The Novice VR Surgeon -Ten mistakes to avoid

Dr. P. Mahesh Shanmugam
Published Online: April 1st, 2021 | Read Time: 12 minutes, 40 seconds

Mastering vitreoretinal surgery is a slow and arduous process with each case being different from the other and it is just about possible to have only a “feel” of a kind of case during the fellowship, not mastery of it. The budding VR surgeon would necessarily have to hone her / his skills in the real world outside their alma mater and the following guidelines can aid mitigate the stress and angst. This is just a comprehensive list, not a complete one, an addendum or a reinforcement of what has been imparted at the fellow ship.

1. Not being familiar with the equipment

Vitreoretinal surgery is machine dependent and an optimal surgical outcome is the result of efficient use of equipment, be it the microscope, vitrectomy machine, laser console etc., Knowing the equipment’s capabilities and limitations by reading the manuals will help exploit the machine’s capabilities to the maximum, resulting in an optimal surgical outcome and also minimize complications during surgery. Equipment at the new place of work may be different from the one at the alma mater and hence all the more the reason to get familiar with it before using it. There is no shame is getting the company engineer to brief about the machine before using it.

2. Not “reading” the case

It is essential to study the surgical anatomy of the case before attempting surgery. The “drawing check” was an exercise aimed at pre-operative planning of the surgery to mitigate complications, follow an effective and quick route for successful completion of surgery and to be prepared with the right instruments for achieving this. A quick fundus check just before the surgery, noting factors such as the degree and areas of posterior vitreous detachment, where to enter the sub hyaloid space, the vitreoretinal adhesions, the instruments that may be required to tackle them, amount of subretinal fluid, where to drain it, if the lens can be left in place or not, vascularity of the proliferation, the peripheral vitreoretinal anatomy, if an encerclage is required or not… An ideal way to do this is to examine the patient sufficiently prior and go through a “virtual” surgery of that case in one’s own mind. This can largely ease the real surgery and also minimize complications.

3. Blaming oneself or the patient for an adverse outcome – striking a balance

There are two kinds of VR surgeons/trainees – one who blames the disease for the adverse outcome and the other, oneself for all the adversity. The first kind uses the disease as a shield to cover their failures and are likely to stagnate, be plagued by poor surgical outcomes, and have to deal with unhappy patients. It is imperative to introspect every surgery, particularly those which did not go as per plan, revisiting their surgical videos, reliving it, and learn from it so as to get better the next time. This would be progress.

The second kind are the conscientious ones who will blame themselves for every failure - this is good for their subsequent patients, as they introspect, blame themselves and try to get better the next time. On the other hand, blaming oneself results in angst, depression and low self-worthiness which can be deleterious to one’s physical and mental health.

It is best to strike a balance- accept when one is wrong and acknowledge if the disease played truant. This is easier said than done but with practice and adequate introspection one can walk this thin line which will be ultimately beneficial for the doctor and the patient concerned.

4. Not being “fully” there

In the initial days, it is easy to get so engrossed in the surgery being performed, one fails to notice things that need to be noticed. For instance, the steady beep of the pulse oximeter, the drone of the vitrectomy machine, what the nurse is doing etc., While it is difficult to keep an ear or eye on these issues that are outside the operating field, it is important as the well-being of the patient and surgical outcomes depend on these as well. It is important to note if there is bradycardia when a muscle is being hooked – to prevent an oculocardiac reflex associated complications. It is important to note if the patient is having pain, straining to control his urge for micturition, factors that can result in tachycardia – progressing with the surgery, oblivious of these can result in disastrous complications such as an expulsive hemorrhage. The altered drone of the machine can mean that the aspiration or cutting is not as it should be and needs to be addressed for optimum surgical result.

It is not difficult to develop this state of mindfulness- keeping an ear open to the noises in the surgical suite and the peripheral vision open and yet concentrating on the surgical process. One can develop this with some conscious practice and it is preferable to start on this right away.

5. Failing to empathize with the patient

As fellows with no real liability, one does not really involve oneself in caring for the patient during fellowship– it is usually a TRD, vit hemorrhage etc., not a one-eyed 40-year-old type I diabetic with a young family to support or a young pregnant mother who has lost her vision suddenly, battling pregnancy on one hand and blindness on the other. Knowing this aspect of the “patient” helps understand their needs, apprehensions, expectations, prompting one to do the best for him / her, not just treating the TRD or vit hemorrhage.

As doctors we start off being empathetic in early days but routine blunts this so much that we fail to see the person behind the patient.

6. Taking short cuts

In a given case where the mind tells that it is better to place an additional encerclage, one can convince oneself that just a vitrectomy would do, just to save that 15 minutes - this can result in significant subsequent heartburn. Similarly, silicone oil is not panacea for adequate relief of traction. Meticulous membrane removal and adequate vitreous removal can be supported by using silicone oil as tamponade, not as a substitute.

If one is conscientious, one goes home after a suboptimal surgery, wondering if that retina will remain attached the next morning, in the process, losing one’s sleep. It is not worth the time saved. As is wont, the retina may redetach despite doing one’s best, but the burden on one’s conscience is then negligible.

7. I have learnt it all

Being a doctor is being a student for life – continued efforts at gathering knowledge is paramount to progress. The humility to accept the inadequacy of one’s knowledge is important – once one thinks that all is learnt is the beginning of one’s end. Similarly, a humble VR surgeon is a hallmark of a learned VR surgeon. The day one feels over confident over their surgical results is the day the disease is waiting to deliver a body blow to the inflated ego. It is imperative remain humble, enhancing one’s knowledge, acknowledge their limitations and constantly work on them to be a successful surgeon.

8. Bite more than one can chew

In the early days, it is not uncommon to overestimate one’s capabilities, thereby taking in rather complicated cases / mis-reading them or posting more than what one can manage and find oneself at the deep end of the pond very soon. This can be demoralizing and detrimental to one’s confidence which is a requisite to become a successful surgeon. Knowing one’s capabilities and building on them gradually, if possible, within the umbrage of an institution in the early days, would be preferable in the long run.

9. Focus on equipment – not what one can do with it

Often the young surgeon looks for the best of the equipment – this particular vitrectomy console, that particular microscope and such. While a good equipment does result in good surgical outcomes, it does not guarantee it – it is the surgeon who guarantees results. It is okay to operate with less expensive equipment, perform 23g surgery rather than 27g surgery, suture a sclerotomy, and such – it is essential to know the limits of the equipment as knowing one’s own capabilities. A healthy marriage between the two is what results in optimal surgical outcomes -not the best of the equipment or the smallest of the gauges.

10. Not setting up appropriately prior to a surgery

It is imperative to set up the surgeon’s position ergonomically for a stress-free surgery. The chair and the table should be set to correct height, sitting erect with the microscope eye piece at eye height, not having to flex or extend the neck to peer into it, foot switches placed at correct place and angle, the hand rest fixed appropriately… A fatigue free surgeon can give optimum surgical results and a consciously ergonomic surgeon, having spared his musculoskeltal system, can have a long and productive career.

I have made these mistakes and learnt from them. It is always easy to learn from another’s mistake than one’s own in medicine. Hope this write-up aids those reading it to learn from mine.

Dr. P. Mahesh Shanmugam
Head of Vitreoretinal and Ocular Oncology Services, Sankara Eye Hospitals.
Dr. P. Mahesh Shanmugam is currently working as Head of vitreoretinal services across all Sankara eye hospitals and ocular oncology services in Sankara eye hospital, Bangalore. His interests are medical retina, surgical retina, vitreoretinal surgery, ocular oncology, pediatric retinal surgery including ROP. He has around 150 articles in peer reviewed journals. He co-founded retnetindia and has won some awards including the Colonel Rangachari, Siva Reddy oration, Swarnalatha Punshi best research worker, M. G. Bhide memorial award, Samar Kumar Biswas award etc. He has been invited in various national and international conferences and he has been training fellows since 1993.
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