Several months ago, I took a dog to surgery for an abdominal exploratory. It was somewhat involved but successful. When closing a dog surgically, there are 3 layers. The first is the body wall. It is the single most important layer of all. If those sutures come out, the intestines and other organs will fall out - often under the skin, since the other sutures will stay in. One of the first things you learn in surgery is how to make sure your body wall closure is perfect. The next layer is the subcutaneous fat and tissue. This is mostly to bring the incision together so that the skin sutures (or staples) look neat, and the incision is lined up. I will reiterate - the layer that matters is the body wall.
In school, you have to close the body wall with simple interrupted sutures. This means you make a knot, then cut your suture, then make another knot, and so on. In an abdominal exploratory surgery where the incision can be a foot or more long, this can be enormously tedious and time consuming, as well as unnecessary. Once you are a confident surgeon, simple continuous (rather like a whipstitch) is perfectly acceptable.
Back to the story: I finished my body wall suture and cut the ends of my suture. I looked at them and thought, "those might be too short...they might come out." Then I mentally lambasted myself for being such a damned worrywart, checked everything, and continued. I do tend to be overly, overly careful in surgery and often fret about things that - in retrospect - were not worth fretting over. Something bothered me about this closure, though.
Longer story shorter: 3 days later, the dog came back in for dripping from his incision. His skin sutures were still in, as were his SQ. However, as I ran my hand down the external body wall, I could feel my fingers go into a cavity. The sutures had come out. I delivered the bad news to his owner. I had to go back in and fix the sutures. The owner had already spent well over $2000 on the surgery, and finances were rapidly becoming tight. They were emotionally distraught.
I asked her had she been letting the dog, Flip, jump, run, or play excessively? She turned positively green and admitted that Flip had been jumping in and out of her huge SUV for the past several days. Additionally, he had been rough-housing with the other dog in the house.
And therein lies the question: had I known that the dog was appropriately cage rested as recommended for any major abdominal surgery, I could say for sure that it was my sutures that failed. Yet, she had been letting him jump in and out of her Escalade - putting enormous strain on his abdominal incision. Further, he was wrestling with another dog 2 days post-exploratory. This is a huge no-no. Still, there was that nagging concern I'd felt when I closed the dog up that the sutures wouldn't hold for some reason. Was this me just fretting, as I always, always do, or did I have a legitimate concern? As I said, had I known that the owner had followed the post-op care instructions to the letter, I would have gladly replaced the sutures for free. Yet, I knew she had not - and I couldn't decide who was to blame - me or her, or even a combination of both.
In the end, I did not tell the owner of my concerns. Why? Because I cannot separate my natural sense of worry about any surgery I do from the reality of it. The knot was secure, but the tags were shorter than I usually cut. Had the dog been rested, though, I don't think there would ever have been a problem. I don't think. But I don't know.
Striving for an ethical compromise, I charged about 1/2 of what I would have had I know for sure that it was the owner's fault.
It still bothers me because it's such a gray area and I truly don't know the answer. The dog did wonderfully and is fully recovered. Had I overdosed him on a medication, had I cut him accidentally when taking his catheter out, had I let him fall off a table and break his leg...I would have taken full responsibility because I would have known that those things were my fault.
In this case, I have questions but no answers. Don't judge me too harshly.