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Copyrighted Material CHAPTER 1 Introduction and prologue Surgery remains only as safe as those wielding the At the same time, there has been a marked scalpel. reduction in the number of hysterectomies performed Tito Lopes as a result of more conservative management options for dysfunctional uterine bleeding. In the nine‐year period from 1995 to 2004, there was a Introduction 46% reduction in the number of hysterectomy operations performed in NHS hospitals in England Surgical training and between 2008 and 2012 there was a further Surgical training in gynaecology has seen dramatic 7% fall in hysterectomies in the UK. changes in both the UK and the USA over the past With the increasing use of laparoscopic surgery 20–30 years. When the current editors were in in elective gynaecology, including for hysterec- training, there were no restrictions on the number tomy, the ‘open’ approach to gynaecological surgery, of hours that they could be asked to work. It was traditionally the surgical ‘bread and butter’ for common to be resident on call every third night in trainees, is also on the decline. Equally, a large addition to daytime work, which often resulted in number of ectopic pregnancies are now managed a working week in excess of 110 hours. In the UK, conservatively meaning that trainees are lacking the European Working Time Directive was exposure to emergency laparoscopic surgery for extended to junior doctors in 2004 thereby reduc- tubal pregnancies. ing the working week to an average of 48 hours. It is vital that standard safe techniques continue In the United States, the Accreditation Council to be taught to all trainees. Thus, although many for Graduate Medical Education in 2003 required procedures have been translated into minimal duty hours to be limited to 80 hours per week. access operations the principles and practice of the Although the reduction in working hours is open version must be learned alongside the mini- important for one’s work–life balance as well as mal access approach. This is especially relevant patient safety, it inevitably has had a major impact wherever a minimal access procedure has to be on surgical training. The concept of the surgical translated into an open procedure because of diffi- team or firm to which a trainee was attached has all culties and complications experienced during the but disappeared. The introductionCOPYRIGHTED of shift systems operation. MATERIAL It is a concern of the editors that the has made it difficult, and in some cases impossible, ‘unusual’ is not being experienced on a satisfactory for trainees to attend the surgical and clinical scale by trainees. Nothing can replace time spent in sessions of their team. This has resulted in some the operating room for building up skills and confi- trainees failing to comprehend the continuity of dence in dealing with the unusual and unexpected. care of a surgical patient, running the risk of pro- A recent comment by a president of a Royal College ducing technicians rather then doctors. compared the time limited training of a surgeon to Bonney’s Gynaecological Surgery, Twelfth Edition. Alberto (Tito) de Barros Lopes, Nick M. Spirtos, Paul Hilton, and John M. Monaghan. © 2018 John Wiley & Sons Ltd. Published 2018 by John Wiley & Sons Ltd. 3 0003393102.INDD 3 05/24/2018 1:46:21 PM 4 Chapter 1 the limitless time application of an Olympic athlete. of being treated by surgeons with a limited experi- Very few gold medals would be won if the Working ence and a narrow range of skills which may be Time Directive was followed! applied in a ‘one size fits all’ pattern. In this text, we have attempted to provide a wide range of Gynaecology training options for management, which we would encour- Current training in the UK is a competency‐based age all trainees to practise assiduously to give their process and it is envisaged that the majority of patients the very best possible chance of a success- trainees will take seven years to complete the ful outcome. programme. In the last two years of training, the Despite the recent changes in gynaecological trainees are required to undertake a minimum of training, the essence of surgery remains essentially two of twenty available advanced training skills unchanged. The editors have, as with previous modules or they can apply for subspecialty training editions, felt it appropriate to retain the prologue in gynaecological oncology, maternal and fetal med- written for the 9th and 10th editions by JM icine, reproductive medicine or urogynaecology. Monaghan based on that of the 1st edition of this It is disappointing that as part of the current training series, A Text‐book of Gynaecological Surgery, published programme the trainee must be deemed competent in 1911 by Comyns Berkeley and Victor Bonney. in opening and closing a transverse incision at It remains just as relevant today as it was a century ago. caesarean section before commencing his or her sec- ond year but need only be assessed as competent for opening and closing a vertical abdominal incision Prologue: after Comyns Berkeley if undertaking the advanced module for benign and Victor Bonney, (JM Monaghan) surgery in years six and seven. The bearing of the surgeon Basic skills and training opportunities A surgeon when operating should always remem- Trainees wishing to develop as gynaecological sur- ber that the character of the work of his subordi- geons should attend appropriate courses, including nates will be largely influenced by his own bearing. cadaver and live animal workshops. However, these While it is impossible to lay down definite rules are no substitutes for learning the basic surgical skills suitable for all temperaments, nevertheless there and picking up good habits, early in training; bad are certain considerations which will prove useful habits are difficult to lose at a later stage. As assis- to those embarking on a gynaecological career. tants, they should question any variations in tech- Anyone who has taken the trouble to study the nique among the surgeons. As surgeons, they should work of other operators cannot fail to have review every operation they perform to assess how observed how variously the stress and strain of they could have done better. operating is borne by different minds and will In relation to laparoscopic surgery, there is no deduce from a consideration of the strong and excuse for trainees not practising with laparoscopic weak points of each operator some conception of simulators, which are often readily available and the ideal. easy to construct. It is readily apparent to trainers The thoughtful surgeon, influenced by this study, which trainees have spent adequate time on will endeavour to discipline himself so that he will simulators. strive constantly to achieve the ideal. By so doing, Sadly, a consequence of the new training is an he will encourage all who work in the wards and inevitable lack of knowledge and experience of the theatres with him – young colleagues in training, ‘unusual’, with the all too frequent result of diffi- anaesthetists, nurses, theatre assistants and order- culties for both the patient and the surgeon. These lies – to appreciate the privileges and responsi- difficulties are often manifest in an almost complete bilities of their common task. Expert coordinated failure to appreciate the wide range of possibilities teamwork is essential to the success of modern for management. Previous editors of this text have surgery. This teamwork has resulted in a significant advocated that any surgery should be tailored to lowering of operative morbidity and mortality. the specific needs of the patient and her condition. However, it is important to recognize the enor- Unfortunately, modern patients are in real danger mous contribution to the safety of modern surgery 0003393102.INDD 4 05/24/2018 1:46:21 PM Introduction and prologue 5 made by other disciplines, especially anaesthesiology. team goes about his or her task with speed and The preoperative assessment and the postoperative efficiency. care carried out by the anaesthetist has rendered It is inevitable that at some point the surgeon surgery safer and has also allowed patients who will come face to face with imminent disaster; even would not in the past have been considered eligible the most stalwart individual will feel his heart sink for surgery to have their procedures performed at such a moment. The operator should always successfully. The role of specialties such as haematol- remember that at such moments if basic surgical ogy, biochemistry, microbiology, radiology, pathology principles are applied quickly and accurately the and physiotherapy are also well recognized. situation will be rapidly rescued. Hesitation and Bonney maintained that the keystone of a sur- uncertainty will all too often terminate in disaster. geon’s bearing should be his self‐control; and while A sturdy belief in his or her own powers and a it is his duty to keep a general eye on all that takes refusal to accept defeat are the best assets of a call- place in the operating theatre and without hesita- ing which pre‐eminently demands moral courage. tion correct mistakes, he should guard against Before operating, the surgeon should prepare by becoming irritable or losing temper. The surgeon going over in his or her own mind the various who when faced with difficulties loses control has possibilities in the projected procedure, so that mistaken his vocation, however dexterous he may there may be no surprises and he or she may all the be, or however learned in the technical details of better meet any eventuality. Likewise, following the art. The habit of abusing the assistants, the the procedure it is valuable to go over in one’s instruments or the anaesthetist, so easy to acquire mind every step in the operation in order to and so hard to lose, is not one to be commended; analyze any deficiencies and difficulties experi- the lack of personal confidence from which such enced; it is only by this continuous self‐assessment behaviour stems will inevitably spread to other and analysis that surgeons can from their own members of staff, so that at the very time the sur- efforts improve their practice.
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