A Day With Didier Ducournau, MD

Vitrectomy a Frenchman’s way

PAUL E. TORNAMBE, MD

I thought I knew everything about vitrectomy surgery and operating room efficiency, and then I spent a day with Didier Ducournau, MD, who practices in Nantes, France. I will affectionately refer to him as Didier, whom I have known for 15 years, in the same way that my mentor percussion instructor, who played with the New York Philharmonic, referred to Leonard Bernstein as “Lenny.” My only regret is that I did not visit Didier 15 years ago!

Didier has a different approach to vitreous surgery — one from which many of us in the United States might benefit. Change is difficult, especially for surgeons. To paraphrase Sir William Osler, surgeons are a curious bunch: when they learn of something new, they say it is not true; when they find out it is true, they say it is not new and that they have done it that way for years.

Here, I will first describe how Didier created an OR protocol and team capable of performing four vitrectomy procedures per hour, followed by a description of his operative technique.

OR PROTOCOL

At a time when the Relative Value Scale Update Committee (RUC) of the American Medical Association is about to devalue vitrectomy surgery compensation, we must either adapt or continue to operate in the same inefficient way and possibly go bankrupt or drop surgical retina from our practice.

I undertook time motion studies a decade ago and concluded that retinal surgery, similar to crime, does not pay. The present RUC wisdom is that, if a surgery can be performed in less time, it should be reimbursed at a lower rate. The reasoning is completely irrational, but that is how RUC government pawns think.

Would you pay an oral surgeon more if he/she took an hour to perform your root canal vs 10 minutes? Years ago, it may have taken two or three hours to perform a complicated vitrectomy, but it now takes an hour; therefore, the RUC concludes we should be paid less.

Not considered in the payment formula is the uncompensated continuing surgical education time to learn the new technology and to apply it safely for our patients. The fixed overhead time component is also not considered, such as traveling to the OR, waiting for the ortho case to finish, setting up the microscope, training the ever-changing surgical techs, which adds time to the procedure, speaking with the family before and after the procedure, performing conscientious postoperative care, and complying with ever-increasing hospital rules and regulations to assure patient safety.

This does not include dictating the operative note, reviewing and signing it later, or maintaining hospital privileges, which may mandate attending monthly surgical meetings, provide free ER calls, and of course, obtaining many hours of expensive CME. How can we become more efficient? How can Didier perform 1,800 vitrectomy operations per year (or 35+ vitrectomies per week)?

The answer is, his team, and I mean team, pulls together, and he is captain of the ship. Cases are managed his way or the highway.

Dr. Didier Ducournau

The Ducournau Way

Didier operates in his own doctor-owned facility in Nantes, which has 25+ ophthalmology doctors, a referral base of 500 ophthalmologists, 70 overnight beds for patients who come long distances (48% of his operations are on people more than 200 miles from his office), and a five-room OR.

He performs 90% or more of his procedures under general anesthesia. Didier prefers general anesthesia, and only the anesthesiologist determines who should be treated under a local. Patients are intubated in a large preoperative room about 50 ft across the hall from his OR. The patient is then disconnected from the anesthesia machine and whisked to the OR suite in about 20 seconds and reconnected to the anesthetic apparatus.

There are marks on the OR floor where the gurney is placed, positioned exactly each time beneath a ceiling mounted Zeiss Lumeris (Carl Zeiss Meditec, Dublin, CA) scope with slit-lamp capability. Five pumps of the gurney raise the head to exactly the correct position.

Didier applies povidone-iodine to the operative field himself, and then he drapes the surgical field. Once the operation is complete (for ERMs and holes about 10 to 15 minutes), he patches the eye, and the patient is disconnected from the OR anesthesia machine, moved out of the OR, and, in 20 seconds, reconnected to the postanesthesia care unit anesthetia machine, again about 50 feet from the OR, where the patient is extubated by the anesthesiologist and managed by the recovery room nurse.

The surgical tech is responsible for generating the operative report, which is done at the end of the day. The floor is mopped and in three or four minutes, and the next intubated patient enters the room to repeat the process.

The team consists of one anesthesiologist and one nurse anesthetist, who monitors the patient while the anesthesiologist is either extubating the last patient or intubating the next patient. There are of course a preoperative nurse, a postoperative care unit (PACU) nurse, and, in the OR suite, two circulating nurses. Each case has a separate OR pack for new cases, consisting of scissors to cut the drape, spring scissors, a few muscle hooks, DORC (Zuidland, the Netherlands) valved cannulas, DORC Membrane blue stain, and DORC Eckhart ILM forceps.

A Day With Didier

We started the surgical day at 8:30 a.m. and completed the 10th case by 11:30 a.m. Almost all were simple epiretinal membranes, vitreomacular traction, or uncomplicated cases of patients with diabetes. The more complicated cases were scheduled for after lunch.

During lunch, Didier spoke to all of the families; some patients were sent home, some would be seen the next day, and all of them will be checked in one month, geography permitting. All of the patients are on eyedrops for about a month.

Notably, the same scrub nurse assisted in all 10 cases without a break. The take-home message is that the surgeon and anesthesiologist only did doctor stuff: all of the other tasks were left to nurses or techs. Didier never picked up a pen or dictated a word. He only performed surgery.

Contrast this to my hospital OR experience. I arrive at 7 a.m. for a 7:30 case. Although I’ve been operating there for more than 30 years and have done thousands of cases, I’ve somehow screwed up the new, confusing hospital EHR order for cyclopentolate drops (actually the system has deleted it). The preoperative nurse, who has worked with me for 20 years and instills cyclopentolate in every case, is forbidden to put in a drop without my computer-generated order.

I must see the patient in the preoperative area, mark the eye, again ask the patient if there are any questions, answer a few questions for a family member, and complete two sheets of paperwork verifying that I am performing the operation. The patient again consents, and I verify that the medical status of the patient has not changed since the history and physical examination were done two days ago.

The nurse verifies a history and examination are on the chart. The patient then is wheeled to the OR, where either I administer local anesthesia or the anesthesiologist intubates the patient. It is a difficult intubation. The anesthesiologist is anxious because he/she knows that I want to get the case started.

Finally, the patient is intubated, the table is turned, and I bring the microscope into place. The scrub nurse preps the eye while I have already scrubbed and am waiting to start the operation. There is then a time out to verify the patient, operation, and eye. We all agree.

The 7:30 case starts at 7:50 and takes 45 minutes to an hour, the circulating nurse leaves for a mandated break in the middle of the case, leaving a nurse not experienced with retina or familiar with the case to find another extrusion soft-tip cannula, which the scrub nurse trainee has dropped on the floor, and to forget about trying to hook up the laser.

The case otherwise goes well. The patient is extubated in the OR but takes longer than usual and 15 minutes later, the patient is taken to the PACU. The room is then cleaned. I dictate my OR report. The hospital wants me to use Dragon dictation software (Nuance Communications, Burlington, MA), so they don’t have to pay a transcriptionist, which I refuse to do, arguing my time is more valuable than theirs.

I talk with the patient’s family, give postop instructions, and schedule the next day’s visit. The OR is not ready to accept the next patient because the room is still being readied. I go to the doctor’s lounge and consume junk food. About an hour following the conclusion of the last case (around 10 a.m.), I start my second case.

At this rate, I do five cases in 10 hours; Didier does 10 cases in three hours. Didier is paid about the same amount per case as Medicare pays me, and he drives home in his Bentley at 3 p.m. I drive home in my Chevy Volt at 7 p.m., exhausted, stressed, and wondering why I’m still challenging my coronary artery patency doing poorly paid surgery in the hospital OR.

I’m sure Didier makes many faux pas if judged by Joint Commission on Accreditation of Healthcare Organizations rules and regulations, not to mention hospital regulations. I doubt that our anesthesiologists would take the medicolegal risk of taking an intubated patient away from the anesthesia machine for 30 seconds and wheeling him/her to the OR or to the PACU or incorporating a nurse anesthetist into the team. I do know that, unless we do something differently in the United States, it will be increasingly difficult to afford the luxury of a surgical practice.

VITRECTOMY SURGERY IN 15 MINUTES?

Although Didier has been interviewed in non–peer-reviewed journals regarding how he performs vitrectomy surgery, I’d like to share my observations and perhaps validate his work.

When I recently spent the day with Didier, I found he has creative genius and thinks outside the box. His surgical approach is quite simple: he addresses the task — no more, no less. He removes all extraneous, nonproductive maneuvers. We started the morning at 8:30 a.m.; by 11:30 a.m., we had completed the 10th case. All were macular surgery problems, puckers, and VMT. All included ILM peeling.

Didier does one major thing differently than the rest of us. He uses the slit lamp feature of the microscope (in this case, a Zeiss Lumeris) instead of a light pipe. This not only provides an exceptional view of the retinal surface, but it also frees one hand to perform scleral depression, maintain contact lens centration, or help steady the instrument in the fellow hand during sophisticated maneuvers, such as ILM peeling.

Didier trained with Mireille Bonnet, MD, who was the first to describe scleral buckling surgery done with the microscope using a three-mirror lens, and Didier applied that experience to vitrectomy surgery. He uses this approach in all vitrectomy cases, with no widefield viewing system. There is also no indirect ophthalmoscope in the room.

He uses the microscope slit-lamp feature, which is built into the Zeiss Lumeris scope and an FCI (Paris, France) plano concave lens for all macular work. FCI also makes a disposable three-mirror lens for peripheral viewing. DORC cannulas (#23) are inserted into the pars plana at 10 and 12 o’clock in all eyes, right or left. The infusion cannula is placed at 12 o’clock, and the vitrectomy instruments (vitrector, forceps, scissors, etc.) are inserted at 10 o’clock (Didier is right handed). He noted the slit lamp view is better in phakic eyes, although I thought the pseudophakic views were excellent.

For macular pucker and VMT, Didier begins 23-gauge vitrectomy over the macula under high magnification. He uses the DORC EVA machine (to be released in the United States later this year) in the flow-controlled mode only; he never uses the Venturi feature. His usual cut rate does not exceed 800 cps, even when dealing with mobile retina. For macula cases, he removes only the deeper vitreous gel over the macula and obvious vitreous opacities, while he tries to leave a cushion of vitreous anteriorly to protect the lens. He also feels avoiding the anterior vitreous minimizes traction at the vitreous base.

In macular hole cases, Didier he removes more midvitreous but tries to preserve the anterior vitreous. He only performs vitreous base shaving for retinal detachments. He determines when all the posterior vitreous gel is removed by the sound the instrument makes in gel vs liquid (higher pitch means higher viscosity due to the vitreous). This takes a few minutes.

He then inserts a few drops of DORC Brilliant blue (not available in the United States), which lightly stains the ILM and negatively stains the ERM. He currently uses the #23 DORC Eckardt end gripping forceps (he is developing an aspiration-capable ILM forceps) utilizing a pinch-and-peel technique, and he removes the ILM broadly (about a one disc diameter radius from the fovea) in about 30 seconds. He will occasionally restain with Brilliant blue to be certain that all ILM was removed because he believes this evokes “healing” by Müller cells, decreasing leakage and macular edema.

He never injects intravitreal steroids because he feels this inhibits the Müller cell response. He never examines the periphery at the conclusion of these routine cases, and he notes his RD rate is about 1.9%. No air is injected for puckers or VMT.

For macular holes he injects 3.2 mL of 50% SF₆ with a two-needle technique. He does not use face down positioning for macular holes. At the end of the case, the cannulas are removed; sutures are usually not necessary. The total operating time is 15 minutes or less.

FINAL POINTS

Didier notes he is now slowing down and performs “only” 600 cases per year (he used to do 1,800 per year), and he has two associates to help carry the load. Obviously, he does many things differently than we do in the United States, but his outcomes are probably the same.

This makes me pause and question whether we are doing more vitreous removal than necessary. Will limited vitrectomy decrease the incidence of postvitrectomy cataract? Does a light pipe help or hinder macular surgery? Avoidance of a light pipe may provide less photic stress on the macula and certainly is more cost-effective.

I questioned Didier about a limited vitrectomy for ERMs, specifically regarding patient complaints of postvitrectomy floaters and RD. He states his RD rate is about 2% (the same as after cataract surgery), and patients don’t complain about floaters. Jerry Sebag, MD, has reported in this magazine that he has been removing floaters with limited vitrectomy and has had about the same incidence of RD as we see with more complete vitrectomy surgery, verifying Didier’s experience. As with many retinal disease treatments, less may be better.

I would encourage retinal surgeons to consider this approach. I would even suggest a trip to Nantes! RP