcement of hemithyroidectomy in case of the difficult surgical anatomy can have a recur- rent lesion as a result. There are further examples on this subject. The consequence of the second alternative might be a lower risk of short-term complications but at the expense of worse results in the long term. In oncologic surgery, for exam- ple, earlier recurrences due to R1 resection status or unsatisfactory functional results represent typi- cal problems. When making the decision to oper- ate or not, but also when selecting the best surgical technique, it would be important to know a patient’s individual risk of intraoperative difficul- ties. From a surgeon’s perspective, intraoperative difficulties are therefore more than just a surrogate parameter for postoperative morbidity, because the prediction of such difficulties could directly lead to modifications of the surgical indication, improved selection of the surgical team, and intra- operative changes in surgical techniques. Ultimately, mortality and morbidity could be reduced by avoiding an operation with a high grade of intraoperative difficulty, by anticipating it and preplanning alternative surgical options, or by modifying the surgical strategy during the opera- tion. Intraoperative changes in surgical strategies are of course not uncommon. In most cases, how- ever, the surgeon has no objective facts to justify his or her decision. The need to justify one’s actions may lead to some pressure not to deviate from the preoperative planning. Thus, surgeons tend to stick to the standards of surgical practice, even if the risk-benefit ratio in an individual patient changes intraoperatively. The present results should be seen as a stimulus for surgeons to take their “gut feelings” seriously. If the surgeon’s sub- jective impression points toward an increased dif- ficulty of surgery, it may be justified to deviate from the surgical textbook.