Curtains Up!

The stage is set. The cast is ready. The backstage team has everything in place. Multiple rehearsals and dress rehearsals have been done. The audience waits with bated breath. The excitement is palpable. The protagonists enter and the show commences. The present day operation suites were originally called ‘operation theatres’, where many interested scholars and students could watch live surgery in progress. A few days back we started the Laparoscopic Donor Nephrectomy (LDN) program at our center. The surgery went successfully, the donor kidney rewarded us with on-table urine output and the donor went home with a happy face. Starting the LDN program was many months in the making, the topmost priority item in my mental manifesto, a dream come true for our team. It was a success story waiting to happen, hidden in the shadows, biding its time - during the initial addition of a new member (yours truly) to our transplant team, the professional lull during second COVID wave, the building up of confidence with extirpative nephrectomies & reconstructive pyeloplasties and purchase of relevant instruments. Performing the actual procedure was a lot like being in a theatre, with many people watching and expecting a good performance; and it was an exhilarating experience to complete the surgery as planned. A lot of learnings cropped up in my mind that day; sharing them in bullet points below, as always –

1. Select your scripts wisely. Starting any new procedure is a huge responsibility. Starting an LDN program ranks almost on the top of the list, and that’s because the donor is not really a patient. So, there is no scope for error. Case selection in the initial weeks is very important. A clean case is the best, as that is the least likely to put you in a tough spot. This helps in building up confidence of not only the surgical team, but the associated specialties (anesthesia, nephrology, OT staff) as well. This also ensures that you start your program with a high success rate. Then you can start tackling the complicated cases.

2. Make sure you have all the props and costumes in place. A surgery without proper instrumentation is a disaster waiting to happen. We perform our renal transplants in dedicated transplant operation theatres, with different surgical instruments and Endovision systems from our routine OTs. Therefore, it is important that you check all the instruments with the staff beforehand; any instrument missing should be added to the armamentarium, any technical fault should be corrected at least a day before. Technical glitches happening during the procedure create undue mental stress and pose risk to the patient.

3. The backstage team is as important as the on-stage cast. Make sure your OT team is well versed with the procedure. This includes the anesthetist (LDN requires good patient perfusion, good on table urine output, a different positioning compared to open donor and pre-clipping iv mannitol), OT attendants (keep the items required for patient positioning ready, take care of the pressure points) and OT nurses (a great nurse studies the procedure beforehand, watches the procedure with you, knows what you are going to do next and replaces your instruments without you having to ask for it).

4. Do your rehearsals. Your rehearsals will be the training you have received in the procedure. Do many non-donor laparoscopic procedures first (radical nephrectomies, simple nephrectomies, pyeloplasties, ureterolithotomies all make the cut). This will make you and your team confident in your abilities and make your staff used to your surgical preferences (which I feel is very important to run the show smoothly; tiny discrepancies make for big irritants). Before the procedure, run the surgery through with your team step by step so that everybody knows what to expect during the surgery.

5. Focus on your performance. When you do your first new surgery, expect all eyes on you. At any time during the procedure, the entire staff, along with the stray visitors may grow up to 15-20 ‘audiences’ for your performance. This can make anyone sweat. Keep calm, remember your training and make use of common sense. If you lose your way, reorient; if you encounter a bleeder, compress first clip later; if you start to lose confidence midway, seek support from your teammates; if you reach an impasse during laparoscopy, convert (it is not a failure! The patient is the priority!). If all goes well, you will come out on top.

6. Give a vote of thanks. After the surgery, thank your team, your nurses, your anesthetist; you couldn’t have done it without them. Inform your teachers, they will be happy to know of your progress. You owe your surgical skills to them.

The performance goes without a hitch. The audience enjoys thoroughly, as do you. It’s done and dusted. The after-party awaits. But it’s not the end. There will be reruns, there will be more scripts. The show must go on …