Safe and Effective Gynecological Endoscopic & Minimal Access Surgery Prakash H Trivedi
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Is Safety an Option or Necessity in Endoscopic Surgery?CHAPTER 1

Prakash H Trivedi
Chapter Outline
  • Philosophy
“Talents hits a target no one else can hit, Genius hits a target, no one else can see”
 
PHILOSOPHY
Endoscopic surgery came with promises beyond the expectations of the instruments and skills of surgeons especially in gynecology where pathologies are diverse. Vaginal surgeries in the hands of experts are safe and so are abdominal surgeries, but they have their own share of complications.
As endoscopic surgery is and was viewed to be competing and replacing open surgery, a resistance from gynecologist and surgeon was obvious, which was overcome by tall claims made by few endoscopic surgeon, but the truth lies ‘in-between'.
In the hands of expert, endoscopic or vaginal surgery is less invasive than open surgery. However, if every endoscopist feels he/she is the expert endoscopist or every gynecologists feels he/she is a great vaginal surgeon, this gives the patient a false expectation that except miracles no complication can take place with gynecological endoscopy and minimal access surgery.
Thus, it becomes imperative that safety is a necessity and not an option in gynecological endoscopic and minimal access surgery.
The pioneers of gynecological endoscopic surgery in world and in India have spent sfficient unselfish donation of time to enhance their skills, increase their knowledge and also give faster recovery to the patient promising safety. Simultaneously the assistants, anesthetist, operation theater staff also had to upgrade their standards of understanding new technology, equipment, limitations and difficulties of each surgery in this group.
“Habits are safer than rules you don't have to watch them or keep them either. They keep you.”
Further a gynecological endoscopist needs to be organized and also a good conventional surgeon, otherwise having great instruments in their hands, can expose only their limitations, problems or inability to convince the observing gynecologist, surgeon, urologist and patients.
The fear of safety and longer duration of advanced endoscopic surgery prevented thousands of skilled gynecologists and surgeons not to venture into a never ending exciting field of gynecologist endoscopy and minimal access surgery.
“Be not afraid of growing slowly, be afraid of standing still. Minds are like parachutes they work best when open”.
These new surgeries also glamorized the younger group of average surgeons and gynecologists 2to take upon endoscopic or minimal access surgery beyond their capacity. Thus, to run down good endoscopic surgery became easy, but as this is the true consumer driven advance on demand of patients either the gynecologist themselves had to do the surgeries or call somebody else to do at their own place. The biggest groups are fertility enhancing endoscopic surgery, benign gynecological pathology, myomectomy, hysterectomy, urinary incontinence surgery. Thus, many gynecologists (but not all) could pick up good cases for gynecological endoscopic surgery in their own center for a visiting expert. The lacuna it created was a gap between the requirements of proper instruments and assistants in many operation theaters in addition to cutting-cost and corners. The meticulous endoscopist overcame this by carrying their own instruments, expert assistants or even operation theater staff.
A phenomenal number of live endoscopic and minimal access surgery made these surgeries reach into the heart and minds of patient and doctors. Hence, person from smaller places and smaller center with skills could match the expectations.
However, universal application of these techniques by poorly trained surgeon or one with inadequate experience always added catastrophic proportion of morbidity or mortality.
As endoscopic surgery is seen on a big screen surgeons skills were observed, whereas few were fanatic about the timings, few about the number of cases, weights, sizes, number of ports, multiple conventional ports or single port or single incision multiple ports and few accepting any new technology before even evidence proved their superiority of safety.
To add fuel to fire the companies promoted products through good role model gynecologists and surgeons, few experts withhold this temptation but many fell for ‘me-first' philosophy.
Gynecological endoscopy and minimal access surgery today in India, is poised on the gateway of excellence in the hand of skilled experienced endoscopist with outstanding safety, yet the neoendoscopist trying to cross the gates in hurry to prove the supremacy of success in a short-time fell into an equal division of achieving and others complicating.
In summary, as India is blessed by skilled vaginal, abdominal, laparoscopic, hysteroscopic and urogynecological surgeons, its imperative for a surgeon ensuing this as a superspeciality to do proper course of training, not only from one center but more than one expert, not only mastering one or two common surgeries but the wide plethora which gynecology provides safely.
After more than two decades of endoscopic surgery in India, now you have to remember about a silent friend and admirer who is impressed with everything you do—he slips in your consulting room impressed with your power of convincing patient for right surgery, meticulous investigations, sonography, proper counseling you do, he also in present prior to your talk to the relatives before starting surgery. In operation theater he watches and admires your set up, team, anesthetists, and your own mastery to show excellence in even difficult cases or handling crisis. After the surgery he is your shadow when you explain patients and relatives about how the surgery went, what postoperative care they should take in the hospital and at home. Restriction, if any of food, bath, walk, resumption of work and when to aim at desired outcome like pregnancy. He is most impressed with your DVDs, photo demonstrations, books, teaching DVD's, busy schedules.
You always wonder why he is not seen, but the moment you affect the safety, morbidity or mortality of the patient he makes his appearance felt and that's the lawyer. So, if you want to take chance keep safety as an option but if you want to deliver the best keep safety as necessity in gynecological endoscopy and minimal access surgery. It's the mind that stimulates you to do new surgery, it's your hands which develops the skills, it's your heart which is concerned about safety to the patient and it's the soul which tells you that you have succeeded in the endeavor finally.
“Ability is what you are capable of doing, motivation determines what you can do, attitude determines how well you do it, and courage is grace under pressure”.