Interscalene for shoulders: Concentrated vs dilute local?

[woopedazz]

I grew up giving people a dead arm for 18ish hours. A colleague of mine is advocating for low concentration blocks that give partial analgesia only; he states when patient's wake up they are comfortable, but don't have the dead/freaky sensation. He reckons they discharge early and cope fine.

I'm all for it, but in my mind I block them deep because it lasts longer. Not necessarily for the depth aspect; that's an unwelcome, but acceptable side effect.

I feel that using lower concentrations will result in optimal post op analgesia for a few hours, followed by significant pain thereafter.

I know of another shoulder guy who gets the best of both worlds and just places a catheter, which seems the best option, but I'm not sure how to go about initiating this practice when I hardly do any shoulders in private.

What local are you guys using? Still doing deep blocks like me? Or am I living in the dark ages?

---

Members don't see this ad.

 

[UscGhost]

Catheters are a bigger logistics challenge (leaks, postop calls, bandage changes) and not worth the hassle unless you have residents

I don't see the point in a light block. Patient just gets uncomfortable far sooner than otherwise would. Pretty rare for a patient to complain about a numb arm, they won't be using their arm for anything anyways.

Bupiv 0.5 20 ml, decadron 10mg IV or in the block. Tell them to take a Norco before bed. Add epi of available. Lasts 20-24hrs and patients do well.

 

[Hoya11]

I grew up giving people a dead arm for 18ish hours. A colleague of mine is advocating for low concentration blocks that give partial analgesia only; he states when patient's wake up they are comfortable, but don't have the dead/freaky sensation. He reckons they discharge early and cope fine.

I'm all for it, but in my mind I block them deep because it lasts longer. Not necessarily for the depth aspect; that's an unwelcome, but acceptable side effect.

I feel that using lower concentrations will result in optimal post op analgesia for a few hours, followed by significant pain thereafter.

I know of another shoulder guy who gets the best of both worlds and just places a catheter, which seems the best option, but I'm not sure how to go about initiating this practice when I hardly do any shoulders in private.

What local are you guys using? Still doing deep blocks like me? Or am I living in the dark ages?

I do a lot and I agree with your thoughts.

I like 0.375 percent at least for ISB

 

[LivetoTell]

I had rotator cuff + SAD,etc surgery at age 50. An acquaintance told me they basically just took Tylenol and Ibuprofen after the block wore off…
Well, after minimal opioid intake, but taking Ibuprofen & Tylenol, I gradually came into the worse pain of my life! At first it was like the pain was a 3, then 7, then 10+++ and nothing was helping the pain. I shamelessly went to my work, and had a colleague give me another block! I then proceeded to load up on all meds, where the next day I don’t even recall talking to the PA during the follow up appointment.

The pain is terrible! Rop. or Bup. 0.5% 30mls + dex/precedex. Maybe Exparel. The block should last as long as possible. The arm is in a sling anyway, who cares if it’s “dead.” I was lucky. I can’t imagine some plebe going to the ER for pain control and probably given some toradol if lucky, or a few laughs out the door.

 

[UscGhost]

I grew up giving people a dead arm for 18ish hours. A colleague of mine is advocating for low concentration blocks that give partial analgesia only; he states when patient's wake up they are comfortable, but don't have the dead/freaky sensation. He reckons they discharge early and cope fine.

I'm all for it, but in my mind I block them deep because it lasts longer. Not necessarily for the depth aspect; that's an unwelcome, but acceptable side effect.

I feel that using lower concentrations will result in optimal post op analgesia for a few hours, followed by significant pain thereafter.

I know of another shoulder guy who gets the best of both worlds and just places a catheter, which seems the best option, but I'm not sure how to go about initiating this practice when I hardly do any shoulders in private.

What local are you guys using? Still doing deep blocks like me? Or am I living in the dark ages?

I worked at a place that had an anesthesiologists who mixed lidocaine and bupiv in his blocks because he "didn't want them to last that long"

The pacu nurses hated it because the patients were in pain postop,and needed Norco and then nauseated....and then the patients were in more pain as soon as they got home.

Defeats the main purpose of a bupiv block.

Patients complain when the blocks wear off...they don't complain about numb arms

 

[coffeebythelake]

Catheters are a bigger logistics challenge (leaks, postop calls, bandage changes) and not worth the hassle unless you have residents

I don't see the point in a light block. Patient just gets uncomfortable far sooner than otherwise would. Pretty rare for a patient to complain about a numb arm, they won't be using their arm for anything anyways.

Bupiv 0.5 20 ml, decadron 10mg IV or in the block. Tell them to take a Norco before bed. Add epi of available. Lasts 20-24hrs and patients do well.

Why add epi

 

[UscGhost]

Why add epi

Extends the duration of Bupiv single shot block.

I don't add it separately but if the bupiv w/epi is available, I will use it over regular Bupiv

 

[UscGhost]

I had rotator cuff + SAD,etc surgery at age 50. An acquaintance told me they basically just took Tylenol and Ibuprofen after the block wore off…
Well, after minimal opioid intake, but taking Ibuprofen & Tylenol, I gradually came into the worse pain of my life! At first it was like the pain was a 3, then 7, then 10+++ and nothing was helping the pain. I shamelessly went to my work, and had a colleague give me another block! I then proceeded to load up on all meds, where the next day I don’t even recall talking to the PA during the follow up appointment.

The pain is terrible! Rop. or Bup. 0.5% 30mls + dex/precedex. Maybe Exparel. The block should last as long as possible. The arm is in a sling anyway, who cares if it’s “dead.” I was lucky. I can’t imagine some plebe going to the ER for pain control and probably given some toradol if lucky, or a few laughs out the door.

Yea, the challenge is the rebound pain.

Decadron appears to reduce that significantly. I also tell patients to take a Norco before bed, to help reduce the chances of that rebound pain.

Exparel is controversial

 

[coffeebythelake]

Extends the duration of Bupiv single shot block.

I don't add it separately but if the bupiv w/epi is available, I will use it over regular Bupiv

Does it??? Are u sure???

 

[UscGhost]

Does it??? Are u sure???

Traditional teaching said yes. Quick review of Google said a little longer although not impressively. Not nearly as much as decadron.

So..kinda sorta?

 

[gcc322]

Traditional teaching said yes. Quick review of Google said a little longer although not impressively. Not nearly as much as decadron.

So..kinda sorta?

According to literature, epi does not add to the duration of long acting local .

 

[psychbender]

I second decadron plus precedex. I had a colleague put that in my ISB cocktail, and never needed narcotics when the block fully wore off POD2. I think the other secret was constant icing.

 

[BLADEMDA]

I typically use 20 ml of volume for ISB. This study showed good results with just 5 ml of 0.5% Bup or 0.5% Rop. I agree with the addition of Precedex for certain subgroups where postop hypotension and sedation are not concerns. I have seen BOTH side-effects with Precedex added to blocks in patients. I recommend caution in adding Precedex greater than 0.5 ug/kg for outpatients particularly older patients.

Comparison of the Analgesic Duration of 0.5% Bupivacaine... : Anesthesia & Analgesia

of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were...

journals.lww.com

 

[BLADEMDA]

What We Already Know about This Topic

• Dexmedetomidine has been suggested to prolong the duration of regional anesthesia when administered by either the IV or the perineural routes, but these have not been formally compared

What This Article Tells Us That Is New

• In 99 patients receiving interscalene block with 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine prolonged the blockade and reduced the 24-h opioid use compared with placebo control, and these effects were similar whether dexmedetomidine was administered intravenously or perineurally

IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial

AbstractBackground. Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the...

pubs.asahq.org

 

[BLADEMDA]

Overall, peripheral DEX>60 μg increases the risk of adverse events, such as bradycardia and hypotension.

Optimal dose of perineural dexmedetomidine to prolong analgesia after brachial plexus blockade: a systematic review and Meta-analysis of 57 randomized clinical trials - BMC Anesthesiology

Background and Objectives Peripheral injection of dexmedetomidine (DEX) has been widely used in regional anesthesia to prolong the duration of analgesia. However, the optimal perineural dose of DEX is still uncertain. It is important to elucidate this characteristic because DEX may cause...

bmcanesthesiol.biomedcentral.com

 

[coffeebythelake]

We've been adding about 5 mcg precedex with our spinals to improve duration and density of block.

 

[ASA6]

I had rotator cuff + SAD,etc surgery at age 50. An acquaintance told me they basically just took Tylenol and Ibuprofen after the block wore off…
Well, after minimal opioid intake, but taking Ibuprofen & Tylenol, I gradually came into the worse pain of my life! At first it was like the pain was a 3, then 7, then 10+++ and nothing was helping the pain. I shamelessly went to my work, and had a colleague give me another block! I then proceeded to load up on all meds, where the next day I don’t even recall talking to the PA during the follow up appointment.

The pain is terrible! Rop. or Bup. 0.5% 30mls + dex/precedex. Maybe Exparel. The block should last as long as possible. The arm is in a sling anyway, who cares if it’s “dead.” I was lucky. I can’t imagine some plebe going to the ER for pain control and probably given some toradol if lucky, or a few laughs out the door.

On the other end of the spectrum I had a biceps tenodesis, SAD, Distal clav excision. I had a block with ropi + decadron. My hand was super tingly and really annoying. I was grateful for the block, I'm glad I woke up pain free and didn't get opioids, but I was definitely ready for it to wear off (which it did right at 24 hours). I took nothing except Tylenol, ibuprofen, and iced RTC for about 48 hours then needed only the occasional prn Tylenol or ibuprofen for the next two days.

 

[pgg]

Bupiv 0.5 20 ml, decadron 10mg IV or in the block.

Are you giving them that IV Decadron at the time of the block (awake)?

 

[UscGhost]

Are you giving them that IV Decadron at the time of the block (awake)?

With induction.

Otherwise they wouldn't be too happy with me

 

[woopedazz]

Are you giving them that IV Decadron at the time of the block (awake)?

I always block asleep. Low litigation risk here. You USA people block awake?

 

[Dr. Rude]

I always block asleep. Low litigation risk here. You USA people block awake?

Yes. High litigation risk here.

 

[Drwine]

I always block asleep. Low litigation risk here. You USA people block awake?

I always do upper extremity blocks awake. I want to be aware of paresthesias for example. Ultrasound is good but not perfect. Lots of possible damage to do in the neck with a needle. Leg or ankle not so much.
To answer the question, I want to maximize my block and don't dilute.

 

[jwk]

I had rotator cuff + SAD,etc surgery at age 50. An acquaintance told me they basically just took Tylenol and Ibuprofen after the block wore off…
Well, after minimal opioid intake, but taking Ibuprofen & Tylenol, I gradually came into the worse pain of my life! At first it was like the pain was a 3, then 7, then 10+++ and nothing was helping the pain. I shamelessly went to my work, and had a colleague give me another block! I then proceeded to load up on all meds, where the next day I don’t even recall talking to the PA during the follow up appointment.

The pain is terrible! Rop. or Bup. 0.5% 30mls + dex/precedex. Maybe Exparel. The block should last as long as possible. The arm is in a sling anyway, who cares if it’s “dead.” I was lucky. I can’t imagine some plebe going to the ER for pain control and probably given some toradol if lucky, or a few laughs out the door.

Isn't anyone using Exparel for ISB? I had it on mine - 80hrs of relief on my shoulder scope, comparable to the catheter ISB I had with my previous shoulder scope. The only thing that sucked was getting the phrenic on both of them.

 

[Dr. Rude]

Isn't anyone using Exparel for ISB? I had it on mine - 80hrs of relief on my shoulder scope, comparable to the catheter ISB I had with my previous shoulder scope. The only thing that sucked was getting the phrenic on both of them.

10ml Exparel + 10ml 0.5% Bupi.

 

[UscGhost]

Isn't anyone using Exparel for ISB? I had it on mine - 80hrs of relief on my shoulder scope, comparable to the catheter ISB I had with my previous shoulder scope. The only thing that sucked was getting the phrenic on both of them.

Data has never consistently showed any benefits to exparel vs regular Bupiv. So it was phased out for us.

In my experience, it was very unpredictable.

 

[IDGARA]

Isn't anyone using Exparel for ISB? I had it on mine - 80hrs of relief on my shoulder scope, comparable to the catheter ISB I had with my previous shoulder scope. The only thing that sucked was getting the phrenic on both of them.

I've never used liposomal bupi. Pacira tried to get FDA approval in 2009 with an active comparator (liposomal vs plain) and got it denied. It wasn't until they used a placebo in about 2013 that they got it approved. And even in 2013, the therapeutic benefit was only in the 0-12hr period. But they skewed the results by comparing pain relief in strange intervals: 0-24hrs, 0-36hrs, etc till they got to 0-72hrs; instead of 0-12, 12-24, 24-36, etc. It's a bad solution in search of a problem.

On a side note, people still do interscalenes? I've been doing superior trunk blocks for two years now and they seem to be working well (regardless of their preop pulm funtion). It's super easy to find when you slide proximal from the supra-clav. 15ml of ropi. Should scopes and arthroplasties.

(edited to change scopes and arthroscopies to scopes and arthroplasties.)

 

[ASA6]

10ml Exparel + 10ml 0.5% Bupi.

My last job this is what we did for most blocks. I know what the data says but the surgeons loved them and we consistently seemed to get at least 48 hours. Sometimes longer especially on pop blocks.

 

[Arch Guillotti]

On a side note, people still do interscalenes?

All the time. Didn't know they were a thing of the past.

 

[Realgassy]

I work at a high volume orthopedic center. We use 0.2% ropi for our blocks for the reasons your colleague described. Our patients go home with catheters which are, frankly, the bane of my existence. It can be hit or miss with overnight phone calls from patients.

 

[coffeebythelake]

I've never used liposomal bupi. Pacira tried to get FDA approval in 2009 with an active comparator (liposomal vs plain) and got it denied. It wasn't until they used a placebo in about 2013 that they got it approved. And even in 2013, the therapeutic benefit was only in the 0-12hr period. But they skewed the results by comparing pain relief in strange intervals: 0-24hrs, 0-36hrs, etc till they got to 0-72hrs; instead of 0-12, 12-24, 24-36, etc. It's a bad solution in search of a problem.

On a side note, people still do interscalenes? I've been doing superior trunk blocks for two years now and they seem to be working well (regardless of their preop pulm funtion). It's super easy to find when you slide proximal from the supra-clav. 15ml of ropi. Should scopes and arthrosopies.

Remember when Pacira sued the anesthesiologist authors of a study that showed non-superiority of their liposomal bupi?

Exparel Libel Suit

This may be of interest, Article: Third Circuit Rejects Libel Claim Actual Opinion Pacira BioSciences, Inc. … sued the American Society of Anesthesiologists, Inc. …, the editor-in-chief of its medical journal, and the authors of three articles for statements made about one of Pacira's drug...

forums.studentdoctor.net

Third Circuit Rejects Pacira Biosciences' Trade Libel Claim Over Article in Leading Medical Journal About EXPAREL

From Friday's Third Circuit decision in Pacira Biosciences, Inc. v. American Society of Anesthesiologists, Inc., written by Judge Patty Shwartz,…

reason.com

 

[Airway]

Remember when Pacira sued the anesthesiologist authors of a study that showed non-superiority of their liposomal bupi?

Exparel Libel Suit

This may be of interest, Article: Third Circuit Rejects Libel Claim Actual Opinion Pacira BioSciences, Inc. … sued the American Society of Anesthesiologists, Inc. …, the editor-in-chief of its medical journal, and the authors of three articles for statements made about one of Pacira's drug...

forums.studentdoctor.net

Third Circuit Rejects Pacira Biosciences' Trade Libel Claim Over Article in Leading Medical Journal About EXPAREL

From Friday's Third Circuit decision in Pacira Biosciences, Inc. v. American Society of Anesthesiologists, Inc., written by Judge Patty Shwartz,…

reason.com

Agree no one gets exparel even if free and they pay me. Put that down as my conflict of interest.

 

[Dr. Rude]

Aware of the studies. We don't round on the patients or call the post op. So no personal perspective.

The surgeons at our high volume well regarded ortho hospital lobbied for and got exparel. We tried catheters with 0.2% Ropi vs single shot 0.5% Bupi vs 10ml 0.5% Bupi + 10ml exparel. Didn't do 0.5% Bupi + decadron.

 

[UscGhost]

Aware of the studies. We don't round on the patients or call the post op. So no personal perspective.

The surgeons at our high volume well regarded ortho hospital lobbied for and got exparel. We tried catheters with 0.2% Ropi vs single shot 0.5% Bupi vs 10ml 0.5% Bupi + 10ml exparel. Didn't do 0.5% Bupi + decadron.

Yea if surgeons want it badly, not worth the fight.

Decadron is key

 

[BLADEMDA]

I've never used liposomal bupi. Pacira tried to get FDA approval in 2009 with an active comparator (liposomal vs plain) and got it denied. It wasn't until they used a placebo in about 2013 that they got it approved. And even in 2013, the therapeutic benefit was only in the 0-12hr period. But they skewed the results by comparing pain relief in strange intervals: 0-24hrs, 0-36hrs, etc till they got to 0-72hrs; instead of 0-12, 12-24, 24-36, etc. It's a bad solution in search of a problem.

On a side note, people still do interscalenes? I've been doing superior trunk blocks for two years now and they seem to be working well (regardless of their preop pulm funtion). It's super easy to find when you slide proximal from the supra-clav. 15ml of ropi. Should scopes and arthroplasties.

(edited to change scopes and arthroscopies to scopes and arthroplasties.)

Any brachial plexus block above the clavicle will work for shoulder surgery. There is good spread proximally and distally with 15-20 ml. The notion you MUST place the local at C5/C6 for the block to work is antiquated data. Second, the key to decreasing dyspnea postop after an ISB is less local (5 ml) or place the block lower/distal like SCB or Superior trunk with less local (10 ml). I have performed many anterior suprascapular nerve blocks and they do work for postop pain relief but not as well as an ISB. I typically will do a anterior suprascapular nerve block with 10 ml of local + 4 mg decadron followed by an ISB at C6 with 4 ml of local + 4 mg decadron. I have had great results with the combo on patients with sleep apnea and/or COPD.

 

[BLADEMDA]

With the anterior approach to the suprascapular nerve, phrenic nerve palsy may occur, yet its likelihood is significantly reduced compared to an interscalene block.3 Use of lower-volume doses or more dilute local anesthetic agents further reduce the incidence. Peripheral nerve catheters may also be placed at the anterior approach location with improved respiratory mechanics demonstrated at 24 hours.12

In conclusion, the anterior suprascapular block based on the SPA anatomy is a powerful tool to provide postoperative shoulder analgesia by single injection or continuous nerve block while minimizing ipsilateral phrenic nerve paralysis.

How I Do It: Anterior Suprascapular Block, Superior Trunk, and the Significance of the Suprascapular Posterior Anterior Anatomy

 

[BLADEMDA]

Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block - PubMed

The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique.

pubmed.ncbi.nlm.nih.gov

Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL - PubMed

Interscalene block performed under ultrasound guidance with 0.75% ropivacaine 5 mL showed analgesic efficacy similar to that with 0.75% ropivacaine 10 mL, but with a lower incidence of hemidiaphragmatic paralysis.

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

Ultrasound-guided subomohyoid suprascapular nerve block and phrenic nerve involvement: a cadaveric dye study: a promising nerve block for shoulder surgery | Regional Anesthesia & Pain Medicine

Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis

A meta-analysis of 16 studies demonstrates suprascapular block results in 24-h morphine consumption and pain scores similar to interscalene block. Pain control may be better with interscalene blocks at 1 h postoperation. Suprascapular block is associated with fewer complications, in particular...

pubs.asahq.org

 

[BLADEMDA]

 

[GassYous]

I've noticed people who mix exparel and regular bupi would get incomplete blocks and patients in pain during the case and in pacu. Then you need to give some fentanyl. So I give the regular bupi first (10-20 cc) then 10 cc of exparel separately and would get pretty dense blocks for 24+ hours and decent anagelsia for another 24-48 without opioid.

 

[BLADEMDA]

I've noticed people who mix exparel and regular bupi would get incomplete blocks and patients in pain during the case and in pacu. Then you need to give some fentanyl. So I give the regular bupi first (10-20 cc) then 10 cc of exparel separately and would get pretty dense blocks for 24+ hours and decent anagelsia for another 24-48 without opioid.

Thanks for the post. When I mixed Exparel with 0.5% Bup my results were mixed in pacu and for postop pain duration. I just abandoned the Exparel altogether and went with 0.5% Bup with decadron. But, if your technique works I will reconsider using Exparel again for ISB.

 

[Lecithin5]

It is precisely because we are in a high litigation society that I don’t want my blocks to last a long time. 20cc plain ropi. Pt gets 14-24 hrs of relief.

 

[Steege305]

10ml Exparel + 10ml 0.5% Bupi.

gotta add that exparel for ISBs.

 

[UscGhost]

We

Thanks for the post. When I mixed Exparel with 0.5% Bup my results were mixed in pacu and for postop pain duration. I just abandoned the Exparel altogether and went with 0.5% Bup with decadron. But, if your technique works I will reconsider using Exparel again for ISB.

With exparel, we also had random blocks that would last 72 hrs. Patients started getting very antsy at that point.

So we felt it wasnt worth the cost and unpredictability plus data never supported it.

So unless the surgeons pushed for it (and thus they accepted the complaints from patient and pharmacy) then it wasn't worth us having to deal with those complaints for the sake of unreliable benefits

 

[Simba1711]

I do 30 cc of 0.25% bupi with 8 of decadron iv. After block they get general anesthesia.

At my other job I would do 15cc of 0.5 % bupi + 15 cc of 2 % lidocaine and 8 of decadron iv. They would get block and sedation.

 

[GassYous]

We
With exparel, we also had random blocks that would last 72 hrs. Patients started getting very antsy at that point.

So we felt it wasnt worth the cost and unpredictability plus data never supported it.

So unless the surgeons pushed for it (and thus they accepted the complaints from patient and pharmacy) then it wasn't worth us having to deal with those complaints for the sake of unreliable benefits

I only add exparel for total shoulders

 

[periopdoc]

I did a light block with a catheter once, for one of our scrub nurses. 1/8 Bupi plus sufenta, IIRC. She woke up completely pain free, but with perfect strength. Last time I did that. We couldn't keep her from using that arm. I learned that you either need some pain or paralysis after shoulder surgery.

 

[nimbus]

I only add exparel for total shoulders

Asking because I don’t know. Do total shoulders hurt more than rotator cuff repairs?

 

[UscGhost]

I did a light block with a catheter once, for one of our scrub nurses. 1/8 Bupi plus sufenta, IIRC. She woke up completely pain free, but with perfect strength. Last time I did that. We couldn't keep her from using that arm. I learned that you either need some pain or paralysis after shoulder surgery.

Yea the catheters have the best theoretical pain control potential.

But man, they were a pain to manage. We had patients turn them off after a day because they didn't think they needed it anymore, then called us screaming 6 hrs later. Then we had to bolus over the phone. Not to mention pacu nurses forgetting to unclamp, loose connections, bandage leaks, etc

 

[periopdoc]

I loved them when I didn't have to manage them. Now, I only put them in for special cases. I sent that nurse home with one of our hospital's epidural pumps, and a bag of bupi plus sufenta. I even took a second bag to her house to swap out. I thought for sure I would get in trouble for the sufenta. Instead, it was the epidural pump that caused consternation. It isn't like they didn't know where she works and they couldn't take it out of her paycheck if she didn't return it.

 

[GassYous]

Asking because I don’t know. Do total shoulders hurt more than rotator cuff repairs?

I think rotator cuffs hurt more but total shoulders hurt for longer. Never had shoulder surgery though