David W Kim M.D. | Rhinoplasty Specialist


What Really Happens In The Operating Room?

Have you ever wondered what really happens in the operating room when a patient has no idea what is really going on? Dr. David W. Kim describes what happens in the operating room when he performs rhinoplasty. He describes how preparedness and routine are the key aspects of successful surgery. Dr. David W. Kim is one of the world’s leaders in rhinoplasty and lectures internationally about rhinoplasty techniques and philosophy.

Hi this is Dr David Kim and this is another video blog about rhinoplasty.  This is a little bit of a different topic compared to the surgical topics I have discussed before.  I was inspired by a patient who recently asked me about the details of what exactly happens in the operating room, not necessarily from a surgical perspective but from an operational perspective.  And it’s understandable for an individual who is going to go through anesthesia and who is going to lose control over the situation, being in a state of vulnerability who may want to know exactly what happens.  I produced a power point in recent months trying to explain to beginning surgeons in terms of what you can do to stack the chips in your favor so that your rhinoplasty can go well, in terms of operations and logistics in the OR.  I took pieces of this presentation and tailored it to try make it appealing to perspective patients or lay people.  I would like to share that with you today.

This is the presentation “what happens in the OR”. Now unfortunately if you let your imagination get away from you, you might think it’s all kind of chaos and pandemonium is happening in the OR.  In reality this is not what typically happens in most situations.  We must remember that what happens in the OR is just one point in the continuum of care for the rhinoplasty patient.  And in terms of what I can do as a surgeon to make sure the rhinoplasty goes well.  I have to think of everything that leads up to the surgery as part of OR experience.  Abraham Lincoln had a famous quote “If I had 8 hours to chop down a three, I would spend 6 sharpening my axe” and it’s the same thing it’s all in the preparation.  This slide shows the lifelong journey of a surgeon.   The patient might come in for a consultation but may not realize all the things that have gone previous to that appointment to make sure that that surgeon is a capable and competent individual.  The development of skills, the development of the reputation and then the first point of contact.  And between that point and the surgery so much is going on with the consultation, managing expectations, developing a reputation, planning the surgery, screening, reviewing the night before the surgery and all the check listed items that are conducted during the day.  Following the surgery there are a whole list of other follow up items that can ensure the patient is in a good place to maximize the chance that the outcome will be good.

The surgeon is really executing a complicated task which is demanding of one’s mind and body.  This requires experience, judgment and skill on the part of the surgeon but it also requires a lot of focus, stamina and hand eye coordination.  And like success in sport, I think success in surgery really come from preparation in lots of things.  As a sports fan I like these analogies, practice is important, repetition, owning your skills, studying the game (really analyzing the individual as well as general principles that guide you in surgery), taking care of your body, preventing injury, making sure your optimal going into a particularly long case and approaching the challenge with intensity, not taking it lightly and being very serious and ready for game time.

I think it is really important to put our patients in a favorable mental and emotional state so I check in before and after surgery, I try to be very welcoming to invite the opportunity for questions to put them at ease.  I think it’s very important to demonstrate compassion to patients, particularly in the vulnerable moments before surgery.  When we are using a team of assistants during surgery.  In addition to the surgeon the operating team includes, the nurse, the scrub tech who assists the surgeon, an anesthesiologist and a recovery nurse.  It is really critical that if the surgery is to go well that you have a team that is familiar with everything that you are doing and we call this the A team .  This is my A team.  These two girls work with me for the majority of my cases, they know all my preferences.  Because of that they know exactly what to do to make sure the chips are staked in our favor so that the surgery goes well.  In those situations where I am not able to use my normal team for example, if I have to work out of another hospital, I spend time with those personnel to go over my instruments, over my set up, over anesthesia, over every sequence of events so there are no surprises.  It is really important to follow a routine.  In my case, I position the table 180 degrees away from the anesthesiologist so that I can stand behind the head, to the side of the head.  I tuck both their arms along the side of the body so I can get really close to the patients.  There are a lot of other technical things in this slide related to draping.  We tape the eyes closed to prevent any injury to the cornea.

There is a very specific tried and true regiment we use for anesthesia.  General anesthesia is safest because it allows us to protect the airway.  We incorporate something called the BIS monitor, which means the bispectral index brain monitor.  This is a very sophisticated apparatus which measures the depth of anesthesia by measuring brainwaves through EEG.  This allows the anesthesiologist to minimize the amount of drugs that are used to keep the patient asleep because they can monitor how deep a sleep the patient is in.  There is no guess work so you don’t have to overshoot by giving too much medication, which allows for easier emergence from anesthesia and reduced risks.

I as a surgeon, before starting a case, place a small gauze pack in the throat to prevent blood from trickling down to the longs or the stomach.  I use a marking pen to mark out each of the landmarks though the surface of the skin so I know what to do in the undersurface.  I inject numbing medicine which reduces pain and also lowers the drug requirement that the anesthesiologist has to give the patient.  There is also epinephrine contained in this medication which reduces bleeding.  Medicinal cocaine is also used on gauze to reduce bleeding and then I review the preoperative photos and notes.  In fact I actually tape up all notes, photos, even email correspondences I have had with the patients.  If they are revisions, I use old operative notes taped up on the board or on the sidewalls so I have this as a point of reference.  This is very helpful to keep me on the right game plan during surgery.  I have a set of key instruments set up at every facility.  We set it up the same way each time so there is nothing unfamiliar at the time of surgery.  I then try to follow a basic sequence of steps.  I generally reduced the bridge if that is necessary.  I work on the nasal bones.  I harvest cartilage from the septum or other sources if septo cartilage is not available.  I then work on the middle vault or mid portion of the bridge, the nasal tip, the nostril base.  I then repeat these steps if any adjustments need to be made and then I fine tune.

I repeatedly check my work against the photos, the notes, the morphed images.  I put the skin envelope down into its anatomically position and make sure that the contours are correct through the skin.  I then walk around and look at the nose from all angles to make sure I have gotten it right.  Meticulous closure is very important.  I will not hesitate to undo a stitch or undo any maneuver to correct any little issue or problem.  We then use taping and splinting usually without packing to stabilize the nose.  After surgery I ensure that the patient is safely awakened and excubated and transferred to the post anesthesia care unit.  I touch base with the family or friend, I talk to the patient when they wake us as well as call later that evening or the next day.  I hope you now have a better understanding of what happens in the operating room.  Preparation is everything.  The surgeon must be ready and able to execute all of the steps that are necessary to create and excellent rhinoplasty outcome.  This involves doing the homework, being mentally and physically ready, selecting the right team and following a protocol that is the same each time or as close to the same each time so that no mistakes can be made.  When you combine this type of disciplined approach with the experience of a capable surgeon, good judgment and a good patient you are typically going to get an outstanding result every time.

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