Intraoperative decision-making process: The art and the science

Surgical procedures related to complex problems of the gastrointestinal (GI) tract carry significant risks and complications, whether performed alone or in combination with abdominal wall reconstruction. Despite the most conscientious preoperative preparations, surprising events may still occur. If the operation takes an unplanned turn, the surgeon has to make difficult decisions. An absolute must is continuous awareness of the intraoperative patient’s physiologic status—including fluid status, urine output, use of blood and blood products, bleeding, current medications (such as pressors), and biochemical endpoints of resuscitation, such as base deficit and lactic acid. Even when the operation is going well, the biochemical profile of the patient may not be optimal or even satisfactory, which may directly affect the outcome. In addition, the surgeon must recognize his or her own physiologic status; if tired, for example, cutting corners and making major errors are likely to occur more frequently. We discuss these and other elements that are important for the intraoperative decision-making process.