Who guides the surgeon’s hand?
Have you ever wondered what happens during surgery? Who guides the surgeon’s hand when removing a tumour from a patient? Behind the scenes, pathologists work away to help surgeons while they operate to provide a specific diagnosis or advise the surgeon whether or not they have removed all of a tumour. We speak to new RCPA president, Doctor Michael Dray, Anatomical Pathologist and Clinical Director of Laboratory Services, Waikato District Health Board, who explains the important relationship between a pathologist and a surgeon.
“An intraoperative consultation (IC) takes place during an operation when a surgeon requests an opinion in order to guide immediate surgical management. A tissue sample will be taken from the patient, and the pathologist will need to process it, examine it under a microscope, formulate an opinion and discuss that with the surgeon, all whilst the patient is still under anaesthetic. The surgeon will then use this information to decide how best to proceed.
“An IC could be unexpected or could be planned. For example, if the surgeon comes across something unexpected during surgery, then tissue will be sent off for examination. In planned circumstances, a surgeon may want to know the status of an axillary lymph node prior to considering whether to proceed with an axillary dissection, or may require the margins of a piece of skin on an area which is technically demanding to operate on, such as around the eye, a nose, or the face,” said Dr Dray.
A frozen section refers to the examination of tissue which is taken intra-operatively to give the surgeon a preliminary diagnosis. Once removed, the surgical specimen is sent to the lab immediately and will be examined by a pathologist upon arrival. Instead of the usual method which involves leaving the tissue in formalin to fix for a number of hours before cutting and staining it, it will be frozen using a cryostat or liquid nitrogen. The sections then are cut, mounted and stained by the medical scientist or anatomical pathologist. This reduces processing time from a day or two to 10 to 20 minutes, and the whole process takes place whilst the surgery is still in progress.
Frozen sections performed during ICs can be used to establish the nature and extent of a lesion, to determine the status of surgical margins and to confirm that sampling of lesional tissue is sufficient for further investigations. What the pathologist finds will determine whether to cut out the tumour, or to transfer the patient to a medical ward for antibiotics.
“It is technically demanding for our scientists and technicians to prepare something useful to look at. In practice, this whole process can sometimes take upwards of an hour, and that can depend on lots of different variables. For example, the tissue provided could be really difficult to process, for example fatty tissue does not freeze very well, or there may be multiple specimens to asses meaning it could take a while to process them all.
“Sometimes the pathologist has to express a degree of uncertainty about their findings so having a collegial relationship, where responsibility and authority is shared, makes it easier to say, ‘I am not sure’ and express your thoughts about being 100% certain. The relationship between the surgeon and the pathologist is therefore extremely important. Together they are a team, and 100% of those interoperative consultations should have some influence over the ongoing management of that patient,” said Dr Dray.
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This article appeared in the December 2019 Edition of ePathWay which is an online magazine produced by the Royal College of Pathologists of Australasia (http://www.rcpa.edu.au/Library/Publications/ePathway).
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