I would like to focus on some skills that I believe are important to practice, in order to improve as a surgeon.
Although teaching is fundamental, much of the surgical art is learned by observing other surgeons. In particular, since it is not a lot of practice, but it is only perfect practice that leads to perfection, it is important to observe excellent surgery.
What is observed is reproduced, therefore it is a good thing to observe it sincerely and it is even better to observe the same operation performed by different surgeons. Finally, it is essential to observe yourself in the act of operating. If we have observed carefully, at first we will have more doubts than certainties. Addressing these doubts and reviewing our certainties will lead us to improve. If at this point we need to imagine a solution, my advice is to help yourself by drawing it.
Imagining and drawing an intervention before doing it is a practice that I consider of fundamental importance.
Here I give the example of my Laparoscopy-Enhanced HIPEC technique.
I learned how to perform HIPEC with the Coliseum technique (open abdomen). I have studied it. Then I saw it done. Then I helped others to do it, with enthusiasm. Finally I applied it, and I began to have doubts: it was impossible to maintain hyperthermia because there was too much heat dispersion, a homogeneous distribution of heat was impossible. I thought it was excellent, I went to review the literature and found that the supposed superiority of that technique was not based on valid scientific evidence. I had a problem: in order to maintain the temperature of the peritoneal fluid, I needed to keep the abdomen closed, but in order to mix the abdominal contents, I needed to leave the abdomen open. I had to find a way to handle the abdominal contents in a closed abdomen.
The solution came to me from my experience in laparoscopy, in particular from my work on the lysis of adhesions by laparoscopy. I reviewed the recordings of some of my laparoscopic adhesiolysis operations, and thought of using the same strategy to free and move the intestines and the abdominal organs during HIPEC with a closed abdomen. The result is in these drawings.
On my YouTube channel you will find some videos on doubts, problems and solutions related to the development of the LE-HIPEC technique. The article describing the technique is available on the Surgical Education Resources page.
Drawing by hand helps you to imagine in three dimensions the development and steps of the intervention you want to build. If you want, you can then have fun translating everything into three-dimensional models, with the help of one of the many open source software available. Finally, it is good to film ourselves while we work, then review the video several times to observe ourselves from the outside, then make us have new doubts and then change the things that do not satisfy us. The cycle has no end, but it is certainly virtuous.
Here are some drawings that I used to imagine some of the techniques I described and applied.
Robotic left colectomy in lateral position, synchronous with excision of a left renal neoplasm
The design of this intervention, to be performed simultaneously with the Urologist, was particularly interesting because it required to solve some problems: 1. to avoid changing the lateral position necessary for the Urologist to work; 2. to minimize the need for additional ports, by mediating between those needed by the Urologist and those needed by me; 3. having to alternate with the Urologist at the operating table, to try to use the same robotic instruments, avoiding the replacement of instruments.
Please visit the Surgical Education Resources page for further information.
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