To cut or not to cut

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I firmly believe that general practitioners are an amazing type of veterinarian who often has an untapped pool of clinical potential. One of the great joys of our profession is that it continually asks us to grow and hone our knowledge and skills throughout our careers.

After 16 years in small animal general practice and 4 years as a full-time mentor to early career veterinarians, I have grown my own surgical skills and supported dozens of new grads and clinical students as they’ve worked on building their own surgical repertoire. We all expect general practitioners (GP) to perform spays and neuters, and we all know large dog spays are no joke, but what about all the patients we diagnose with surgical problems? How do we decide which of those patients to cut ourselves, and how do we build up our surgical skills to ensure the best outcomes for our patients?

To explore these questions, I’ve asked 2 of my colleagues to share their perspectives on surgery in general practice. Philippa Pavia, VMD, DACVS-SA, Thrive Pet Healthcare’s vice president of medical field operations, Central Region, and who is passionate about supporting her colleagues in their surgical endeavors. Danling Ye, DVM, a 2021 graduate of the Cornell University College of Veterinary Medicine and currently practices as a small animal GP at Bayview Animal Hospital in Webster, New York, part of the Thrive Pet Healthcare community of hospitals.

Fish: Pavia, as a boarded small animal surgeon, what is your opinion on GPs performing nonroutine surgical procedures? 

Pavia: There are as many answers to this as there are surgeons and GP. My personal feelings are as much about perioperative management as the surgery itself. I have known many extremely skilled surgeons in non-specialty environments, but the limitation on procedure types is often the ability to care for a critical patient. Could I teach an excellent GP surgeon to do a thoracotomy – of course – they likely have much better tissue handling skills than I did as a resident, but do they have an anesthesiologist, critical care specialist, and an overnight licensed veterinary technician (LVT) team in case that dog has re-expansion pulmonary edema or a problem with their chest tube? 

The answer also depends on where you are practicing and what access to care looks like. I would have a different perspective on a non-boarded veterinarian doing tibial plateau leveling osteotomies in urban Los Angeles, where there are multiple specialty hospitals and multiple mobile boarded surgeons within a 2-mile radius, compared to a rural town where you must drive 4 hours to get to a specialist. 

The most important things are your support network, level of training (not just going to a lab and trying it out on a live patient), and self-knowledge of what you can and can’t handle. 

Fish: As a GP who loves surgery, I’ve realized there’s an innate algorithm I think through when I face the opportunity to perform a non-routine surgery. Is referral to a 24-hour specialty center an option and in the patient’s best interest? If yes, that must be part of the conversation with the clients. Have I performed the surgery before? Do I agree that this patient is a good candidate, and that the hospital (facility and team) is equipped to provide good perioperative care? If the answer to any of those questions is no, I start to consider what I can do to set my patient and team up for success. As you mentioned, Pavia, it’s so important to have a means of assessing what you can and can’t handle. Some cases are an immediate hard no because I either don’t have the skill or necessary peri-operative support. And then, for some, I need to learn more, so I dig into my resources. I think it’s imperative that we go through this inner monologue and, even better, have the conversation with a more experienced surgeon (boarded or GP).

Fish: What types of surgeries do you think GPs should avoid unless they have additional specific training? 

Pavia: Orthopedics, chest cases, livers, and gallbladders. In humans, surgeons often only do orthopedic surgery on 1 body part – and lots of research shows that case numbers (ie, experience) are predictive of outcomes. These are surgeries with a learning curve and a high risk of severe complications if something goes wrong, as well as significant needs during and after surgery from an anesthetic and support perspective. Orthopedic cases are rarely emergencies, so referral or bringing in an outside veterinarian with more experience is often possible. In addition, errors are apparent on radiographs, which can increase liability if the outcome is not ideal.

Fish: Ye, as an early career veterinarian, can you tell us a little bit about the growth of your surgical skills over the past few years?

Ye: One of the best parts of veterinary medicine is the variety of cases we are equipped to handle as GPs – including surgical cases. I have always loved anatomy and surgery. One of the main criteria for my first job was finding a place with good surgical mentorship. I’m fortunate to have a team and mentors who support and encourage me to take on challenging cases. I graduated during COVID-19, which limited the amount of surgical experience I could get before starting practice. The repetition of performing surgery in practice, especially when I have a mentor present, has drastically improved my efficiency, skill, and confidence.

Fish: Repetition, repetition, repetition, that is the key! Do the common stuff repeatedly until the tissue handling becomes second nature, and the anatomy recognition is automatic. Spays and neuters are a great way to get this experience. Many areas have shelters or spay/neuter events that welcome outside surgeons.

Ye is one of my mentees, and we’ve partnered on 2 cases recently that have stretched my surgical skills. Thankfully, Pavia has been available as our phone-a-friend in both of those cases. Ye, would you like to tell us about those cases and how we leaned into our resources?

Ye: Sure! The first was an 8-year-old female intact pug mix with an inguinal hernia. I was not comfortable performing this surgery on my own since the defect was very large. I hadn’t observed a surgical repair before, and none of my colleagues, including Fish, were comfortable with the surgery. Fish introduced me to one of her surgical mentors, Pavia. After we all talked, Fish and I felt more confident that it was a surgery we were equipped to do in general practice. I prepared by reading about the procedure in a surgery textbook, and Pavia gave us some practical tips and tricks. 

Fish: Ah, you mention a great resource – the surgery textbook! I always reread the procedure steps before cutting something that isn’t routine. However, the surgery texts have a way of making things sound easier than they are. As you mentioned, we were cautious not to rely on a surgery text alone.

Fish: What did the client communication look like in this case?

Ye: I talked to this client about a referral, but the dog was stable. The client had already declined surgery for many years and also declined a referral. We discussed the possibility of complications, most notably failure of the hernia repair. Ultimately, the client trusted us with her pet, and we performed a spay, removed the left uterine horn and ovary from the inguinal hernia, and repaired the hernia site. The patient is doing great.

Another good example was a 2-year-old, male neutered, domestic short-haired cat with a 3-day history of inappetence. I diagnosed him with septic peritonitis, which I suspected was related to an enterotomy performed to remove a foreign body 1.5 months prior at another hospital. I knew he needed an exploratory laparotomy.

Fish: Yes, I remember him too. I know we were both very uncomfortable with the idea of cutting a patient with a septic abdomen in general practice. Let’s talk about protecting ourselves from liability when trying to do the best for our patients under less-than-ideal circumstances.

Pavia: Communication is always the best way to avoid liability. Pet parents should be given the best available options, and the pros and cons of referral should be discussed and documented (always offer a referral, and don’t make assumptions about your client – they may have more resources than you think or wish to start a GoFundMe). Affirmative consent from the owner, indicating that they understand and accept risks, is vital. There should also be evidence that the veterinarian did all they could to be prepared for the procedure: they can reach out to their support network and any available resources (textbooks and even YouTube videos from boarded surgeons) to prepare carefully, even making notes. Ideally, they also have a “phone-a-friend” available for Facetime, Zoom or Microsoft Teams support if they run into a question mid-procedure.

Fish: What struck me about this patient was how remarkably stable he was. Did that play into your decision to perform the explore yourself?

Ye: Absolutely. A few factors helped me decide to do the surgery myself. It has to be the right surgery, the right patient, and the right client. This cat was stable, he was young, he didn’t have any comorbidities, and the owner had a strong preference against referral. I explained that I’m comfortable performing many gastrointestinal surgeries but that I might discover something that is outside my surgical capabilities. His owner understood the risks, that referral was the better option, and chose to pursue surgery at my practice.

To prepare for this surgery, I read the surgery text, specifically refreshing my knowledge of resection and anastomosis, and talked through the case with more experienced colleagues. Fish was able to scrub in with me, and we had Pavia on FaceTime at one point so she could see what we were seeing and help us determine the best plan. We found a leaking enterotomy site, performed a resection and anastomosis, and the patient made a full recovery.

Fish: Those cases were both examples of surgeries going as planned. We all know there are times that we encounter the unexpected, even with elective surgeries (did somebody say dropped pedicle?). I’d love to hear your thoughts on what to do when you find yourself hurtling toward the “panic zone.”

Pavia: Breathe. Stop the bleeding first, then pause, speak with your anesthetist and see where the patient is regarding stability. Despite all the stereotypes about surgeons on TikTok, we recognize that surgery is meaningless unless your patient makes it. Then go back to anatomy and your training – we often have the answers within ourselves, but we forget when we panic. I do not shy away from printing out pictures, bringing textbooks into the operating room, or even my laptop if I want to re-watch a portion of a video. And, of course, the “phone-a-friend” option is wonderful if you have it. I have about a decade’s worth of interns with my cell phone number who know they can call me anytime if they are stuck in the middle of a procedure.

Ye: I’ll add that after I take a deep breath, I remind myself to get good visualization—extend the incision and have an assistant scrub in to retract it. Also, I try to prepare as much as possible. I like to talk through the surgery steps with someone who has performed them before or write down the steps ahead of time. This helps me solidify my understanding and reveals any areas of uncertainty so I can address them before surgery.

Fish: Thank you both for sharing your experience and insight! To close, Pavia, do you have any final suggestions on resources to help GPs who want to grow their surgical skills?

Pavia: In-person, laboratory-based continuing education is the best way to start in a low-risk environment. Cadaver labs are vital to our training (whenever I’m in a cadaver lab, I make a point to pause with my teachers or students to honor the lives lost to end up in a teaching lab). However, these can be expensive and don’t mimic the real-life scenario with bleeding and beeping machines. YouTube videos . curated by a boarded surgeon, are another fantastic resource for seeing what things are like in “real life.” The best option, of course, is to find someone where you can “apprentice” and learn from them with cases. Many surgeons will welcome visitors. Of course, they cannot allow outside doctors to perform surgery but watching a procedure from start to finish can be very helpful, including the surgeon's thought process. If there is another experienced doctor in your practice already, ask them to call you when they have a case you’d like to learn from.

Many hospital networks or groups have internal resources where an experienced surgeon will come and perform a planned procedure with the learner in their home hospital. That's probably the gold standard!