Dr. Tyler Rouse is an anatomical pathologist at the Huron Perth Healthcare Alliance in Stratford, Canada, and an adjunct professor in the Department of Pathology at the Schulich School of Medicine and Dentistry, Western University. He is the creator and host of the history of surgery podcast ‘Legends of Surgery’.
Why should you care about the history of surgery?
To begin with, it is unquestionably fascinating and fun. The history of surgery is filled with heroes and villains, triumphs and tragedies, progress and setbacks, but continuously moves towards the easing of suffering and the protection and prolonging of life. Yet there is something deeper and more meaningful that can be gained from the study of history. It grounds us, gives us a richer understanding of the world in which we live, and tells us how we arrived at this point in history, and provides a sense of identity and belonging in the world.
The knowledge we now possess finds its origins in the writings of Hippocrates and Galen and the classical world of ancient Greece and Rome, which is reflected in the Latin and Greek roots of the words of the ‘lingua franca’ of medicine that we use every day. This was preserved and advanced during the Dark Ages by the physicians and surgeons of the Islamic Golden Age, and then “rediscovered” in the Renaissance, until the scientific revolution of the Age of Enlightenment shook us from the bonds of classical dogma and led to an explosion of medical and surgical knowledge through experimentation. The Industrial Age created added significant technological advances, arguably the most important of which was the ability to inhibit pain and avoid infection, allowing surgeons to delve ever deeper into the mysteries of the human body. This opened the window to the contributions from surgeons from across the globe that have brought us to this moment in time. This accumulated knowledge has been passed down from master to apprentice, teacher to learner, staff to student, in an unbroken chain that directly links us with the surgeons of the past.
Their influence is all around us when we step into the operating theatre, from hand washing (Semmelweiss), to the asepsis of the operative field (Lister), to the wearing of surgical gloves (Halsted) to the countless eponymously named instruments, procedures, and anatomical structures, that are part of every operating theatre around the world. Just about every part of an operation links us to the past, and to the people that came before us who discovered this hard-won knowledge.
Studying these individual surgeons can both inspire us, and serve as a warning by demonstrating how good intentions can lead us astray. In addition to their contributions to surgical practice, many surgeons were basic scientists, Nobel Prize winners, public health advocates, artists, musicians, writers, and influential public figures that captured the imagination of society, both with their innovative breakthroughs and sometimes, their larger than life personalities. The English surgeon Percival Potts discovered the link between chimney sweeping and scrotal cancer in 1775, considered the first identification of an environmental carcinogen. American neurosurgeon Harvey Cushing won a Pulitzer Prize for his biography on Sir William Osler. South African surgeon Christiaan Barnard, who performed the world’s first successful heart transplant, was also an outspoken opponent of apartheid. And there are countless other examples.
Surgeons have also experimented on the unwilling; for example, J. Marion Sims (of Sims retractor fame) did much of his ground-breaking work on obstetrical fistulas on African-American enslaved women in the mid-1800s. A number of surgeons were associated with the Nazi party, including Nobel Prize winner and French surgeon-scientist Alexis Carrel and the pioneering German thoracic surgeon Ferdinand Sauerbruch. And surgeons have taken part in the eugenics movement and forced sterilization, among other failings. Studying these examples shows us how surgery is not practiced in isolation, but rather affects and is effected by the world, society, and history. Surgeons have the potential to accomplish great things, but are also human, with all the flaws that come with it, and are not immune to the ills that plague society at large. It is important to recognize the bad with the good, and to ensure that history does not repeat itself.
Finally, one of the greatest challenges in medicine and surgery today is the epidemic of burnout, the causes of which are multifactorial, but includes a loss of finding meaning and purpose in work, and a feeling of disconnection. I believe that knowledge of our shared history, and studying those that came before us, can give a sense of identity and meaning to the practice of surgery. In an era of increasingly burdensome administrative tasks, it is easy to feel a sense of detachment and futility. But by studying the history of surgery, a greater sense of being rooted in community and purpose can be nurtured, and inspiration can be found to further the development of surgery towards better treatments and innovations, and to advocate for the patients that, too, have been a part of this shared history.
By Mr Henry G Smith MBBS MRCS PhD, specialist registrar at The Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen
The number of hours in training that it takes for a surgical trainee to achieve both clinical and technical competence is a seemingly endless topic of debate. The significant global variation in a surgical trainee’s average hourly week begs the question as to why such variation exists and to what extent all training programmes are created equal (1). Given the increasing recognition of burnout amongst medical professionals, and its association with excessive workloads, it is reasonable to think a shorter working week may benefit the surgical trainee’s wellbeing (2). However, any potential benefits much be weighed against the risk of reducing training opportunities and clinical exposure. Having personal experience of both British, with its nominal 48-hour working week, and Danish general surgical training, where surgeons work a 37-hour week, it is clear that whilst these countries have very similar healthcare systems, they differ markedly in their approach to training. Whilst neither training programme is without its limitations, their differences highlight potential ways in which the efficiency of surgical training may be improved.
The most striking difference between the British and Danish programmes is the absence of the ‘firm’ structure in Denmark. Trainees belong to the department rather than to subspeciality specific teams. The same is true of acutely admitted patients, who whilst broadly divided into those with upper and lower gastrointestinal conditions are not ‘owned’ by the consultant who was on call at the time of admission. As a consequence, there are no ward rounds, post-take or otherwise. Instead, the acute and elective inpatients are divided more or less equally between consultants and trainees alike, with a typical ratio of 2-3 patients to be seen by a single doctor each day. The lack of a rigid structure dictated by a team-based ward round leads to much greater flexibility in all other aspects of the working day. These days are thematic, with trainees having 4 major functions: elective operations, endoscopy, outpatient clinics and on-calls. When a trainee is not assigned to one of these functions, they have zero hours to be used as they see fit.
The flexibility of the Danish system brings two major advantages. The first is that the structure leaves the trainee with the feeling that the majority of time spent at work is spent training. That feeling is emphasised by the organisation of the operating days in particular.
Whilst the trainee spends undoubtedly fewer days in an elective theatre than in the British system, these days are almost exclusively spent attending training lists. Attended by a single trainee and a consultant, comprising repeated exposure to the same operation and booked on the presumption that the trainee will be the primary surgeon, these lists maximise training opportunities. The same is more or less true in endoscopy, where the trainee has their own full day list, with a supervisor on hand if needed. The second advantage is that the planning of absence from work for annual leave, courses or conferences is far less complicated. The minimum number of trainees required at work is determined at a departmental level, avoiding the need to organise cross cover between firms. As such, denied requests to attend conferences are very much the exception rather than the rule and it is almost unheard of that a trainee would be unable to take all of their allocated leave during a rotation.
These structural differences are accompanied by an in-house culture that not only prioritises training but is also ferocious in its defence of working conditions. There is a greater expectation for trainees to be actively involved, at least in part, in the majority of operations, and independent operating is encouraged at a much earlier stage. Senior house officers are expected to be capable of independently performing common acute operations, such as appendicectomies, and whilst consultants are often present for laparotomies, their presence is not compulsory. ‘Service provision’ is rarely mentioned, perhaps a reflection of a healthcare system that is better resourced to match the demands of its population. With regard to the working environment, trainees hold a structured monthly meeting for both positive and negative feedback on issues ranging from training opportunities and supervision to the frequency of on-call duties and conditions of the on-call rooms. The vocal complaints in a recent meeting of the comfiness of the on-call beds are not only a far cry from trying to catch some rest on an old sofa in a British hospital mess but also give an insight into how seriously the Danes take their working conditions.
However, not all the differences are positive. The greater flexibility in the Danish system places greater demands on the discipline of its trainees. Although there are still dedicated rotations in trauma and tertiary centres, the lack of other subspecialty specific rotations means that the trainee must take more responsibility for ensuring that they meet the specific requirements of the training programme. Whilst focused trainees may turn this to their advantage, allowing them to focus on their preferred subspecialty at an earlier stage of training, those who are as of yet undecided may be at risk of drifting in a less structured system. In a similar vein, for a trainee raised in the British system, the absence of the firm structure is accompanied by a sense of a lack of belonging, at least at the beginning of a new placement, although this is somewhat lessened by the daily morning conferences, attended by the whole department. A further concern is the consequences a more flexible system has on the quality and continuity of care. It is not uncommon for acutely admitted patients to be seen by a different doctor each day, a situation commonly thought to increase the risk of delays in discharge or investigations. However, this does not appear to have an adverse effect on patient outcomes, with a 30-day mortality following high-risk laparotomies of approximately 20% in Denmark, mirroring the reports from the National Emergency Laparotomy Audit (NELA) in Britain (3-5). Finally, one must remember that achieving competence as a surgeon is not only about developing technical skills. As the old saying goes “good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate”. Although the Danes may have a more efficient approach to the technical aspects of training, it is undeniable that the clinical exposure of British trainees is far greater. The cumulative clinical experience of following both elective and acute patients from admission to discharge is difficult to replicate and whilst any differences in decision-making seem to have disappeared by the end of training, these skills appear to develop more rapidly in the British systems. Disruptions to the continuity of care present another barrier for clinical exposure in the Danish system, with the following up of the patients seen on-call or in the operating theatre left to the trainee’s own initiative.
The hourly week occupies much of the debate on surgical training and, in doing so, prioritises quantity over quality of training. With a focus on maximising the efficacy of training opportunities, the Danish surgical training system demonstrates how surgeons can be effectively trained on a shorter working week. Whilst this system has its own limitations, the organisation of a trainee’s operative commitments in particular provides an example for other systems to follow. Surgical training faces major challenges ahead, with a global pandemic that has not only limited training opportunities but also taken an inevitable toll on workforce morale (6). Furthermore, the backlog of operations cancelled since the beginning of the pandemic is likely to place a huge emphasis on efficiency in operating theatres, which may have further negative effects on training opportunities (7-8). However, the return of some degree of normality will also offer the opportunity to reconsider the structure of training and perhaps in doing so, the best aspects of these respective training systems could be combined, shifting the focus away from the number of hours spent at work to the amount of time spent training.
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Boyd-Carson H, Doleman B, Herrod P J J, et al., on behalf of the NELA Collaboration, Association between surgeon special interest and mortality after emergency laparotomy, British Journal of Surgery, Volume 106, Issue 7, June 2019, Pages 940–948, https://doi.org/10.1002/bjs.11146
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1. Rebecca C Grossman MA MBBS AKC DHMSA MRCS, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
2. Graham Mackenzie MD FRCPE, Penicuik Medical Practice, Imrie Place, Penicuik, UK
3. Julio Mayol MD PhD, Professor of Surgery, Chief Medical Officer, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense, Madrid, Spain.
Competing interests: The authors declare no competing interests.
Funding: No funding was provided for this study.
Previous presentations: The findings of this study were presented as a poster at the Society for Surgery of the Alimentary Tract 60th Annual Meeting on the 21st May 2019.
It has long been the tradition to publish the Proceedings of surgical conferences 1. Over the last 15 years, the way surgeons interact has transformed extensively due to the advent of social media, with much of the conversation moving online 2-3. The covid-19 pandemic acted to accelerate this transition 4. The microblogging platform Twitter provides a vast library of information and allows real-time communication and dissemination of information, grouped along themes via a “hashtag” (metadata tag) 5-8. Twitter use is increasing among surgeons, researchers, healthcare professionals, and patients.
Organised conversations on Twitter, so-called “tweetchats”, are a forum through which experts, trainees, and patients from around the globe can communicate and discuss topics of shared interest via a hashtag and moderated by a host 5,7,9. Tweetchats allow real-time back and forth conversation, similar to face-to-face interactions10. These conversations are a treasure-trove of ideas that can provide great insight into the most cutting-edge trends in surgical practice 7,11-13.
On 28th July 2018, a social media initiative was created by Julio Mayol via his Twitter handle (@juliomayol), to focus on specific surgical interests, connected via the hashtag #SoMe4Surgery (Social Media For Surgery) 14. The aim was to bolster a more inclusive, multidisciplinary surgical community. Since the inception of #SoMe4Surgery, a number of tweetchats were planned and undertaken using the hashtag. In November 2018, a tweetchat was held with the subject of surgical technology. This theme was chosen as surgical technology is rapidly evolving in many directions, under multiple influences 15, and the authors felt it was a key time to take stock in where we are and where we are going. The aim of this study was to identify the main themes of the chat on surgical technology and to estimate the potential reach of the tweets.
No ethical approval was required for this retrospective study as it did not interfere with any patient or human data beyond measuring internet activity among Twitter users using publicly available tweets.
Sampling and data extraction
A retrospective analysis was performed of the tweetchat that was led by two surgeons with 941 (@rebgross) and 24,539 (@juliomayol) followers on November 23rd 2018, with ten predefined questions. The #SoMe4Surgery ecosystem was the primary target of the conversation. Ten tweets containing questions for the audience were posted in a 60-minute period (9:00 pm – 10:00 pm Madrid time).
Data analytics and visualization were carried out using two different online tools. Twitonomy is available at http://www.twitonomy.com, and provides advanced network analytics of tweets, hashtags and tweetchats, under subscription. Twitonomy analytics were performed by author JM on November 29th 2018, of tweets posted between November 22nd 2018 at 8:15 pm and November 29th 2018 at 8:17 pm using the two hashtags, “#some4surgery” and “#surgicaltechnology”. Potential reach was defined as the total aggregate number of followers of the people who mentioned both keywords in their tweets. Potential reach may be overestimated as Twitonomy may make assumptions to estimate impressions and/or audience, and geolcations are sometimes misclassified; therefore NodeXL analytics were also examined by author GM. NodeXL is a spreadsheet template that allows the creation of visual network graphs (Social Media Research Foundation; California, USA; https://www.smrfoundation.org/nodexl/). Using NodeXL, the extracts for 23rd November 2018 were extracted and mapped as described elsewhere 16.
The tweets from the tweetchat were manually reviewed on Twitter by author RG by searching for the terms [#SoMe4Surgery since:2018-11-23 until:2018-11-30] on 18th June 2019 to identify the themes of the chat for content analysis. Replies to the questions posted by the moderators were also reviewed to avoid missing tweets that did not include the hashtag. The handles (usernames) and profiles of the users were manually reviewed.
Twitonomy analytics revealed that, between 22nd November 2018 at 8:15 pm and 29th November 2018 at 8:17 pm, there were 348 tweets and retweets including the two hashtags posted by 60 users (40 men, 13 women, 7 unknown) from 50 geolocations in 5 continents. From the biographical information available in their Twitter profiles, specialties included general surgery (5), HPB/transplant (4), plastics/cosmetic (2), vascular (4), ophthalmology (1), hernia (1), colorectal (5), cardiovascular (1), endocrine/bariatric (1), spinal (1), global (1), trainees (1), associations (1), and non-medical (5). Conflicts of interest of individuals participating in the tweetchat included working for private health tech companies (4), criminal defence lawyer (1), and running the tweetchat (2).
From Twitonomy, the potential reach was 1,883,455 accounts. A tweetmap of the users of both #SoMe4Surgery and #SurgicalTechnology hashtags can be found in Fig. 1.
NodeXL data revealed, over the 1-day, 2-hour, 48-minute period from Thursday, 22nd November 2018 at 19:15 UTC to Friday, 23rd November 2018 at 22:04 UTC, there was a network of 39 Twitter users whose recent tweets contained both #SoMe4Surgery and #surgicaltechnology hashtags (Fig. 2), or who were replied to or mentioned in those tweets. There were 39 vertices, 71 unique edges, 303 edges with duplicates, 374 total edges, and 22 self-loops. Reciprocated vertex pair ratio was 0.19, and reciprocated edge ratio was 0.32. In a connected component, there were 39 maximum vertices and 374 maximum edges.
Over the 21-hour, 40-minute period from Friday, 23rd November 2018 at 00:18 UTC to Friday, 23rd November 2018 at 21:59 UTC, there was a network of 152 Twitter users whose recent tweets contained the #SoMe4Surgery hashtag (Fig. 3), or who were replied to or mentioned in those tweets. There were 152 vertices, 329 unique edges, 546 edges with duplicates, 875 total edges, and 44 self-loops. Reciprocated vertex pair ratio was 0.13, and reciprocated edge ratio was 0.22. In a connected component, there were 128 maximum vertices and 848 maximum edges.
From Twitonomy, the ten most influential users (8 men, 1 woman, 1 unknown) had a median number of followers of 16,648 (range 747-344,648). The ten most engaged users (4 men, 3 women, 3 unknown) posted a median number of 27 tweets (range 11-346). The top hashtags were #SoMe4Surgery, #surgicaltechnology, #surgicalpractice, #AI and #SSI.
Current technological improvements to surgical practice
In a poll asking which surgical technology has most significantly improved surgical practice (Question 4), preoperative imaging received the most votes (53% out of 288 votes), with intraoperative imaging receiving 10% of the votes (Fig. 4). @WarrenRozen stated that preoperative imaging is certainly of benefit, while intraoperative imaging has not yet demonstrated this effect despite having great potential. @MrRJEgan stated that preoperative imaging reported by specialists can improve quality and outcomes. @perbinder highlighted that this was particularly important in vascular surgery, where preoperative Duplex and CT angiography are widely used. @SJ_Chapman suggested that in colorectal surgery, medical imaging in general had revolutionised patient care before, during and after surgery, for example with the use of post-processing CT colonography, PET-CT, and MR. @EUrologyReg agreed, stating that the now widespread availability of CT scans has had a huge impact on surgical decision-making.
Energy delivery systems received 33% of the votes. @DrSantiagoOrtiz explained that technologies such as laser, phacoemulsification, and vitrectomy had revolutionised his field of ophthalmology. @MrRJEgan stated that the main benefit of energy devices lies in efficiency and reduced operating times.
Biomaterials received the fewest votes (4%) and were considered more likely to be of benefit in the future (@WarrenRozen), although @DrSantiagoOrtiz thought that they were becoming very relevant in ophthalmology with the use of intraocular lenses.
@A160186 reported that endoscopy and endoluminal surgery have also changed the face of surgery, and that interventional radiology has radically impacted the management of surgical conditions, pointing out that it is a non-surgical technology, and that saving the patient from having an operation should be considered an achievement in itself. @DrSantiagoOrtiz agreed that non-surgical technology will likely have the highest impact in surgical practice.
In a poll asking which surgical technology is most frequently used for intraoperative bleeding (Question 7), 82% of the 102 votes were for energy delivery devices, 10% for fibrin sealants, and 2% for thrombin gels (Fig. 5). @YorkLawLondon stated that intraoperative bleeding can be problematic in fibroid surgery, and that pharmacological therapy, such as preoperative hormone suppressants and intraoperative vasopressin, is frequently used to counter this.
In a poll asking about the use of surgical technology to reduce the rates of surgical site infection in surgical practice (Question 5), 40% voted “yes” (of 78 respondents), 22% voted “sometimes”, and 31% voted “no” (Fig. 6). @DrSantiagoOrtiz expressed surprise by the high proportion answering “no”, stating that the use of such technology is widespread in ophthalmology.
Future innovations in surgical technology to improve patient safety
A wide range of technological innovations were proposed to improve patient safety in future surgical practice. These included energy devices, advances in anaesthesia, pharmacology, information technology services and data management, radiology and nuclear medicine, and advances in medical allied medical specialities such as gastroenterology, clinical genetics, and medical oncology.
An area in which many Twitter users were interested was navigation-guided surgery, particularly with respect to finding the right planes and avoiding at-risk structures (@dr_samehhany81). @A160186 described a “surgical GPS or an intraoperative Siri/Alexa” to guide surgeons through tough terrain. @polom_karol took this further, adding a preoperative diagnostic tool overlay and the help of artificial intelligence to assist in surgical decision making.
“It would be great if during a lap cholecystectomy [you] could just go ‘Siri [please] tell me if this is the cystic duct’ (hoping she’d have the right answer).” (@A160186)
@Eric_Vibert and @jamestoml1 both highlighted the importance of the OR Black BoxTM in changing the relationship between surgery and human error, which has a significant impact on patient safety. @schnitzb suggested that direct loop feedbacking would lead to a reduction in human error.
The most commonly mentioned technological advance was laparoscopic and robotic surgery. @CelestinoGutirr argued that robotic surgery improves the technical precision of surgery; @alessiominuzzo countered that as it has been introduced as an “instrument” and its indications have altered, its use should be considered “off label surgery”, or should only be in the context of research. It was compared to laparoscopy, with @RNCsantander and @anhanssen suggesting that the outlook for robotics was similar to that of laparoscopy in its early days, and @DrSantiagoOrtiz stating that the evidence has shown laparoscopy to improve patient safety, while the jury is still out for robotics. Overall, the consensus was that, in the future, the evidence would reveal robotic surgery to be beneficial to patient safety.
In a poll asking how robotic surgery will evolve in the future (Question 2), 42% of respondents (134 votes) predicted that robots would be smaller (Fig. 7). Only 11% of respondents thought that robotic surgery would be phased out. @tuttlejebetsy argued that the “the case reimbursement is too low for sustainability and widespread adoption”, suggesting that robotic surgery only has a future as long as it can demonstrate a sustainable, cost-effective return on investment.
@RNCsantander questioned how we can improve the learning curve and training in robotic surgery to generalize its use. The high cost of the technology was felt to be a barrier to its accessibility (@A160186, @RNCsantander, @rcanterocid). @rebgross suggested the use of simulation training, and @A160186 suggested that robotics should be included in training or fellowship programs, arguing that one must have seen it to practise, and subsequently teach, the technique. @JoshuaTylerMD stated that skill monitoring and improved mentorship via online platforms were essential in improving training.
Three-dimensional printing for surgical practice
In a poll, 51% of 164 individuals voted to say that three-dimensional (3D) printing might be useful for surgical practice (Question 6), while 35% said it will have a big impact, and 7% voted for “it’s a fad” (Fig. 8).
Participants of the tweetchat had found 3D printing to be useful in colorectal (@dr_samehhany81) 17, orthopaedic and maxillofacial (@rcanterocid), and vascular surgery (@TMCAvascular).
@GaneshPuttu and @JasamineCB both stated that 3D printing has been useful in complex cases or with complex anatomy, to assist in visualisation for pre-operative planning, as well as an education tool for trainees and patients, with @MMakgasa suggesting they be used in the consent process. @TMCAvascular called 3D printing fundamental for case planning, posting “before” and “after” images of a ruptured cannulation site pseudo-aneurysm treated with an atrial septal device via brachial approach with intravascular ultrasound and intracardiac echography with the aid of 3D printing.
@LumsdenHMDHVC stated that his centre had moved away from 3D printing for training purposes, for which they used virtual simulation, but that its use was better indicated in case planning and device printing. @jmills1955 thought that the ability of 3D printing to allow the creation of patient and anatomic-specific devices would lead to it having a significant impact. @VerranDeborah echoed its use for implants and extended this to the biofabrication of tissue, suggesting that it may pave the way for the printing of organs in 10-20 years.
Artificial intelligence and its impact on surgical practice
Overall, the consensus was that artificial intelligence (AI) had the potential to have a significant impact on surgical practice. @juliomayol suggested that AI will change the way decisions are made and outcomes are monitored. @dr_samehhany81 and @Dr_A_Sturiale countered that AI would aid and complement the work of humans, but will never replace them.
In particular, it was thought that AI would have the largest impact in medical specialties in which imaging plays a crucial role in diagnosis (@DrSantiagoOrtiz). It was also felt that AI may result in a lower workload and administrative burden, with more time left to devote to direct patient care (@schnitzb). @polom_karol had a dramatic view of AI, stating: “AI will change all”, and that it was “the biggest revolution since [the] early beginning of surgery.” @hgok went so far as to suggest that in only 10 years, appendicectomies and cholecystectomies would be performed by AI-controlled robotic platforms, but that in hernia surgery this would take more time to develop.
@A160186 felt that one of the biggest benefits of AI would be found in patient safety, by creating “safety checkpoints” in clinical decision making, leading to the standardisation of diagnostics and procedures. She added that it was not clear whether AI would ever be autonomous; @YorkLawLondon and @DSoybel suggested this would mean it would only be as good as the data entered, and, for example in diagnostics, a diagnosis could be missed. @DSoybel further posed the critical question of who would control the data and algorithms. @YorkLawLondon added that any outsourcing could lead to companies exploiting or restricting data access and profiting from it; @DSoybel answered: “If neither data nor algorithms are proprietary there would be chaos. If both are proprietary there would be monopoly and potential for gaming. If one is and the other is not, there will be competition.”
“I’m sure surgeons prefer artificial intelligence over lack of intelligence.” @A160186
The patient’s perspective
There were some very insightful answers given when patients were asked which surgical technology they most valued. They can be found here. The most common theme was that the surgeon was valued above the technology.
Ethical issues in the development of new surgical technology
The issue of data ownership again arose when discussing the ethical issues surrounding the development of new surgical technology (@polom_karol).
The evaluation of risks and benefits was frequently mentioned (@CelestinoGutirr, @RNCsantander). Other issues included the dangers of optimism bias (@rebgross), as not all innovations are successful or result in improved patient care, and publication bias (@SJ_Chapman), leading to research waste 18. @SJ_Chapman also stated that it is ethically essential to determine not only if biotechnology results in patient benefit, but also the mechanics of why it works and has benefit, and that this would require well-designed qualitative work and patient and public involvement to facilitate the future development of the technology. @DrJamesGlasbey raised the issues of learning curves, proctorship, and early outcomes reporting. @schnitzb added the problems of rushing a product into market based on inadequate data. Finally, @coezycoe suggested that value and cost would have an impact on patient access to new surgical technology.
“[We] need to avoid ‘try it, bin it’ attitudes when evaluating surgical [biotechnology].”@SJ_Chapman
The tweetchat reached a global audience across different surgical specialties, as well as attracting engagement from patients.
The form of surgical technology currently found to be the most useful among the tweetchat participants was preoperative imaging. Energy delivery systems were the most commonly used technology to assist with intraoperative bleeding. Most participants employed surgical technology to reduce the rates of surgical site infection. Exciting avenues for future innovation included navigation-guided surgery, increased use of the OR Black BoxTM, and developments in laparoscopic and robotic surgery. The use of 3D printing and AI were both considered to increase in the coming years, with potential advances in automation. There were numerous important ethical issues to consider when developing new surgical technology. Finally, the consensus among patients was that, while advances in surgical technology were welcome, they were not as important or valued as the surgeon who employs them.
Limitations of analytics
It should be noted that Twitter polls are unvalidated and subjected to selection bias, and one person may also control multiple accounts. Although some users provide information about their areas of expertise in their Twitter bios, this is unregulated, and they may not include conflicts of interest. There is therefore the risk of non-expert or uncited opinions being included in the synthesis. This caveat must be emphasised when sharing such data.
Some data may be confounded by “incidental retweeting”, whereby if a tweeter uses two hashtags together, it is not always possible to determine from which hashtag the retweet results. Third party social media tools tend to overestimate impressions and audience. Although Twitter Analytics may provide a more accurate measure of impressions, this is not possible to collect from a tweetchat in which multiple Twitter accounts are engaged. Finally, collecting such data is subject to the Hawthorne effect, where changes in behaviour may be affected by the act of observation 19.
To validate the findings, further research could incorporate validated methods of qualitative research, such as thematic analysis.
Social media may be used to disseminate information within a vast surgical ecosystem, engaging surgeons with a strong social media presence. The use of a standardised hashtag in a tweetchat allows information to reach a high volume of global Twitter users in the surgical community in a short space of time. Tweetchats between a diverse group of surgeons, allied health professionals, and the general public, can be a goldmine for determining the direction of future surgical innovations.
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Mackenzie G, Grossman R, Mayol J. Beyond the hashtag: describing and understanding the full impact of the #BJSConnect tweet chat May 2019, BJS Open, 2020;, zraa019, https://doi.org/10.1093/bjsopen/zraa019
Brady R R W, Chapman S J, Atallah S, Chand M, Mayol J, Lacy A M, Wexner S D, #colorectalsurgery. Br J Surg. Volume 104, Issue 11, October 2017, Pages 1470–1476, https://doi.org/10.1002/bjs.10615
Hawkins CM, Hillman BJ, Carlos RC, Rawson JV, Haines R, Duszak R Jr. The Impact of Social Media on Readership of a Peer-Reviewed Medical Journal. Journal of the American College of Radiology. 2014;11(11):1038-1043.
Topf JM, Sparks MA, Phelan PJ, et al. The Evolution of the Journal Club: From Osler to Twitter. American Journal of Kidney Diseases. 2017;69(6):827-836. doi:10.1053/j.ajkd.2016.12.012.
Litchman ML. Diabetes Online Community User Perceptions of Successful Aging With Diabetes: Analysis of a #DSMA Tweet Chat. JMIR Aging 2018;1(1):e10176 https://agingjmirorg/2018/1/e10176/. 2018;1(1):e10176.
Bolderston A, Watson J, Woznitza N, et al. Twitter journal clubs and continuing professional development: An analysis of a #MedRadJClub tweet chat. Radiography. 2018;24(1):3-8. doi:10.1016/j.radi.2017.09.005.
Mackenzie G, Murray AD, Oliver CW. Virtual attendance at an international physical activity meeting using Twitter: how can data visualisation provide a presence? Br J Sports Med. 2018 Mar;52(6):351-352.
Emile SH, Wexner SD. Systematic review of the applications of three‐dimensional printing in colorectal surgery. Colorectal Dis. 2018;2017:ArticleID4574. doi:10.1111/codi.14480.
Chapman SJ, Aldaffaa M, Downey CL, Jayne DG. Research waste in surgical randomized controlled trials. Br J Surg. 2019 Oct;106(11):1464-1471. doi: 10.1002/bjs.11266. Epub 2019 Aug 8.
Fry DE. The Hawthorne Effect Revisited. Diseases of the Colon & Rectum. 2018;61(1):6-7. doi:10.1097/DCR.0000000000000928.
Maria Picciochi (@MariaPicciochi), Hospital Prof Doutor Fernando Fonseca, Portugal
Dmitri Nepogodiev (@dnepo), University Hospital Birmingham, UK
Virtually all elective surgical services around the world suffered some form of shutdown due to the COVID-19 pandemic1. Now, patients and surgeons are desperately looking to re-start services. Efforts to re-start after the first waves faced multifactorial challenges, including patient safety and ensuring enough staff along the whole patient pathway to support operating theatre availablity.2,3
The impact of the reduction in surgical capacity is likely to be staggering. Initial estimates of 28 million cancelled operations likely escalated to 50 million towards Autumn 2020, and may now be in excess of 100 million. That is only one part of the story, since the many undiagnosed patients with surgical conditions sitting in the community over the last 12 months may never make it to a surgeon or waiting list. Without adequate surgical capacity, there will be a major global decline in population health due to the burden of a full range of inadequately treated non-communicable diseases.
There is no single factor or solution that will enable surgery to re-start at scale, quickly. There is no single set of solutions that will work across every region. Since every single hospital around the world functions differently, context specific and whole system solutions are needed.
Vaccination will hopefully provide solutions to the current pandemic, although the global rollout is occurring at different paces globally, meaning surgical recoveries will differ. Cultural challenges across countries are adding to this variation. Unlike acute major incidents which disable elective surgical but are quickly over (e.g. major trauma or bombings), this pandemic has exposed specific, longer-term weaknesses of current systems. Post-pandemic planning will now happen across all spectrums of society. Surgeons need to lead efforts to create resilient elective surgical services that are pandemic resistant for the future, advocating for hospital and political awareness.
The COVIDSurg collaborative has taken a data driven approach to supporting safe surgery, and for 2021-2022 will provide further data to support re-starts globally. Data is needed across the whole system and patient pathway, that includes referrals, preoperative selection, perioperative testing and safety, postoperative risk reduction, and structural organisation of hospitals4–6.
Figure 1 – Centres enrolled in COVIDSurg studies
Learning from other non-medical disciplines, surgeons have little barometer of how secure their elective surgical services are compared to everyone else’s. COVIDSurg will deliver a validated Elective Surgery Resilience Index in the first half of 2021, allowing surgeons to test their systems and identify areas for immediate strengthening.
Re-starting surgery safely will be a complex interplay of these multiple factors. Not all resources will be available across all regions, and in some resource limited settings, surgery is at risk of being seen as a burden. To further support the re-start, an easily accessible, digital, online toolkit is needed that will provide key take-home messages and downloadable pathways for surgical teams to take and adapt. This will include the ability to self-certify individual department and hospital level of COVID Secure Surgery. This will provide the building blocks to provide ring-fenced, pandemic secure surgery by 2030.
Conflicts of interest: We have no conflicts of interest to declare.
Funding: No funding was received for this blog article.
1. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:10.1002/bjs.11746
2. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov-2 infection: An international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
3. COVIDSurg Collaborative. COVID-19-related absence among surgeons: development of an international surgical workforce prediction model. BJS Open. doi:10.1093/BJSOPEN/ZRAA021
4. COVIDSurg Collaborative. Outcomes from elective colorectal cancer surgery during the SARS‐CoV‐2 pandemic. Color Dis. December 2020:codi.15431. doi:10.1111/codi.15431
5. COVIDSurg Collaborative. Elective cancer surgery in COVID-19–Free surgical pathways during the SARS-cov-2 pandemic: An international, multicenter, comparative cohort study. J Clin Oncol. 2021;39(1):66-78. doi:10.1200/JCO.20.01933
6. COVIDSurg Collaborative. Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic. Br J Surg. 2021;108(1):88-96. doi:10.1093/bjs/znaa051
Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: 5-year outcomes of merged data from two randomized clinical trials (SLEEVEPASS and SM-BOSS)
Recently published as open access in BJS, the 5-year results of the merged Finnish SLEEVEPASS and Swiss SM-BOSS randomised controlled trials comparing laparoscopic sleeve gastrectomy with laparoscopic Roux-en-Y gastric bypass shows that Roux-en-Y led to greater weight loss and better control of hypertension than sleeve gastrectomy, with no difference in outcomes for type 2 diabetes, obstructive sleep apnoea, or quality of life. More details can be found in the paper.
Yongbo An (@an_yongbo), Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
Vittoria Bellato (@vittoriabellat0), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
Gianluca Pellino (@GianlucaPellino), Department of Advanced Medical and Surgical Sciences, Universita degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy; Department of Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
Tsuyoshi Konishi (@yoshi_konishi), Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, Texas 77030
Giuseppe S Sica (@sigisica), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
on behalf of S-COVID Collaborative Group
The epicentre of the SARS-CoV2 outbreak has been shifting from place to place, hitting many countries in the world. The feelings of angst, distress and desperation have also spread along with the virus among healthcare workers (HCW). It is hard to forget the early voices from the frontline HCW, the rapidly worsening situation during the escalating phase,1which seems to be occurring again in countries that are being hit by the second wave.2
1/ I may be repeating myself, but I want to fight this sense of security that I see outside of the epicenters, as if nothing was going to happen “here”. The media in Europe are reassuring, politicians are reassuring, while there’s little to be reassured of. #COVID19#coronavirus
The early working experience originally narrated by an Italian doctor Daniele Macchini. English translation by Silvia Stringhini on twitter.
Surgeons’ fear of getting infected by SARS-CoV-2 and developing COVID-19, as well as the change of their daily surgical practice, has been described since the early stage of the pandemic.3 Despite the varying rates of infected people among countries, surgeons have experienced globally a common angst about the virus due to their high-risk job.
China, as the first country facing the virus, had limited previous knowledge and experience about COVID-19 to refer to. The HCW were immediately frightened by what they witnessed: emergency rooms filled with patients infected by an unfamiliar type of virus, followed by overwhelmed intensive care units. Since the escalation of the epidemic in Wuhan was so rapid, most elective surgeries in China were cancelled and not resumed until mid-March 2020.4 The fear of the unknown had forced most hospitals to stop surgical practice, leading to a serious backlog of surgical patients. Due to lack of staff, many surgeons were frequently re-employed to work in intensive care unit or fever clinic, causing a feeling of inadequacy to work in a medical area for which they were not trained. During the post-epidemic period, the mental stress among surgical staff persisted due to the extensive surgical backlog and the additional work involved in ensuring a safe environment for newly hospitalized patients through creation of selective safe routes and adequate personal protective equipment (PPE) adoption.5
Surgeons in Europe have probably suffered even worse situations. Fear of getting infected has led HCW to feel a threat to their life because of their work. In the early phase, a vascular surgeon from the UK spoke out about such dreads, and acknowledged the importance of looking after surgeon’s mental well-being.6 Otolaryngology-ENT, and maxillofacial specialties were regarded as those at highest risk, therefore, a team from the Head and Neck Unit of the Royal Marsden NHS Foundation Trust and Lewisham Child and Adolescent Mental Health Services analysed the impact of COVID-19 on the mental health of surgeons. The fear of contracting the virus and transmitting to family members represented important factors affecting mental health of HCW during the pandemic.7 Many HCW were self-isolating from their family and many decided to left their homes, while others moved into their garages and basements.8, 9
In US, where the pandemic hit in the summer, surgeons also expressed their angst during work. Shortage of PPE and lack of a coordinated pandemic plan from the central government further exacerbated the fear. During the early phase of the pandemic, surgeons from US declared “guilt and fear are to some extent pervasive in medical practice”, “any provider during this time that says they aren’t impacted is not being truthful with themselves”.10, 11
Another key element that has generated stress among doctors has been the uncertainty of how to treat a completely unknown disease. Data were lacking and indications were changing frequently, causing confusion and misinformation. An explicative example is given by guidelines on use of surgical masks: WHO and many governments initially banned the use of adequate PPE in hospital daily practice when dealing with asymptomatic people, due to lack of scientific evidence and lack of stock of PPE.
Surveys among HCW have become a fast and effective way to provide updated data to guide medical choices during this unprecedented time.12, 13 A survey from Mexico investigated personal feelings among 150 vascular surgeons; with ten short but detailed questions, the results of the survey showed that the greatest fear was to infect their families. More than half of the respondents thought that PPE supply was inadequate and 61% of the respondents did not agree with the way government and the Health secretary have handled the pandemic.14
A survey among 150 vascular surgeons from Mexico, investigating their feelings and life during COVID-19 pandemic.
Another regional survey from a tertiary academic centre in Singapore investigated psychological health condition among 45 surgical providers during the pandemic. The results revealed that 77.8% of respondents were experiencing fear of contracting COVID-19, and 88.9% reported fear of spreading the virus to their families. Doctors in training suffered worse mental health condition than other colleagues;15 a national survey explored factors associated mental health disorders among 1001 young surgical residents and fellows in France, finding that enough PPE supply and sufficient training on preventing COVID-19 could decrease the possibility of developing anxiety, depression and insomnia.16During early April 2020, the S-COVID Collaborative conducted a global survey among surgeons from 71 countries, revealing that the fear of getting infected by COVID-19 or infecting others was indeed very common among the respondents from all over the world. Furthermore, the analysis showed that shortage of surgical masks, dissatisfaction towards hospital’s preventive measures and experiencing in-hospital infections were associated with surgeon’s fear.17
A global survey of surgeons’ fear of getting infected by COVID-19, conducted by S-COVID group
Indeed, factors associated with surgeons’ fear, elicited from the above global survey, are preventable. Since comprehensive meta-analysis and reviews have clarified the effectiveness of face masks,18 and additional supply strategies have been established,19 the shortage of face masks and other PPE could be fully managed. Another action which could reduce anxiety and stress of the HCW would be intensive SARS-CoV-2 screening. In Wuhan, universal screening for all 10 million residents was completed in May. “The physical lockdown on the city was lifted on April 8, and after the testing campaign was finished, the psychological lockdown on Wuhan people has also been lifted.” Such universal screening would also reassure the surgeons as well as other HCW.20, 21
Unfortunately, before the normal life and work could be resumed (even if known as “new normality”), the second wave of the pandemic started. Sentiments of fear, angst, anxiety are likely to impact heavily citizens and HCW. The surgical staff is already facing heavier workload due to the backlog of surgical patients during the pandemic – which might be even worse, as many did not have enough time to recover from the first wave. If one takes into account that more than 28 million elective surgeries have been cancelled or postponed worldwide,22 the resulting picture is extremely worrisome. Besides the upcoming enormous workload, asymptomatic COVID-19 patients are still acting as threats for hospitals, making the daily work of surgeons harder than usual.23
It is well acknowledged that surgeons are always working under great pressure, burnout due to work is a common finding among surgeons.24 However, the pandemic has generated an unprecedented situation, in which HCW are being overwhelmed by their angst and fears. Medical litigations are also likely to increase in the next months, adding to HCW sense of uncertainty and inappropriateness.25 It is mandatory that the public opinion, the press and social media contribute to offer a balanced and realistic overview of the conditions in which HCW are being forced to work; and that societies and entities collaborate to create strategies to prevent such conditions,26 and to help HCW who are struggling, left alone.
13. Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS. Screening policies, preventive measures and in-hospital infection of COVID-19 in global surgical practices. Journal of global health 2020;10(2): 020507.
15. Tan YQ, Chan MT, Chiong E. Psychological health among surgical providers during the COVID-19 pandemic: a call to action.n/a(n/a).
16. Vallée M, Kutchukian S, Pradère B, Verdier E, Durbant È, Ramlugun D, Weizman I, Kassir R, Cayeux A, Pécheux O, Baumgarten C, Hauguel A, Paasche A, Mouhib T, Meyblum J, Dagneaux L, Matillon X, Levy-Bohbot A, Gautier S, Saiydoun G. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France.n/a(n/a).
17. An Y, Bellato V, Konishi T, Pellino G, Sensi B, Siragusa L, Franceschilli M, Sica GS, Group S-CC. Surgeons’ fear of getting infected by COVID19: A global survey.n/a(n/a).
18. Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 2020.
19. Zeidel ML, Kirk C, Linville-Engler B. Opening Up New Supply Chains. New England Journal of Medicine 2020: e72.
23. Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS, Group S-CC. Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic.n/a(n/a).
25. Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk, and second victims in surgery: care for the carers to protect the patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.
26. Pellino G, Vaizey CJ, Maeda Y. The COVID-19 pandemic: considerations for resuming normal colorectal services. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.
Recently published as open access in BJS, this prospective quality improvement study showed a reduction in surgical site infections using an adaptive, multimodal surgical infection prevention programme for low-resource settings. Further information can be found at the Lifebox website.
The COVID-19 pandemic has impacted healthcare around the world. Patients who have vascular disease (problems with their arteries or veins), are at high-risk of having complications if they develop COVID-19. This is because patients with vascular disease usually have many medical problems. Some of them are also elderly and might be frail. We do not know how the COVID-19 pandemic might have affected the care of patients with vascular disease.
The COVER study is an international study trying to assess how the COVID-19 pandemic changed the medical care of patients with vascular disease. The first part of the COVER study was an internet survey. In this survey, doctors and healthcare professionals were asked questions (every week) about the care of vascular patients at their hospital. The results were published in this article.
The results showed that the COVID‐19 pandemic had a major impact on vascular services worldwide. Most of the 249 hospitals taking part from 53 countries, reported big reductions in numbers of operations performed and the types of services they could offer to patients with vascular disease. Almost half of the hospitals stopped doing routine scans to detect artery problems and a third had to stop all clinics in the height of the pandemic. There were major changes in the resources available to treat blocked leg arteries. Most non-urgent operations, especially for vein problems, were cancelled.
In the months during recovery from the pandemic peaks, there will be a big backlog of patients with vascular disease needing surgery or review by vascular specialists.
It is a surgical aphorism that it is more difficult to decide when not to operate than when to operate.
In the study “Learning from Regret”1, surgeons contributing to Queensland’s Audit of Surgical Mortality were asked to reflect on deaths following surgery. They were asked whether they would have done anything differently in retrospect. The aim was to explore surgeon’s reflections on what might have been done differently for patients who died under their care. The secondary aim was to assess for the presence of regret – defined as the presence of personal responsibility and realisation that another decision could have been better.
Post-decision regret was explicitly identified in 16.9% of responses. One of the scenarios specifically referred to was regret surrounding with proceeding to surgery in cases where the likelihood of survival was slim (“the decision entailed the alternative of certain death rather than probable death”). The fields of behavioural economics and psychology give us several reasons why we shouldn’t reflexively regret decision-making in these types of charged scenarios – because regret is the de facto outcome of a decision to operate in this scenario.
Firstly, the fact of operating rather than palliating in this scenario makes us more likely to regret it in retrospect when the outcome is poor by the mere fact of one having acted rather than not acted. Actions are more salient (i.e. easier to recall) than inaction and, therefore, more prone to regret upon reflection from a psychological perspective2. Humans also tend to regret action (acts of commission) more than inaction (acts of omission) because having acted, we then attempt to mitigate the cognitive dissonance that arises between our ideal and actual selves by reducing the dissonance by deriving lessons learned from the perceived error3.
The authors of “Learning from Regret”1 highlighted that surgical decision-making in cases associated with deaths were uncertain, complex and subject to situational pressures. In not operating, the surgeon would have to violate the norms of usual surgical behaviour4 that in the face of certain death without an operation, an operation should be performed.
In fact, in scenarios where treatment is highly likely to be futile, expected utility theory would tell us that our choices are very limited. In classical economics, expected utility theory is the theory of how rational actors make decisions. That is, that rational beings choose the option to maximise the risk: benefit ratio. When applying expected utility theory to medical decision-making, as the net treatment benefits increase, we become more uncomfortable withholding treatment even when the probability of a good outcome is relatively low and the risks are substantial. Therefore, when the counterfactual treatment outcome is certain death, if we apply traditional rational economic decision-making theory, then there are few circumstances in which the certainty of this poor outcome can outweigh the small possibility of a good outcome (especially where survival and not functional outcome is the primary outcome).
Furthermore, we increasingly recognise that medical decision-making employs dual-processing theory5. Rather than employing the neural pathways utilised in rational decision analysis, medical decision-making also draws from type 1 or emotional decision-making. This tends to make medical decision makers more risk-averse. Dual-processing of this nature also means that it is more challenging to apply rational thinking behaviours to decision involving how we must act, than it is to rationally decide how others should act6.
Clearly, aiming to avoid futile treatment that increases suffering at the end of life is an important goal in emergency surgery, however, making these types of decisions will always be difficult because surgeons are human and prone to all of the cognitive biases inherent to this state.
One of the consequences of COVID-19 has been greater attention on the risks of infection to clinicians. Much has been made of the need for personal protective equipment, including FFP3 masks, visors, and respirator hoods. Unfortunately these can also impact on communication. This can be due to muffled speech, or loss of ability to read lips. This is important in an operating theatre, where clear communication is critical.
Experience suggests that surgeons probably use some gestures to aid communication when operating. The use of sign language in clinical settings has been previously addressed in the literature, mainly as a proposal to manage increased noise levels in the OR. Sign language has also been suggested as an alternative to handle language differences in surgical team members of varied nationalities, as well as to improve action response within a procedure.
A new sign-language?
To reduce verbal communication that may be limited by impaired speech or hearing, the authors have proposed a surgery-specific sign language. The vocabulary consists of technical information that is easy to learn and replicate and allows fluent communication in the OR. These are summarised in the video above.
A full version of this article can be found in special correspondence to the editor on the BJS website.