Newsletter July 2023: There is only one patient on the operating table

Gabriel M. Gurman, MD
Chief Editor

A recent paper published in a highly esteemed journal (1) discussed the issues faced by patients with high-risk factors for surgical complications. It highlighted the challenges that surgeons encounter when deciding whether to undertake an elective procedure. 

The paper presents a series of factors that could adversely affect the postoperative outcome, including obesity, smoking, and diabetes (2). It also recommends that surgeons assess the risks associated with surgery and calculate the risk versus benefit for each case. 

The paper also addresses other aspects of the problem, such as the patient’s opinion and the ethical considerations of operating on a patient with a low chance of survival while other patients await their turn and could benefit from the surgical intervention. 

Furthermore, the paper suggests that surgical training should incorporate these types of problems as they exemplify the decision-making process. 

Surprisingly, the paper does not mention the role of the anaesthesiologist throughout the patient’s journey, from the preoperative examination and evaluation to the operating room and recovery period. 

Centuries ago, Ambroise Pare (3), a surgical pioneer, declared that “the surgeon is not the only captain/master on the ship.” In 1901, John B. Murphy, a renowned surgeon of that time, wrote (4) that “the anaesthetist should not be considered a mere satellite of the surgeon but recognized as one of a distinct class.” 

Today, the anaesthesiologist is considered a full-fledged member of the surgical team, responsible for managing and ensuring the patient’s outcome, and an active participant in discussions concerning surgical and anaesthetic risks. 

Unfortunately, the paper seems to overlook this simple and undeniable reality. 

Thus, the professional relationship between surgeons and anaesthesiologists remains a subject of debate and discussion in the literature. 

I will mention only Cooper’s recent paper on this subject (5). 

Here is a paragraph from the introduction of that article: “I can find little research about this relationship in the literature. How do anaesthesiologists and surgeons perceive each other? What are their expectations of one another? Do their values differ, and if so, how might it affect their ability to make the best decisions for a patient? How does their effectiveness as a dyad (team-GG) within the larger team influence the team’s function? When faced with challenges, what aspects of this relationship contribute to success or failure? And if the relationship is critical to safety (both for the patient and the caregiver) and is sometimes or often dysfunctional, what can be done to improve its performance?” 

I am confident that our everyday reality provides answers to all the above questions. 

Day and night, we are involved in caring for the same patient, each offering our professional expertise and working together to solve problems during the perioperative period. 

Obese, diabetic, or smoking patients pose challenges and concerns not only for the surgeon but for the entire surgical team. This is why cooperation between these two professionals is essential and crucial to ensuring the best outcome in each case. 

While conflicts of opinion may arise, as Cooper mentioned, “When the dyad is highly functional, it greatly serves the interests of the patient; each can help and ‘rescue’ the other. Moreover, a good working relationship creates a much more pleasant working environment for everyone involved.” 

All of the above is a reality today. 

Nevertheless, from time to time, there is a need to demonstrate the fact that surgeons and anaesthesiologists are jointly responsible for the care of the same patient who is destined to reach our operating theatre and be placed on the operating table. 

This proof was provided at the 3rd Ambulatory Anaesthesia and Analgesia (AAA) Symposium, recently held in Zurich, Switzerland. To the best of my knowledge, this was the first time in many years that a scientific event offered a platform to both anaesthesiologists and surgeons, featuring panel discussions covering various domains of our daily activities: eye surgery, orthopaedics, neurosurgery, gynaecology, robot-assisted surgery, endoscopy, and postoperative management and pain. 

Each speaker presented specific details of their respective fields, presenting new data and facts while also discussing the collaboration between the two disciplines, especially in challenging cases and situations where the patient’s preoperative medical condition raises concerns. 

Obesity, diabetes, smoking, as well as old age and paediatric patients, were thoroughly discussed during the symposium, with speakers and the audience jointly seeking solutions for each problem. 

The fruitful meeting in Zurich not only extended our collaboration from the operating room to the pre- and postoperative periods but also served as a reminder that at the end of the day, there is only one patient on the operating table, and both the surgeon and the anaesthesiologist share equal responsibility for their care. 

References 

1. Leeds IL et al. New Engl J Med 2018; 379:389 
2. Bilimoria KY et al. J Am Coll Surg 2013;217:833 
3. Hernigou P. Int Orthop 2013;37:543 
4. Griffith B, Yao J. J Am Coll Surg 2000;191:419 
5. Cooper JF. Anesthesiology 2018;129:402 

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