It takes a certain kind of arrogance to take knife in hand and carve into a living patient. To begin, no matter how you prepare or plan, nothing is ever quite as predicted. Little variants, as personal as fingerprints, ensure that no two patients are ever alike, and all those immensely detailed drawings found in the anatomy textbook are “really more like guidelines.” Only an idiot thinks it’s possible to wade into such a morass and maintain any semblance of control. I am that idiot.
I like surgery. There is something wonderfully satisfying about cutting into a patient and physically removing the disease from its body. Cancer surgery is particularly gratifying. One minute, a malignancy is threatening to destroy an animal’s life; the next minute, the problem tumor resides in a jar. Surgery cannot possibly cure everything and some cancers have extended far beyond the limited reach of a surgeon long before the incision is made, but when things are right, surgery can be a sweet, clean, definite solution in a world terribly full of what-ifs and maybes. At least, that’s the way it’s supposed to work – and it often does.
Other types of surgery present much less uncertainty. Wounds are fun: We start with an ugly rent in a patient’s flesh, often decorated with rocks or twigs or grass, and turn it into a clean happy closure where everything is in its place and infection will have no place to take hold. Fracture repair is a carpenter’s dream. A surgeon can actually look at the x-ray and plan (remembering that life is what happens when we’re making plans) and then go in there with pins and plates and wires and screws and all kinds of cool hardware to make that patient better! I feel sorry for carpenters: When I repair a fracture and a little piece of bone is lost or damaged beyond salvage, I know that my patient will heal and fill in the defect. It’s something that mere wood can never do.
Plastic surgery is gratifying. This type of surgery involves moving skin from one place to another to close a defect that would otherwise need to be healed as an open wound. There are a veritable alphabet soup of options: X-, Y-, and Z-plasty, sliding-H grafts, U-flap plasty, rotating and pivoting flaps, and freeform skin mobilization techniques that make it possible to close what would otherwise be impossible wounds left by tumor removal or injury. Another common form of plastic surgery refits eyelids whose margins curl inward (entropion) or outward (ectropion) due to congenital or acquired malformations. Plastic surgery allows these problems to be corrected, eliminating the patient’s discomfort when their eyes cannot close properly or when the eyelashes scratch the surface of the eye.
Knee surgery is my absolute favorite. The knee is a challenging joint with numerous internal and external ligaments, as well as a variety of other moving parts. Anterior cruciate ligament injuries are both common and crippling, particularly in large breed dogs. These are active, athletic animals whose quality of life depends on maintaining their mobility. A cruciate-deficient knee really hurts and renders the dog more or less three-legged. To make matters worse, a big fraction of the dogs that rupture a cruciate ligament will eventually break the opposite cruciate when the first is not repaired. That’s no way for a dog to live and cruciate repair surgery restores these patient’s ability to run and play. I favor the High-Strength Lateral Stabilization technique because I consider it the “tried and true,” reliable and relatively inexpensive way to fix a cruciate ligament rupture: patients recover quickly, walk well, and only rarely need additional knee surgery once repaired – very satisfying! See my previous articles, “The Cruciatus Curse” and “The Cruciatus Cure,” for a detailed discussion of the various cruciate surgery options. It’s a pleasure to see a big happy dog running around only three months after having its knee repaired!
Of course, cutting a patient causes pain, but our approach towards pain management – and especially pain PREVENTION – has really expanded in recent years. We now manage pain preemptively, with pain control beginning BEFORE any painful event takes place. Patients begin pre-anesthesia with a hefty dose of narcotic to prevent the brain and spinal cord from perceiving and thereby practicing the perception of pain BEFORE a knife ever touches the skin. Local anesthetics or local nerve blocks are frequently applied PRIOR to surgery, even though the animal is already asleep. Once the patient is anesthetized and the incision made, surgical wounds may be flushed with local anesthetics and narcotics to generate local pain control right down to the nerve-ending level. Non-steroid anti-inflammatory pain relievers are used in addition to local and general anesthesia to suppress pain through a completely different mechanism. Post-surgical pain control begins with a local anesthetic at the incision and often involves multiple doses of narcotic through the night, then continues with multiple pain relieving medications that are administered orally with breakfast the next day.
Because the patient’s pain has been so carefully suppressed, they don’t have a chance to practice feeling pain. Without practice, they don’t develop as much pain perception later during their recovery. The result is a more comfortable patient who is more active, goes home sooner, heals faster, and has a smoother, more rapid recovery.
Am I knife happy? Not always, but for certain problems, I’m happy to wield a knife.