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CurrentTechniques in Surgery: A new universal language, a new literature, and a new multimedia training tool for operative surgery on CD-ROM

M. H. Edwards and P. J. Trigwell
Friarage Hospital, Northallerton, UK

A crisis in surgical training

Surgical training faces a multifactorial crisis, likely to rapidly worsen. The scope and scale of operations increase daily. The operations become more and more specialised. Their complexity increases. Technology races ahead. Equipment and materials develop and change by the week. Whole new vistas suddenly open, such as transplantation, joint replacement, and keyhole surgery, requiring new skills and procedures.

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 The size constraints of the book persist, and much of the book is out of date as soon as it is published.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.

A new approach

Surgical training has been re-examined using the latest information technology. At present, the surgeon may be unable to teach his assistant. When engrossed in a particularly difficult move, he may not have time to explain what is going on. Textbooks rarely mention the tiny details which may be all important. Their accumulation gained over many years of surgical work is popularly called experience. Our view is that a great deal more can be done to ensure that summation of many life time experiences can be built on and expanded using some more effective means than at present, surgical training should accelerate and improve, despite the adverse factors already mentioned.

The new language

We have developed an exciting new system of making relevant information accessible to surgical training, which may well have universal importance to all forms of training in complex processes. We have called CurrentTechniques in Surgery a new surgical language to stress its uniqueness. Its potential is hardly imaginable at present.

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.

    What equipment
    What material
    End points
    What if you can't
    What if it goes wrong
    Beginners' problems
    When to call the boss
    Anything else
    What equipment....

    Use gauze dissection from the spermatic cord right up to the internal ring, and INTO the internal ring.

    ***You may need to inject more local anaesthetic into the neck of the sac.

    Avoid the vas which lies very close to the sac.

    If the sac tears, clip the edge of the tear with an artery forcep to prevent the tear extending up into the peritoneal cavity.

    Hold the apex of the sac between 3 artery forceps...
Panel 1: the basic CurrentTechniques stepPanel 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.

  1. Double clip the cystic duct.

  2. The surgeon has the same options for ligating the cystic duct and artery during laparoscopic cholecystectomy as in the open procedure. Surgical clips, free ties, and suture ligatures are available. In the vast majority of our cases we use titanium surgical clips to control both the cystic duct and artery. Both reusable and disposable laparoscopic clips appliers are now available. The reusable instruments hold only one clip and therefore must be withdrawn from the abdomen each time it is loaded. Although these clip appliers work very well, they can add as much as 15 to 20 minutes to the surgical procedures. Often as many as eight clips or more are used, and each time the surgeon and camera operator must reorient the laparoscope and the instruments. In addition, these clips fall off the end of the applicator as it is being inserted through the sheath. Therefore we prefer a multi-fire, spring loaded clip applier.
Both texts are absolutely correct, but they do not supply the information which we feel is of immediate importance to the trainee at this step in the operation. The relevant part of our text is as follows.

CurrentTechniques in Surgery

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,
   or does not extend completely across the duct,
   or is lying obliquely,
   start clipping afresh, on the gall bladder side of the unsatisfactory clip.

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.

The new literature

The text covers each operation from start to finish. It includes the assembly and testing of surgical equipment and materials. It provides a list of all instruments and materials for that operation.

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 multimedia learning tool

The multimedia learning tool consists of text, with more text on Hypertext screens. There are sections on anatomy, pathology and physiology. There is information for patients about to have an operation. We include ward care plans for the nursing and other staff. There are diagrams, photographs, animations, and video runs, plus a choice of UK and USA English sound track. Interactive features include customising each step of the operation, and the equipment and materials. There are calculators for safe volumes of drugs, and of the difficulty and duration of the operations. Simulators advise trainees when to convert to a safer operation. There are quizzes with scoring.

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].

The future

The future holds exciting possibilities, but care is needed not to overstate the value of the system. It has not been demonstrated to be better than a textbook, though with at least fifty times the amount of information, common sense would suggest it was. It should be easy to test the system objectively by randomly training groups of junior surgeons with or without CurrentTechniques in Surgery, and measuring speed and thoroughness of learning.

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.


  1. Kirk, R. M. & Williamson, R. C. (1987). General surgical operations. Edinburgh: Churchill Livingstone.

  2. Blandy, J. P. (1993). Practical transurethral resection. London: Butterworth-Heinemann.

  3. Grimm, S. J. (1882). How to write computer manuals for the users. London: Van Mostren.

  4. Alexander-Williams, J. (1992). Best books on general surgery: A person choice. British Medical Journal, 305:659.

  5. Edwards, M. H. (1995). CurrentTechniques in Surgery. Norwood Ma 02062-5043, USA: Silver Platter Education.

Authors: M. H. Edwards and P. J. Trigwell
Dept of Surgery, Friarage Hospital, Northallerton, North Yorkshire

Scalpel Information Systems
12 Staindrop Road, Darlington, Co Durham, UK

Tel: 01609 779911 Fax: 01325 364624 Email: 100611.64@compuserve.com
WWW http://www.SilverPlatter.com/catalog/CTIH

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

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