The entire OR staff and I sat waiting. The nurse was looking for safety pins. No more safety pins were in the cabinet. We were out. The patient’s surgery was complete. Her bra had been placed. But she had six drains. And no pins to help secure them. The anesthesiologist looked at me. I told him, “We are just waiting on the safety pins.”
In today’s world of surgery via TV, YouTube, and Instagram, many may not be aware of the before and after of surgery — not the photos, but the process, the routine steps that we surgeons perform every day. It’s through the practicing of these steps, not just the surgery itself, that an outcome becomes successful — even if it means waiting for safety pins that will help secure drains that, if unsecured, may result in pain for the patient if they get pulled or tugged, or may become dislodged, leading to an accumulation of fluid and a possible aspiration.
We surgeons are committed to getting the details just right. Some may believe that these particulars are just us being picky, but they are also due to us having lived through numerous complications and knowing how to prevent them. Surgery requires precision during the entire process, and it requires the preparation of all stakeholders — the patient, the surgeon, and the staff.
As surgeons, we put a lot of thought into how we care for our patients. I witnessed this consideration for the first time when I was 15, observing my surgeon father at work. After his patient’s procedure was complete, my father donned new gloves (now, I understand that you don’t use bloody gloves because then the gauze will look dirty) and applied the facial dressing, which seemed as if it took as long as the actual surgery. He then used freshly fluffed gauze to wrap the kerlix roll in a kind of rhythm to create a secure turban. The ace wrap that followed the roll was unfurled with the same care — always with the free edge of the wrap at the bottom.
In a similar vein, I remember watching the well-known rhinoplasty surgeon Jack Sheen operate when I was a resident. Dr. Sheen applied a nasal splint following a rhinoplasty with exactitude: the steri-strips were cut precisely and secured to the nose — no raw edges. He followed the advice I received later on in my career: “If your dressing looks sloppy, the patient will think that their surgery was sloppy.”
In surgery, it’s all in the details: Small decisions like clean gloves and precisely cut strips have the power to have a significant impact on the patient and the outcome. One may argue that the manner of cutting the steri-strips is irrelevant, but it has to do with how the splint is applied and ensuring that the pressure on the nose is distributed and shaped equally.
Dressings are just one component of the small details that matter. And the details don’t just begin when we first mark the patient in the pre-op holding area — I would argue that being detail-oriented begins in the days to weeks before surgery when the patient is preparing for the operation. Surgical preparation starts with making sure the patient is optimizing her nutrition, eating a diet high in protein, and appropriately hydrating. Then surgical preparation continues with the surgical plan and the surgeon marking the patient, positioning the patient, and prepping the patient. If the patient isn’t positioned appropriately, the surgery is harder. If the patient isn’t prepped appropriately, the surgery is restricted.
Personally, I was trained in an era when the surgeon herself prepped the patient, not the nurses. One day, I was delayed, and I walked into the OR after the patient was asleep and prepped. It turned out that only one breast had been prepped — the one I was operating on. As a plastic surgeon, it has been routine for me to assume that both breasts will always be prepped and draped for surgery — an important concept for assessing symmetry. Yet, for other surgeries this isn’t the case. I have watched general surgeons only prep the side that is having the mastectomy.
Further examples of the importance of getting the details right abound. For instance, when performing an abdominoplasty or a DIEP flap, to close the abdomen after the lower-abdominal skin is removed, the patient’s bed has to be flexed. What happens when the bed isn’t positioned correctly and you can’t flex the patient’s bed? During the COVID-19 pandemic, staffing in the hospital was variable, and one day I had a new nurse. The minor detail of how the bed was positioned was overlooked, meaning that when it was time to flex the bed for the abdominal closure, we couldn’t flex it the right way. It was a challenging process of placing pillows under the patient’s legs and trying to get the right degree of flexion to close her abdomen. Every tiny action has the potential to have a downstream effect, which can change the outcome for the patient. Each somewhat inconsequential detail isn’t really inconsequential — it is critical for the success of the procedure.
The writer-physician Atul Gawande has written extensively about how small details have a huge impact in reducing complications and infections. He writes about this relationship between details and outcomes in terms of checklists in the OR, in the ICU, and in other health care settings. And I suppose that each of us has our own internal checklist about each step in the process. As a resident, I used to write down each step for each surgery as I would prepare for the day ahead. Once I started my own practice and had my own OR, I created a notebook with step-by-step details for our common procedures so that my nurses and assistants would know what to expect and could be prepared. The safety pins are just one of the small details that I added to my checklist. Though checking items off the list may seem time-consuming, eventually it becomes automatic, and saves time in the long run by ensuring a more successful outcome.
Intuitively, as a surgeon, I strive to be consistent and efficient in the OR. I do my surgeries the same way, in the same order every time — for example, when I do a bilateral DIEP flap, I start on the same side of the table and move in the same sequence for every surgery. I perform all of my surgeries with a degree of predictable consistency. When there is complexity with what we do, consistency can help to minimize errors or oversights — this is true for both intra-operative pre- and post-operative care.
And the dressing is a part of that consistency. Some surgeons use compression garments, others use abdominal binders. Some surgeons place their patients in bras, others don’t. Why? Each has a rationale. After liposuction, I believe that appropriate compression and molding has the power to impact the outcome. Gentle compression feels good for the patient too, and if the patient feels better, recovery is smoother. We may not have scientific data in peer-reviewed articles, but we all have seen what happens when we don’t follow through on these small details. And that experience means that we always follow through. These are frequently the small pearls that we discuss with our peers — our keys to success.
Others may wonder or roll their eyes — time is wasted as we wait for the safety pins or as we reposition the patient — but we have to remember that these seemingly random things are really an important part of the surgical process.
What steps go into your surgical checklist? Share in the comments below!
Dr. Anureet Bajaj is a plastic surgeon in private practice in Oklahoma City, Oklahoma. She enjoys running, painting, and spending time with her dogs and family. Her IG handle is @bajajplasticsurgery. Dr. Bajaj is a 2022–2023 Doximity Op-Med Fellow.
Animation by Diana Connolly
