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An easy going hand crafted operation of five years ago may now be surpassed by an operation using equipment requiring very exact procedures. Some techniques may require special training to improve the coordination capacity of surgeons.
At the same time, the experienced trainers in the UK are required to personally perform more operations to fulfil hospital time limited contracts. There is less time to train the junior surgeons, and less time to allow the juniors to do the operations themselves, yet the Government is committed to the training and appointment of a large number of new surgical consultants. The trainees are working fewer hours, and are expecting to reach consultant levels of training in half the time of their predecessors. The trainers themselves are expecting to be reassessed every five years. Patients are becoming less forgiving. The consequences of a technical mistake in an operation may involve very large settlements, enough to break the finances of a large hospital.
In comparison, the development of training techniques has lagged behind. The operative surgery textbook, supported by assisting the experienced surgeon, remains the mainstay of operative training. The size constraints of the book persist, and much of the book is out of date as soon as it is published. There have been some moves to produce loose leafed manuals with facilities for updates in the last few years. Training courses, suture schools, and surgical simulators, go some way to developing surgical skills, but attendance at a course is no guarantee of competence at the end of it. Indeed, trainees can receive certification for the Fellowship of the Royal College of Surgeons and still be technically unsound.
There is a growing awareness of the need to improve training, and to make it quicker and more effective. The tradition of "see one, do one, and teach one", is no longer acceptable. The UK trainee may well be over experienced, but is likely to be under trained. There is a need to steepen the learning curve, preferably with the trainee only performing the operation when he is nearly at the top of the curve.
The language consists of breaking surgical operations down into their constituent steps. This has been the work of Kirk[1] and Blandy[2]. We have developed the structure on the lines of computer manuals[3] and pushed it as far as computer technology will allow.
Once the constituent step has been clearly identified, we add unlimited, but structured information. The next step follows with the same basic structure. The amount of detail possible here should provide a trainee with all the information he needs to complete that step. The structure gives the reason for doing the step. what equipment, what materials, the technique, landmarks, end points, do's and don'ts. It includes what to do if he cannot do the step, what to do if it goes wrong, what errors he should be aware of, and even when to call a more experienced surgeon. Plus there is space for "any thing else". The structure is demonstrated in Panel 1 and an example is given in Panel 2.
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| Panel 1: the basic CurrentTechniques step | Panel 2: An example from a hernia repair |
As an example of inappropriate information, we show below excerpts from the texts of two world authorities about how to clip the cystic duct in a keyhole operation to remove the gall bladder.
| CurrentTechniques in Surgery STEP NUMBER | |
| 248 FIT THE JAWS ON THE CYSTIC DUCT | Choose a clear site on the gall bladder end of the cystic duct, out of any danger of common bile duct.
Rotate the jaws for the best angle. Make sure you do not rub the clip out of position in the jaws. Check the posterior jaw is clearly visible. |
| 249 CLIP THE DUCT | Close the jaws smoothly and slowly by steadily squeezing the handles of the applier as hard as you can.
Avoid any jerking movement. Release the handles gently. Carefully withdraw the jaws from the clipping zone. |
| 250 CHECK THE FIRST CLIP | Check it is At the correct site. At exactly 90 degrees to the cystic duct. Projecting 1 mm at least beyond the duct. Not attached to any other structure. If the clip has fallen off, ignore it and start the clipping afresh.
If the clip is loose, Do not place one clip on top of another. Do not try to fit 2 clips end to end across a wide vessel. If the applier is stiff in the port, lubricate it with saline. Use a disposable port if a non-disposable port is causing serious sticking. |
So far, we have written the texts of over 60 elective general surgical operations ranging from a groin hernia repair to a removal of the gullet.
At this point, the advantages of the computer start to become apparent. Using the word processor, the texts already eclipse the traditional textbook. First of all, the texts are updated continually as techniques, equipment and materials change, and as problems are solved. Pencilled inserts are added to the texts as needed at the end of each operation. From time to time, our secretary types these changes onto the word processor disk, to make a neat new printout. Print outs are available for all junior surgical staff, for scrub nurses, for students, for operating department assistants, and for theatre visitors. The texts in loose leaf manuals are used for training, for reminding and for reference about infrequent operations. Sections of text are printed separately for training staff in the use of, for instance, the laparoscopic insufflator or endoscopes. We print out separately and file the lists of instruments and materials as a neater alternative to the normal Cardex files.
From sources outside the operating theatre, we add information to the texts about hints, tips, new ideas gleaned from colleagues, meetings, and the surgical literature. The system acts as a personal information bank. Further afield, colleagues have edited our text with great ease to record their own preferred surgical regimes. An hour or two of editing provides them with a disk with their operation written in CurrentTechniques in Surgery, printouts for their operating team, and the opportunity to add and modify their texts in the future at will without any restraint. On average, colleagues have altered about 10% of our texts to suit their requirements.
Our texts have proved valuable in demonstrating to purchases of our services, that the quality of our surgery is of a satisfactory standard.
We can transmit our texts to any part of the world using the computer network Internet.
The system may well eclipse many traditional methods of training in operative surgery. It has been recognised as the way ahead for the surgeon of the future[4]. It already qualifies for Continuing Medical Education Credits from the American Medical Association[5].
CurrentTechniques in Surgery can be used for all operations, emergency as well as elective, in all specialities. World authorities could present their unique operations written in CurrentTechniques in Surgery. Presentations at meetings, and papers in journals would be greatly enriched by having complementary information available in CurrentTechniques in Surgery. We foresee a central computer bank to provide and collate surgical information of this type on a world wide basis.
The computer facilities are expanding by the week. We see data compression, large memories, and better data handling by the computers as a way of storing more video runs.
We appear to have developed a simple step by step system for teaching surgery at a time when, fortuitously, there are very rapid developments in computer information technology to take advantage of this. The ultimate beneficiary of the two complementary innovations will doubtless be the surgical patient.
| Authors: M. H. Edwards and P. J. Trigwell Dept of Surgery, Friarage Hospital, Northallerton, North Yorkshire
Scalpel Information Systems
Tel: 01609 779911 Fax: 01325 364624 Email: 100611.64@compuserve.com Please cite as: Edwards, M. H. and Trigwell, P. J. (1996). CurrentTechniques in Surgery: A new universal language, a new literature, and a new multimedia training tool for operative surgery on CD-ROM. In C. McBeath and R. Atkinson (Eds), Proceedings of the Third International Interactive Multimedia Symposium, 119-122. Perth, Western Australia, 21-25 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1996/ek/edwards.html |