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Vets Clinical Research
Making veterinary surgery alive
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Practise Makes Perfect
In
Enterectomy?
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date:
14 April, 2010 |
 toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129 |
To excel in
veterinary surgery, one must have lots of
practice. In human medicine, surgery is a
post-graduate study and specialty but vets after 5
or 6 years of undergraduate studies are expected
to be competent in veterinary surgery. There are
veterinary specialists in surgery but he or she
will not be able to earn a living in Singapore or
in many countries.
Therefore, it is good to know that the 4th year
students are given hands-on experience on
intestinal surgery in the pig. 3 in a group. One
would be a surgeon, one would be an anesthetist
and one would be a recorder at any one session.
Anne was the one doing surgery yesterday. She had
the short stick of the draw.
I did advise her to practise a lot on stitching
pig intestines prior to the test. Reading notes
and watching video may give the theory. But in the
real McCoy, she needed to demonstrate competence
if she was to get HD (High Distinction). For this
high-achieving student, failure is not an option.
Failure means having to repeat the test but I
doubt that the University would be funding a pig
for this repeat. It must be expensive and
time-consuming. So, yesterday would be her trial
by fire.
 I
discovered that she was a high-achieving student
when her mother told me. It is rare to meet
high-achievers doing internship in my practice and
in veterinary medicine and surgery. There are
around 70 graduates per year. 150 students might
have started first year. The drop-out rate is
high. In 70 students, only one veterinary graduate
may get the University Medal for being amongst the
top 7 in the whole campus. I presume the winner
will be from the crop of the top 2%. It is not
easy.
Veterinary medicine and surgery is a very tough
subject unlike human medicine where only homo
sapiens is the only species being studied to
death.
A vet student has to study so many animals and
each animal has its own diseases and various
medicines to treat them. It is a wonder how the
undergraduates can memorise and pass the
examinations.
"How's the practical test on your intestinal
surgery today?" I phoned Anne who was the surgeon
in a group of 3. I was curious to know what makes
a student so passionate in veterinary medicine and
surgery and therefore followed up on Annie's
struggles to get the University Medal. She did not
tell me that she was aiming for this prize but I
assume from her actions and diligence in studying
and competing with one mature classmate. "Nobody
knows till the award of the medal," I encouraged
Anne who deemed the competitor unbeatable. Life is
a marathon. Anything can happen till the finishing
line. One must be focused and industrious in the
home-turn, using a horse racing analogy.
I had advised lots of practice on pig's intestines
prior to the test if she wanted to get high marks.
No 4th year student or even new graduates can
demonstrate competence in stitching up the
intestines because of the Western model of
veterinary education which prohibits practices on
live animals due to animal welfare concerns.
I was surprised that Anne accepted my advice and
sourced for pig intestines from the butcher's shop
to practise surgery. A butcher told her that pig
intestines are never sold in Perth. Yet she found
one selling at Northbridge. So, she practised and
the vets and nurses at the vet surgery she stayed
helped out.
I had many questions to ask about how she did the
surgery on the pig. I don't do pigs. "Enterectomy,
enterotomy and gastrostomy," she said. "How long
did it take? Around one hour?" I asked
optimistically. "The total surgery including
stitching of the linea alba and skin stretched
from 1.30pm to 4 pm."
I was just interested in one result regarding
intestinal anastomosis. "Did the intestines leak
after joining the two parts of the cut
intestines?" Performance counts. You fail if your
appositional sutures did not close the defect. The
patient would suffer peritonitis and there will be
a need to operate again.
"Did the intestines leak?" I asked again. This was
her first intestinal surgery and she had
diligently practised. "In a live pig, the
intestines are mobile," Anne said. "It is not easy
to stitch (unlike the dead specimens from
Northbridge. The mucosa is hard to stitch up."
"So, did the intestines leak?" I asked patiently
again. I could not afford to talk too long in
international phone calls and this was the answer
I wanted to know. You can have beautiful
stitching. But the life and death issue is whether
the patient's intestines, uterus, bladder, heart,
blood vessel leak contents after your stitching.
"Yes," Anne explained to me that it was hard to
stitch interrupted appositional sutures to join
the two intestines. The sutures should not evert
or invert. They should just close up tightly as in
simple interrupted sutures in the skin. "Why don't
you use inverting sutures on the serosa?" I asked.
"Fine 4/0 absorbable sutures inverting the serosa
as in gastrostomy?" Anne said, "The professors
said that only one layer of appositional sutures
would do as there may be intestinal blockage."
Well, I did read the professor's lecture notes
which taught what Anne just did in the Murdoch
University bookshop. Such books are for
sale. The lectures said wrapping of the omentum
and tacking it to close the anastomosed area. Or a
serosal patch after intestinal anastomosis. Did
Anne do the wrapping or the patching? But I had no
time to talk.
This anastomosis of intestines is a rare surgery
in a general practice. Practice on Caesarean
sections would help a vet hone his skills.
Unfortunately, there are not many Caesearean
sections unless the vet has lots of dog breeders
and provide dirt-cheap surgeries attracting them.
"Why was there a leak?" I wanted to know. "Didn't
you check after stitching?"
It is easy to criticise when one is not on the hot
seat. "It was closing time," Anne explained. "I
had to rush." Failure is really hard on high
performers. Nobody wants to talk about the pains
of failures. We learn more from failures. "Do you
know your marks after the practical?" I was asking
a stupid question.
"No," she said with great patience. I think she
would not get a HD for this surgery. And after all
her hard work. But I believe she will score high
marks. Grading depends on the standards expected
of a first-timer in intestinal anastomosis.
Practice on dead specimens is never the same as on
a live mobile tissue. Doing 3 surgeries
(enterotomy, enterectomy and gastrostomy) at one
time must be really stressful for any student.
The other 2 in the group of 3 would have benefited
from observing her mistakes and would be at a
competitive advantage. I wonder whether the
professor takes that into account in grading? Had
Anne sufficient practices? Practice Makes Perfect
in an enterectomy if one is operating on live
specimens. This was not practical. I assume that
the first of the 3 in a group would be
disadvantaged in a surgery competition for top
grades. The other 3 would do the necessary checks
and corrections to prevent leakage. But
would they have had prior practices on intestines?
If not, my bets are on Anne.
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Be Kind To Pets
Veterinary Education
Project 2010-0129 |
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