Through the keyhole – improving surgical skills

One of the biggest challenges facing us in modern surgery is how to take tomorrow’s surgeons from relative novices to the expert that you and I would wish to have repair a vital organ. There was a time not so long ago when  young surgeons practised their embryonic skills on patients in the middle of the night –  often with the help of an even less-experienced assistant. Now this is actually not as scary as it might sound as, in general, these young surgeons were a carefully selected group. They would have spent many hours assisting and carrying out parts of more complex procedures with their boss. They tended not only to be highly dextrous but also had a keen sense of their own limitations and when to call for help. I myself was one of these surgeons who developed their craft by hours of observation and then application often in the middle of the night.

But this mode of practice has for a variety of reason disappeared to a greater extent. The drive towards a service ‘delivered by the boss’ has meant that the opportunity for trainees has diminished significantly. It takes great fortitude, stamina and nerves of steel for a senior surgeon to repeatedly attend at whatever time of day or night and act as assistant to a training surgeon. A great part of the problem is that with such an onus of responsibility on the senior surgeon to ensure that everything runs perfectly and in a timely fashion, it is far easier just to get on and do the operation him or herself  – and of course that is what we know the patient would want anyway. But what does this mean for tomorrow’s doctors? Will they be able to perform operations competently on their own with all this hand holding?

It doesn’t look likely that the status quo is going to change any time soon, especially considered the rise of litigation in the NHS. But fortunately, a solution may well be key-hole surgery and its reliance on optics which beam images of the operating site onto big screens in the operating room.

When we perform traditional open surgery, only one person in the OR sees the operation from the surgeon’s perspective – the surgeon himself. His trainee is at best in a reversed and compromised position and, at worst, unable to see at all. Even filming open operations for later teaching purposes is very challenging.  However, when a keyhole operation is performed by a surgeon and beamed up onto a large TV monitor, not only the surgeon but also his trainee and every other person in the OR sees exactly what the surgeon sees. This not only makes learning by observation far more effective for the trainee but it also provides five or more pairs of eyes who can all potentially spot a problem in the operative field. When it comes to the senior surgeon supervising the trainee he can be far more in control of exactly what manoeuvres the trainee is making.

The MATTU was the UK’s first International Centre of Telemedicine based at Surrey University and the Royal Surrey County Hospital. It has been telementoring surgeons for many years. Its advanced ergonomic OR theatres allow key-hole specialist surgeons to coach people from as far afield as America, China and Africa in the latest techniques. Viewers can interact with the surgeons in real time. Cameras and microphones relay live broadcasts which are also recorded for future online viewing. Recent advances in robotics and imaging techniques mean that trainees can now watch detailed live keyhole surgery with 3D projection systems. This has added further enhancement to the sense of immersion in the operative field making it easier to grasp the essential steps of surgical procedures. The training facility has also established very realistic simulation systems using computer animation, cadaveric specimens and tissue models. This provides trainee surgeons with a completely safe environment in which to take their first steps in the learning of complex surgical skills, which they will then need to transfer into the OR for real-life surgical cases.

But, however intensive we make this training, at some point these surgeons are going to need to perform their first cases. Beyond that there will come a moment where they will need to learn to take full responsibility for all their actions in the OR. But with such a demand for consultant-delivered treatment and punitive actions in a variety of guises for poor performance, there is a real risk that we will prevent our trainees reaching the stage of independent practice while they are still in the relative safety of a training post. It is far better that they learn to operate and make decisions independently (and inevitably some mistakes) while they still have the opportunity to call upon a senior mentor who maybe close by but not immediately on hand. Far more terrifying is the prospect of a newly appointed senior surgeon who finds him or herself having to make their own decisions and take actions for the very first time when there is absolutely nobody to turn to.