Extension of Medical Decision-making Connecting ‘Spiritual Intelligence’

Introduction

Undue postoperative pain and suffering can often be minimized if a surgeon incorporates conscientious compassion and integrates spiritual intelligence, commonly referred to as SQ.

SQ is considered the “ultimate” intelligence and underpins the effective functioning of both Intellectual (IQ) and Emotional (EQ) intelligence. It is not about being ‘religious,’ but is supported by recent neurological and psychological research [1]. SQ’s potential to enable creativity, reframe situations, and combine multiple forms of intelligence can significantly enhance clinical decision-making at critical moments. In this context, SQ opens new avenues of conscience and compassion, guided by wisdom that transcends self-centered experiences.

This article presents a case in which the author, both a physician and a patient, experienced severe postoperative complications unexpectedly following classical direct inguinal hernia repair one year apart by two reputable general surgeons. A single yet overlooked act—thorough CO₂ desufflation(i.e., surgical deflation) from both extraperitoneal and suspected intraperitoneal spaces—might have spared the patient considerable suffering, had it been guided by conscientious compassion at a critical moment.. This case underscores SQ’s potential to improve outcomes through empathetic, meticulous decision-making beyond ‘standard’ expertise and highlights the crucial role of painstaking care in preventing avoidable suffering. It would reassure the expert audience of the importance of their practices.

Case description

The patient’s verbatim report

“In the PACU, I woke up with severe dry mouth and moderate abdominal distension with a tympanitic dullness. The surgical team assured that this is not unusual after laparoscopic surgery. On postoperative day 1, abdominal distension, pain, and distress remained in the entire abdomen. On postoperative day 2, the upper abdominal pain and aching spread notably to the left shoulder and neck, mimicking an acute cardiac event. However, vital signs remained stable, and there was no indication of cardiac compromise such as chest pain, cold sweats, dizziness, nausea, or vomiting. A portable Electrocardiogram (ECG) was obtained, which revealed a normal sinus rhythm with isoelectric ST segments.

With every attempt at breathing, especially at the end of inspiration, severe aching pain in the ‘catch-type’ ensued. Being unable to lie flat on the bed mandated sitting up at a 45-degree angle, helplessly leaning on the back support for four consecutive days. Abdominal distention and distress with referred pain in the left shoulder required more than a week to resolve. It was finally tapered, while leaving some ‘expected’ pain from the open inguinal repair. The postoperative course for the initial two weeks was formidable, with LUQ and referred pain in the left shoulder, followed by swelling and purplish discoloration in the entire lower abdomen and pubic area, which persisted until it finally dissipated in four weeks.”

Clinical findings (Vitals/Labs)

(Table 1)

Figure 1: Preoperative ECG (sent as Figure 2): 7 days before surgery, showing normal sinus rhythm.

Figure 2: Postoperative ECG (sent as Figure 3): Day 2, 4 AM, at the peak of chest/shoulder pain using a portable Kardia unit, which showed a normal sinus rhythm.

Technique description

A healthy, otherwise male in his mid-seventies, diagnosed with a reducible direct inguinal hernia on the right side, underwent an elective open repair with mesh placement performed by Surgeon A, who reportedly used #2 Prolene mesh suturing. Within a year, the hernia recurred, prompting a second opinion. Surgeon B recommended a laparoscopic approach. Under general anesthesia, multiple unsuccessful attempts were made to create an operative space laparoscopically. Surgeon B finally decided to convert the procedure to an open repair. Upon re-incising the previous site, a ‘defect’ was identified in the medial aspect of the pubic tubercle area and repaired with #0 Prolene suture. Despite technical ‘success,’ the patient experienced severe stormy ‘unexplainable’ postoperative complications. Upon reviewing the operative reports of both surgeons, the patient had become ‘awakened’ to realize how vital a simple act of conscientious compassion—ensuring adequate CO₂ evacuation from both the extraperitoneal and intraperitoneal spaces—might have dramatically impacted the helpless patient under general anesthesia. It highlights the importance of spiritual intelligence and meticulous care in surgical practice, inspiring a more empathetic approach to patient care.

Conscientious techniques to minimize retained gas:

1. Active suction to both compartments during deflation(desufflation).
2. Manual gas expression via gentle abdominal pressure.
3. Trocar port evacuation.
4. Reinsertion of Veress needle if needed to decompress intraperitoneally.

Attending to such seemingly minor details can have a profound impact on outcomes. Integrating SQ prompts clinicians to pause and reflect compassionately, particularly in rushed clinical settings.

Discussion

LUQ abdominal pain with a referred shoulder pain (a sign of diaphragmatic irritation, known as Kehr’s sign) strongly suggests residual CO₂ in the intra-abdominal cavity. This well-documented complication of laparoscopic procedures occurred because carbon dioxide (CO2) was inadequately deflated(desufflated). Despite carefully employing the Totally Extraperitoneal (TEP) approach, inadvertent perforation of the peritoneum could be possible, unwittingly allowing CO2 to leak into the intraperitoneal cavity. Subsequent desufflation addressed only the extraperitoneal space, leaving residual CO2 in the peritoneum, which caused diaphragmatic irritation mimicking a cardiac event. While TEP aims to avoid entering the peritoneal cavity, perforations can occur during dissection. A more thorough desufflation approach, addressing both spaces, could have significantly altered the postoperative course. This oversight underscores the importance of meticulous attention to detail in surgical practice, as it can prevent avoidable complications and distress.

The inguinal hernia is one of the most common surgical pathologies that general surgeons encounter. More than 800,000 cases are reported annually in the US, and approximately two million worldwide [2]. The recurrence rate ranges from 0.5% to 15%, depending on the hernia site, type of repair, and clinical circumstances [3]. Common sites for recurrent direct inguinal hernia are at the pubic tubercle, where intestines enter the inguinal canal ‘directly’ through a weakness in the posterior wall of the canal, termed Hesselbach’s inguinal triangle (formed by the lateral edge of rectus abdominis, the inferior edge of the inguinal ligament, and medial to inferior epigastric vessels). Direct hernias occur more commonly in older patients, often secondary to abdominal wall laxity, especially during an attempt at a significant increase in intra-abdominal pressure. It is most common in the first year after the initial surgery, and 23.5% of recurrences develop within two years [4]. This translates to approximately 4,000 to 120,000 recurrent cases in the US alone. Early recurrence is often associated with technical factors, including inadequate tissue repair, inadequate mesh fixation, or an inappropriate mesh size [5]. Retrospectively, if Surgeon A had employed adequate mesh fixation and tissue repair using thicker Prolene, the subsequent recurrence and complications could have been avoided. Meticulous examination and adequate desufflation of CO2, particularly when peritoneal perforation can be suspected, would be a simple yet crucial step that can significantly alter postoperative recovery.

Diagram 1: Hesselbach’s Triangle and Recurrence Schematic.

Diagram 2: Hernia Desufflation Flowchart.

Diagram 1. Hesselbach’s Triangle and Recurrence Schematic

Diagram 2. Hernia Desufflation Flowchart (submitted as Figure 4)

Linking empathy/SQ to surgical outcomes

Although formal studies directly correlating SQ with metrics such as length of stay or complication rates are lacking, emerging literature highlights the role of empathy in improving outcomes, reducing errors, and increasing patient satisfaction. Developing SQ may enhance the surgeon’s awareness, presence, and responsibility, which naturally extend to better clinical performance.

Ethical considerations

Informed surgical consent was obtained in accordance with standard general surgery practice, outlining the typical risks and potential complications associated with the procedure. No IRB approval was required, as this is a personal case experience authored by the patient.

Conclusion

This case highlights the importance of integrating spiritual intelligence and conscientious compassion to improve operational outcomes. SQ fosters empathy and meticulous care, enabling surgeons to prevent hidden, avoidable complications and distress. Complications may still occur even with the best care, but paying greater attention to detail can minimize these risks. SQ serves as the foundation for ultimate intellectual and emotional expertise, addressing the profound needs of patients beyond routine care. The adoption of conscientious compassion enhances the patient’s satisfactory experience and reinforces the physician-patient relationship. Surgeons could be encouraged to incorporate these ideals into their practice, thereby fostering a culture of empathy and meticulous care that ultimately leads to improved patient outcomes. Learning SQ, however, requires a unique understanding of the concept of ‘wholeness,’ espousing morally based practice.

This revolutionary idea was scientifically validated from a rational perspective of quantum physics, which suggests that the concept of nonlocality, with its progression into the sequence of “nonlocality-nonduality-wholeness” (NNW), enables the integration of ‘morality’ reasonably within the framework of modern science [6]. This critical review, although not directly related to hernia repair, offers a unique insight that can be applied to the field of medicine.

Sharing this case aims to promote a culture of empathy, thoroughness, and “spiritual intelligence” in medical decision-making. By adopting these principles, we can uphold the highest standards of patient care, thereby minimizing suffering and optimizing outcomes.

Appendix

1. Zohar D, Marshall I. Connecting with our Spiritual Intelligence. New York: Bloomsbury Publishing; 2000;3-17.
2. Morrison Z, Kashyap S, Nirujogi VL. Adult Inguinal Hernia [Internet]. Treasure Island (FL): StatPearls Publishing; 2024. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537241/
3. EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh: meta-analysis of randomized controlled trials. Ann Surg. 2002;235(3):322-332. Available from: https://doi.org/10.1097/00000658-200203000-00003
4. Lee CS, Kim JH, Choi BJ, Lee JI, Lee SC, Lee YS, et al. A retrospective study on the prevalence of recurrent inguinal hernia: a large-scale multi-institutional study. Ann Surg Treat Res. 2020;98(1):51-55. Available from: https://doi.org/10.4174/astr.2020.98.1.51
5. Søndenaa K, Nesvik I, Breivik K, Kørner H. Long-term follow-up of 1059 consecutive primary and recurrent inguinal hernias in a teaching hospital. Eur J Surg. 2001;167(2):125-129. Available from: https://doi.org/10.1080/110241501750070583
6. Choi JJ, Choo BH. The Buddha’s empirically testable “Ten Criteria” challenges the authenticity of truth claims: a critical review and its potential applicability to debunking the various post-truths. Religions. 2019;10(12):645. Available from: https://doi.org/10.3390/rel10120645