Wednesday, April 20, 2011

Pushing the Envelope

Complacency is extraordinarily common in every line of work. This is no different in surgery. Surgeons will commonly learn new techniques only after they have been widely published with prospective randomized placebo controlled trials. Less often, they will learn new techniques if there is a public demand. And even less commonly, surgeons will learn new techniques simply because they push the envelope of surgical technology.

A great example of this is SILS, or single incision laparoscopic surgery. This technique utilizes the same instrumentation and essentially the same operative technique as traditional laparoscopic surgery but it does so through one incision site which is hidden inside the belly button. As a result, patients get a virtually scar-less operation. This technique is being slowly adopted throughout the United States.

Surgeons are commonly reluctant to learn this new technique because it achieves only cosmetic improvement and makes fairly simple operations slightly more time-consuming and certainly more difficult. I learned this technique almost 3 years ago and immediately began to adopt this in my practice. Admittedly, it was a steep learning curve and no doubt added some extra time to my operations. However, as my technique improved, operative times decreased to roughly the same as traditional laparoscopic surgery.

Interestingly, I have noticed an added benefit. By pushing the envelope and forcing myself out of my comfort zone, I have become a markedly better technical surgeon. In all aspects of my laparoscopic surgical technique I have noticed better conservation of motion (a technical quality of no wasted movement; more efficient) and much improved surgical technique.

It is important to note that many surgeons will never learn this technique and will still have excellent outcomes and excellent patient satisfaction. So why would one want to do this? I propose two reasons.

First, I have come to realize that pushing the envelope and putting yourself outside of your comfort zone to learn new techniques is really an integral part of being a good surgeon. Without learning this technique, my skills would not have advanced as they have. I am convinced that my patients all benefit from this regardless of the operation they are getting.

Secondly, it contributes to the advancement of surgical care not only by improving one's general operative techniques but by pressuring technology to improve. Already, we have seen integration of single incision surgery and robotics and without the push towards the single incision movement this may not have been realized as quickly.

Currently, this technique is usually applied to the more routine operations, such as gallbladder and appendix removal. But, given the speed of technological innovation, it is reasonable to imagine most major abdominal operations being performed through one very small incision in the abdominal wall, and probably by robots with extremely small but versatile instrumentation. 

However, for this to happen, surgeons need to continue to push the envelope in not only their operative technique but also their forward thinking.

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