12 May 2010

Never get complacent

It is not everyday that you look down, and your "routine" breast case has turned into a chest case. THANK goodness that it is not everyday!!

Young woman--35--diagnosed with breast cancer 3 years ago. At that time, she had her (unilateral) mastectomy and tissue expander placement. Then, skin necrosis and excision, followed by failed tissue expander--they were unable to expand...

So, she went through her chemo, never had radiation, and we come to this year and her care with me. Back in February, I exchanged her tissue expander for a new one (in fact, there was a hole identified in the old one--presumably from a needle stick). I expanded her over the next 3 months. She is finally happy with size, so we schedule an implant swap--gel (silicone) in place of saline tissue expander--and to augment the other side to match. Enter yesterday...

Cancer side: trying to release capsule, I made a plane inside the pectoralis. I caught it right away, but still... not the way things are supposed to go. "Prophylactic side:" Tooling along, releasing the pec and suddenly I am looking at lung. It was not my day.

Cancer side: oversewed muscle plane and started over again... finished capsulorrhaphy and placed implant--success.
Prophylactic side: oversewed intercostal muscles over a red rubber catheter, oversewed with pec... got a post-op chest xray: tiny apical PTX

Kept her overnight, got serial chest xrays. She is fine, felt greal this morning, pneumo is resolving, and she went home. She feels like a queen, and couldn't stop thanking me. I feel like crap. I consider myself a safe, conscientious surgeon--not a cowboy or careless. How could this happen?! I have heard from a few people that the only way to become an expert is to make and overcome the mistakes.

So, maybe I don't want to be an expert!!