Subinternship Surgery · Year 4 · from Subinternship Surgery
Case 3: Intraoperative Decision-Making and Discovering Unexpected Findings
Clinical Image
Source: Wikimedia Commons - Surgical Procedure - CC BY-SA 4.0
Case Presentation
A 70-year-old man undergoes planned right hemicolectomy for a cecal cancer staged as T3N0 on preoperative imaging. The operation begins with laparoscopic approach. During initial exploration, the surgeon notes multiple small nodules on the peritoneal surface of the liver and diaphragm that were not seen on preoperative CT. Frozen section biopsy of one nodule confirms metastatic adenocarcinoma. The surgeon pauses to consider the decision: the operation was planned as curative, but the finding of peritoneal carcinomatosis changes the situation to Stage IV disease, which is not curable by surgery alone. The attending discusses options with the assistant: (1) proceed with resection for potential palliation (preventing future obstruction/bleeding) or (2) abort the curative resection and pursue systemic therapy. The primary tumor is not causing obstruction currently. The attending decides to close, biopsy several lesions for complete staging, and defer further surgery until the patient and oncology can discuss systemic therapy options. Post-operatively, the surgeon has an honest conversation with the patient and family: "We found the cancer has spread to the lining of your abdomen in a way we could not see on the scans. This changes the situation significantly. We took biopsies and closed to allow you to recover. We will need to discuss with oncology what the best next steps are." The patient ultimately receives systemic chemotherapy, and the primary tumor is addressed later when he develops partial obstruction.
Key Learning Points
- Intraoperative findings may change the operative plan; surgeons must be prepared to adapt when findings differ from preoperative imaging
- When curative intent is no longer possible, consider whether the planned operation still provides palliative benefit or if aborting and pursuing alternative treatment is better
- Honest communication with patients about unexpected findings is essential; explain what was found, what was done, and what the revised plan is
- Multidisciplinary input (tumor board) often guides management after unexpected staging findings; systemic therapy may take precedence over surgery for metastatic disease