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Simple surgical advice holds true over the years
Uday Devgan revisits three tenets to mark his 100th Back to Basics column.
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Richard L. Lindstrom
This installment of Back to Basics marks Uday Devgan, MD’s, 100th column for Ocular Surgery News. It is fitting that his columns are geared toward teaching because Uday is as tireless a teacher in his role as Chief of Ophthalmology at Olive View at UCLA as he is as a skilled surgeon in private practice in Los Angeles. He carries that teaching over to his numerous papers, lectures and video tutorials, as well as his Back to Basics column for OSN. Along with OSN’s editorial staff and our readers, I am highly appreciative of Uday’s contribution to the publication and his efforts to educate ophthalmologists around the world.
Richard L. Lindstrom, MD OSN Chief Medical Editor
After more than 8 years, we have reached the 100th monthly installment of Back to Basics, a column designed to review the building blocks of ocular surgical techniques. The resident physicians with whom I operate often ask me for advice to aid in their development as surgeons. These simple bits of advice have been carefully gleaned after thousands of surgeries over the course of nearly 2 decades.
Keep up with changes within the field
Because ophthalmology advances so rapidly, the way that we do things today is not the same as it was at the start of this project. Cataract surgery is now more refractive in nature, glaucoma surgery has moved toward minimally invasive techniques, endothelial transplantation has transformed corneal surgery, and intravitreal injections have become the mainstay for treatment of many retinal diseases. The only constant in ophthalmology seems to be change.
At the beginning of my career, I would have been intimidated by this dense cataract with extensive pseudoexfoliation and a relatively shallow anterior chamber. With surgical judgment and experience, this has changed into a respect for the difficulty of the case but a confidence that it can be successfully operated and any challenges can be overcome.
Image: Devgan U
Keeping up with new changes in ocular surgery is critical to providing our patients with the best possible outcomes. Surgical techniques evolve and new technologies are introduced every year, with the goal of making surgery safer, less invasive, more predictable and increasingly efficient. If it is not feasible for your practice or surgery center to purchase costly new technologies, see if you can get privileges at other facilities or even use a rental service so that you can use these devices yourself. While it is useful to read about the experiences of others, ultimately your best understanding comes from actually using these devices during surgery. You can then decide if it is something that is worth pursuing.
The learning curve
Every new technology and technique comes with a unique learning curve. While it may take 1,000 cataract surgeries to truly feel comfortable with all combinations of potential complications, other procedures can be mastered with far fewer numbers. When femtosecond lasers were first introduced for cataract surgery, the complication rate was higher because surgeons had not yet climbed the learning curve for this device.
The keys to mastering surgical techniques are frequent practice and the desire to hone your skills. Make it a point of reviewing every surgery that you perform and ask yourself if there was a way that you could have done it better, safer or more efficiently. You can video record every surgery you perform and then review the footage of the tough and challenging cases. Think about each step of the surgery and how it could be improved. Whereas a novice will see our corneal phaco incision as simply an entrance into the anterior chamber, a more experienced surgeon will notice the incision architecture, balance and positioning. In fact, entire articles in this series of columns have been written about just the incisions for surgery.
The golden rule of surgery
Among the most difficult aspects of surgery to learn is surgical judgment — when to do which steps to give the best outcomes for our patients. Sometimes, novice surgeons will be too eager to operate even when the risks outweigh the benefits. And other overly conservative surgeons will be reluctant to operate even when surgery is likely the best solution to a difficult case. The best surgical judgment is likely somewhere in the middle. At the beginning of our careers, it is helpful to emulate mentors and follow their lead, and then as we mature as surgeons and gain more experience, we can develop our own surgical judgment.
Ultimately one of the most useful guides is the golden rule of surgery, which simply states that we want to deliver the same high level of care that we would want for ourselves. This means when you see a complicated patient with a challenging case, the best course of action becomes clearer when we ask, “What would I want if this were my eye?”
This approach also reminds us that each case is unique and that each patient deserves your best. Surgery is a pleasure, and it is the highlight of my practice. There is simply no greater satisfaction than giving patients the gift of sight. Keep these few bits of wisdom in mind as you develop your surgical skills, learn new techniques and explore more surgical concepts in the next 100 columns of Back to Basics.