Obesity Control Center Bariatric Center
The team based approach -- two surgeons working together
Nov. 16, 2014 by Sofia Luna
Q&A with the surgeons...
(This content relates to the video embedded below)
Question: You perform surgeries with two full bariatric surgeons side by side rather than one. What's up with that? (Is it rare? Twice as fast? Better for patient safety? Twice as expensive?
Related Video:
Above, Dr. Martinez in the OCC operating room.
Dr. Martinez Answers...
Overall in bariatrics it's not all that common to have multiple surgeons in any dedicated all-the-time way. A majority of surgeons, including some of the best surgeons out there, work alone as their primary method of doing things. Beyond this, it can sometimes be not too uncommon for some surgeons to work with other surgeons being in the operating room as visitors or as temporary team members. This might be in a training capacity. Some types of training are formal. Device companies often hook surgeons up with other surgeons more experienced with using their devices on a particular procedure.
Other times surgeons might operate with other surgeons to train informally in a spirit of collegial mentorship (and/or we surgeons are sometimes a competitive lot; not likely to miss too many opportunities to show off our skills to one another).Aside from operating with other surgeons per se, bariatric surgeons are, on the other hand, often likely to have a non surgeon assistant with them in the operating room. These are officially licensed as physician assistants or "PA's" and can become the surgeon's right hand man in there for some or all surgeries.
What we have at our center is different from the above in that both Dr. Ortiz and myself are fully trained surgeons. Each of us has about 15 years experience. That in itself is somewhat more than the average weight loss surgeon out there, especially amongst surgeons who only do bariatrics. We only do bariatric surgery. We could each do surgeries all on our own without any problem. We chose to do surgeries together, though. In particular, though we chose to do 100% of our bariatric surgeries together. Not only that, but we've been doing things this way for the past 12 years.
All over the world and the US in particular there are some very good bariatric surgeons who have been doing bariatrics as only a fraction of their overall practice for less than 10 or 8 or even 5 years. We've been doing only bariatrics, with 12 years of experience with the exact same two surgeons working with each other side by side on every surgery. That kind of thing is fairly rare.
Is it important, though? Different providers would of course have different opinions. By our way of thinking, for starters, yes, it is faster. I wouldn't say necessarily twice as fast, but definitely significantly faster. From minute that a patient goes under to the time when they are completely closed, a typical weight loss surgery these days might take 45 minutes. At our center this tends to be around 30 minutes. Why is that important? It means that patients are under anesthesia for a shorter period of time. Why is that that? It's because as in a great many surgeries performed on relatively healthy patients, one of the greatest risks of surgery is the process of being put under anesthesia in the first place. When people ask "is weight loss surgery safe?" the answer is similar to, say, "is an appendectomy safe" or "is surgery for heartburn safe?".
The risk for any given patient is likely to have far more to do with how healthy the patient is than it is for the procedure _type_ itself. More important are things like the experience of the team and, as for the operation itself, how long the patient is under. Now, the potential problem with that isn't that you're not likely to wake up. Rather, the issue is with how the human body wasn't designed to be knocked out as happens when you're under. Certain aspects of the circulatory system slow down in ways that result in a greater risk that some of the blood might start to clot.
This happens more commonly in the veins. A severe form of this is called "deep vein thrombosis" or DVT for short. These can cause nasty life threatening problems if they break loose and get to, say, the lungs. We work really hard to target what we do around putting patients at risk for this for a shorter period of time both in the OR, and, also, after surgery. All patients need to get up and walking after surgery as soon as possible. In our center, this is mandatory after four hours after surgery, but we like to see this after 2 1/3 - 3 hours ideally. So, faster surgery means less time under anesthesia _plus_ this also means a faster recovery time (less anesthesia in the system). These contribute to at lower risk DVTs and pulmonary embolisms.
Aside from this benefit in all patients, shorter OR time is also of particular benefit to higher risk patients. A a smaller % of our patients have a higher BMI than most. This is usually associated with an above average amount of visceral body fat. That, in turn, leads to harder operations. If you've ever seen video of surgery, all the yellow stuff you see is fat. Also, if you see any black marks, that maybe be cauterized tissue from surgical cutting. The best surgeries are ones with the least yellow, which in turn, result in the least black. When we do surgery it is actually kind of like doing three kinds of surgeries in one. First we have to set everything up laparoscopically. Then there is the actual technical procedure (itself with many steps).
Before this, however -- and also during -- we have to remove or "take down" the fat. The more of this there is to do the harder it is to get to the organs we need to work on, but, also, the longer everything takes. (So, if you are pre-op, please help your surgeon serve you better by losing as much weight as possible before surgery!). Every patient is unique. The minority that are the hardest to do technically can generate a very distinct kind of risk of the technical procedure itself possibly taking, say, twice as long to do.
If a hard patient might take a solo surgeon 60 minutes to do instead of 45 minutes -- an extra 15 minutes -- then having two full surgeons might make the procedure, say, 35 minutes rather than 30 minutes -- an extra 5 minutes. Of course these are all made up numbers. Every patient is unique. The point is that the biggest difference can be for the minority of cases where the surgical team might wind up running into harder going because of the patient's anatomy. Sometimes having extra hands in there, say, tackling a really tough dissection, can make a big difference if they know exactly what to do.
Thirdly, another advantage of having two surgeons involves simply having an extra pair of eyes and brains looking out for things. Two brains think better than one. I look for certain details and my colleague looks at other details. It's a lot less likely that anything -- especially the unexpected things -- will slip by us unnoticed. Patient safety has a lot to do with risk, and of how well prepared a center is to handle those problems that don't take place very often. Maybe 99% of the time all these additional factors won't make any actual difference for the patient. No one, however, wants to be that 1%, or to have anything less than the best in the unlikely chance that they wind up being that 1%. It's that extra security that patients are likely to wind up having more of when they pay more for a program and less of when they go to a less expensive center that cuts various corners, even if that cutting is done intelligently or efficiently. This is why our outcome statistics are _very_ favorable.
Dr. Ortiz Adds...
I would, if I may, like to take this opportunity to add a few words to the wonderful description just given by my esteemed colleague Dr. Martinez (who I try to keep in the OR as much as possible least his clear articulation outdoes me in the patient education role… :) :)…. )
Regarding teamwork, there is another even more important advantage to having two surgeons. Over the years I've found that having Dr. Martinez around has really helped me learn at a faster rate and to be less afraid to try new things. After we've done something several hundred times a certain way and have gone through the same learning experience he will sometimes say "why don't we just do it this way?", and I'll think to myself "… that's right….that's exactly what I've been thinking," but for whatever reasons I hadn't yet gotten around to actually saying that myself, or the reverse will happen.
The impact is that we're less likely to remain stuck doing things that could be done better and more likely to move to the next iteration. In a way it is kind of like once or twice a year weight loss surgeons have these big meetings where they all present their findings and compare notes and discuss methods. Having a really good surgeon as a partner is kind of like having a mini 24/7 version of that where we can constantly throw ideas back and forth at each other.
Mind you, when I'm talking about improvements here please understand that these are very particular specific aspects of the procedure. It's not like we're making stuff up as we go along day by day. Rather, we're talking about very careful, intentional, specific refinement of the details. It's like if you compare, say, a luxury automobile with a non-luxury automobile and ask "what is the difference between these two?", the answer usually pertains to the fine details of craftsmanship in all the nooks and crannies. The same applies to surgery. If you are at a high volume center where you can do a particular, say, stitch in exactly the same way for 500 patients, and if you start doing that same stitch in a slightly different way for the next 500 patients, and you compare the two, then sometimes that can make a big difference in surgical success.
Over the years patients have wisely asked us all the time what procedure might be the best and we always tell them that outcome has a lot to do how invested a surgeon has been, in millions of ways, into making that particular surgery type -- or all of the types that he performs -- successful. You could have two different surgeons perform two very different kinds of surgeries but those surgeries are still technically the same surgery type. Meanwhile the same surgeon could do two different procedure types but the overall experience of those patients might have more in common with one another than with those of the same procedure at other centers. The overall program and how it is run makes a big difference. If the program is a good one, then most patients could experience success with any number of different procedure types.
That addresses the other part of the question….if having two surgeons means it costs twice as much. I can understand how surgeons get -- and deserve -- so much attention at some level, but when it comes down to it, just like with the technical aspect of the actual procedure, what matters in an entire program are all the details. Could we, for example, get by with only 1 receptionist? Yes. Could we get by with merely double redundancy in the OR versus quadruple? Yes? Could we skip investing tens of thousands in our mobile patient followup app? Yes, those and hundreds of other things that would save money.
Perhaps the most important question a patient can ask is how much a center has invested in its overhead where if there is, say, an economic downturn then there is real risk there where that surgeon has an investment to protect and keep together, the way we've kept so much of our family together over the years. You need to look at the big picture. So, would I say that two surgeons are better than one? In our case, sure, but patients are more likely to succeed in their choice of programs when they understand why that can be the case.
As an upshot, this comes down to why our outcome statistics are so good. Our patient success rates -- as best as we can track there -- but also our very low operative risk rate. We keep all our patients with us for five days after surgery where we know _everything_ happening and we also have a VERY good idea of they they are for the first month after surgery in particular, and then for months and years after that. Our rates of complications are extremely low. True, we do have some selection bias -- our patients tend to be more highly motivated, more high on the socioeconomic/functioning ladder, and healthy enough to travel; that's certainly _part_ of why our outcomes are so far off the scale above "average" for "weight loss surgery" overall.
The real benefit, though, comes from that PLUS everything else we are talking about above… from the larger number of surgeries (15,000), to the long period of teamwork, to the entire center approach. We don't talk about these things just because, say, we like to brag -- though there is that joke about what the difference is between surgeons and god ** -- but, rather, because it's simply what we do, because it's who we are, because though less important than, say, family or other things, we are put simply just super passionate about these kinds of things. So, after my colleagues excellent answer I just wanted to add those two three extra statements. :)
** God doesn't think he is a surgeon.
Test Yourself
After reading the above, feel free to see if you can answer any of the following (we all just desperately miss being in school, right?):
1. How long might a typical procedure last?
2. What is a specific clinical complication that can happen as a result of surgery?
3. What are some of the things that make any surgery risky?
4. What are some of the advantages of having two surgeons doing surgery at the same time?
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