Complex surgical procedures carry significant risks and potential for complications, whether performed alone (as single procedure) or in combination (as multiple surgical procedures). Despite the most conscientious preoperative preparations, surprising events may still occur. If the operation takes an unplanned turn, the surgeon has to make difficult decisions. Some of the most important elements of any surgical procedure are the decisions that the surgeon makes before, during, and after the surgery itself. Notewithstanding its enormous significance and regardless of the implications that this decision-making process (DMP) has on surgical outcomes, the subject has received minimal attention in the literature [1, 2]. Subsequently, there are only a few studies that investigate how these decisions are made, although DMP is of great importance both for training and patient safety purposes. How do we surgeons make intraoperative decisions under what can be inauspicious conditions? Some describe these decisions as “intuition” or “gut-level” responses. However often we surgeons have difficulty in describing exactly how we came to specific decisions during surgery. Clearly, there are many factors that affect decision-making of surgeons before and during operations. These factors are the physiologic state of the surgeon, the harmony of teamwork, external factors at work, and the surgeon’s ability to adapt quickly to a changing environment, to name only a few. Yet, the question remains, how to perform an evaluation of the surgical decision and gaining a better understanding of a seemingly gut-level process, which helps surgeons combat the external factors experienced before and during surgery?

When a patient is dying from bleeding that we cannot control, when irreversible metabolic shock does not respond to anything that we do, when new problems emerge unexpectedly, when things go alarmingly wrong in such dire moments during a carefully planned operation, how do we decide what to do next? Many surgeons decide on the next step based on “a gut feeling” or “intuition” or the “gray hair effect,” among other techniques. In this chapter, I review theoretical as well as objective elements that we, as surgeons, use to make intraoperative decisions. Most of the many theories and hypotheses in the literature have been created by individuals who are not surgeons. But, our collective firsthand experience as surgeons points to a combination of factors contributing to our intraoperative decision-making process, including training and education, clinical expertise, mentoring, the creativity and the excellence that comes with long practice and with strict surgical discipline.

A number of naturalistic and complex problem-solving theories have attempted to explain how high-risk professionals make decisions [3], but such theories lump surgeons with other high-risk professionals whose decisions demand superb accuracy, such as pilots, nuclear plant scientists, and others. Indeed, it has become fashionable to compare pilots with surgeons. However, there are distinct differences between these professions. Pilots have in their hands the most sophisticated machines ever created by humans, but the pilots are backed by powerful computers and, frequently, have full support from the base on the ground. Although surgeons, just like pilots, have a team with them in every operation, they themselves make the final and most important decisions; they are in charge of carrying out the procedures that may be detrimental to patient’s life. This decision may be very difficult, since, once in a perfect condition, the human machine being operated on operating table may be in grave condition and may not respond to any intervention that the surgeon can come up with.

So, surgeons have to rely on their own experience and knowledge, on their understanding of the patient’s clinical information, and, of course on their assistants’ help. This is a dynamic process that changes often from minute to minute and involves monitoring and assessing the situation, taking appropriate actions, and reevaluating the patient’s response [1, 2].

However, DMP model encompasses components such as intuition (also known as “recognition-primed decision-making” analytical ability), flexibility, and creativity [4]. Nowhere is this model more applicable than in complex reoperative surgical procedures, which are often associated with an array of unanticipated problems. To this end, it is essential to be continuously aware of the patient’s physiologic status—including fluid status, urine output, use of blood and blood products, bleeding, use of medications used by anesthesiologist (such as vasopressors), and biochemical endpoints of resuscitation, because, even when the operation is going well, the biochemical profile of the patient may not be optimal, or even acceptable, and this may directly affect the outcome of surgery.

In my opinion, an important theoretical component that has not received sufficient attention, and is beyond surgeon’s technical abilities, is the surgeon’s leadership [5]. Adroitly taking charge of a calamitous, often hopeless, situation—applying proper technical skills, assigning different team members to different tasks, and communicating in a timely, effectively, clear, and calm manner—can make a significant difference. In fraught intraoperative situations, few surgeons have reported that they make decisions through analytical, rational heuristics or through trial and error [6, 7]. Rather, studies among surgeons have shown that the basis of surgical decision-making process is primarily task visualization, communication, and the mental state of the surgeon, that is, on what is called a mental model [8]. Other critical factors influencing intraoperative surgical decision making have been described [9–11]. In addition to the surgeon’s training, education, leadership ability, physiologic and mental state, creativity might be the most critical element of all. Historically, surgeons have demonstrated an amazing creativity that has often changed the way we practice medicine and surgery, defying the anatomy and physiology of the body and reaching new horizons in medicine. However, for this creativity to be fruitful one has to have an open-mind, willing to change their own mind and change the status quo of the management of the disease and disease process and demonstrable flexibility. While respecting sound surgical principles, the surgeon must be ready to adapt to any new intraoperative challenge at any time. Creativity in the service of excellence does not come easily, however. It takes dedication. It takes a lifetime of continuously studying the art and science of surgery [12, 13].