Ok life has become really boring without operation rooms.

Let’s get into details, we’ll comment on all the details of this video, the mistakes, the maneuver being done, the anatomy, the condition itself and the alternatives available nowadays to make this less brutal!
3, 2, 1 Go

Before you say oh that’s not my area to work on, there’s a good chance you might need to do this once in a life time, be a general, cardiac, vascular, thoracic, trauma, acute care or less likely an ENT surgeon :)

Medical students: this is not NETFLIX. It’s more of a snuff film.

Ok start guessing what’s happening, it has something to do with the tracheostomy you see in there.

Why do you think he’s moving?

So, let’s break down the events:

A sentinel bleeding after tracheostomy has been there few days to few wks post insertion, then massive bleeding. This is a tracheo-innominate fistula and it’s the most dramatic complication of tracheostomy insertion.rate is 0.1-1 % of the cases

It happened in the morning time so the patient was lucky (or not maybe), they managed to take him directly to OR after the surgeon who saw him did a maneuver called “UTLEY MANEUVER”: compression of innominate art. In pretrachial space against the sternum. Stops bleeding in 90%

It’s unlikely that anesthetist wasn’t around at that time, my guess the pt. was moving & awake because they thought he’ll collapse if given any drug before they control the bleeding.

Just like you prepare everything before you open a pt. for rupture AAA

Any anesthetist opinion?

The sternotomy was carried out with a Lebsche sternum chisel knife. To be honest that was quick and good, maybe even quicker than a electrical saw which might not always be available. Again the patient shouldn’t feel pain at that time, and you feel less pain when you are bleeding

You can see they managed to ligate the brachiocephalic artery (innominate).
One mistake here is that the assistant keeps showing he wants to do sth instead of helping the surgeon on the right. That lead to injury of a vein after ligating the artery. NO SUDDEN MOVEMENTS ALLOWED.

Alternatives to this? If you are lucky enough to diagnose your patient before it’s massive bleeding, you can go for endovascular stenting of the innominate artery; either with retrograde carotid approach or via brachial approach. COVERED STENT will do the job nicely. No drama !

This procedure gave the patient few extra days only. It doesn’t come without a price. 50% mortality. Risk or stroke (remember no more carotid!) , risk of injury to many vital nerves and structures. We don’t do this unless it’s death vs life.

Patients take huge risks, always!

This doesn’t happen everyday, but looking into these cases makes you realize:
Being a surgeon is all about:
- solid anatomy knowledge
- being calm
- quick decisions
- accepting consequences

Think always of alternatives and “what did I do wrong?” And above all, respect your pt.

Read more about the topic: (I have one patient suspected to have the fisula, and I don’t want that video to be filmed again :) )

https://reader.elsevier.com/reader/sd/pii/S0007091217352753?token=C9C2AF5204BC9AD6664B158B30D0557EC6A736FBD05A20065F24AA115F788C279E942AE961E963CEBC11C7A09BDE34CE

Residents: if there’s only one enough advise; it would be “be prepared for the worse no matter how unlikely it sounds“

Oh and one more thing:

DRAPES & STERILITY for god sake, if he’ll survive everything, he would die of mediastinitis !

Being quick doesn’t mean you bypass the rules.Even life saving situations have rules. Sticking to rules make them habits.

Being a surgeon by habit is awesome!