I have recently been asked this (or a very similar) question at a number of meetings. I have given this issue considerable thought over the years. The most common response I receive from both trainee surgeons and colleagues is that yes the surgeon should call for assistance in the event that there is unplanned damage to an adjacent organ. The most common setting is inadvertent damage to the bowel or bladder. At first glance this seems appropriate – the specialist surgeon can repair the damage and decrease the chance that there will be an adverse outcome. This also plays into the hands of the lawyers who would argue that you need to get a specialist surgeon involved to decrease the litigation risk in the event that a legal suit is filed.
Increasingly I am starting to believe that this approach is flawed and potentially a significant step backwards for our capacity to train high quality endometriosis surgeons for the future. The process, like much of medicine, is driven by lawyers attempting to decrease or (even worse) remove risk from the surgical process. The difficulty is that it is not possible to remove all risk from a surgical procedure. Whilst we can usually predict what is going to happen in most circumstances it is not always possible to do so. New ultrasound imaging techniques and better equipment have certainly helped the predictive process in recent years, especially picking up deep invasive bowel and bladder endometriosis. There will, however, always be lesions and areas that were not predicted or anticipated.
Don’t get me wrong – I am not advocating a situation that does not involve a multi-skilled surgical team for the performance of the surgery. If bowel endometriosis is predicted then I firmly believe a bowel surgeon should be involved. The issue then is WHEN the surgeon is involved. A topic for another blog.
The endometriosis surgeon needs to be able to do as much of the procedure as possible before involving other surgeons. To gain the confidence to do this involves being able to dissect out spaces and divide dense adhesions. At times there will be damage to adjacent organs that was not planned. In the event that this happens, I believe the gynaecologist should be able to repair most (if not all) of these injuries. Often a surgical colleague may be able to assist or offer an opinion but this will not always be the case. There may not be any colleagues around. The procedure may have taken place out of hours or in a smaller hospital with minimal other back up. The real world dictates that the endometriosis surgeon must be able to effect these repairs.
A related problem is the situation where it is clearly in the best interests of the patient to have something done that was somewhat unexpected. The most obvious examples I see involve patients who are having difficulties conceiving and who are also limited with time because of their age. Consider a patient who is 40 with a low AMH and a small bowel lesion that was not predicted on scan that is readily able to be removed. The patient has been consented for removal of endometriosis and the surgeon has mentioned the risks, including colostomy. You could take the conservative, traditional approach and defer surgery and get them to come back with a bowel surgeon. But what if the wait for repeat surgery is another 6 months and then another 6 months if IVF is required. Most of these patients would not be happy to have repeat surgery that required a significant time lag and potentially shut down their fertility window.
There are also clearly times when the surgeon should appreciate that even with significant skills, if the appropriate surgical back up is not available (especially when the risk is high) then the case should be abandoned. This relates to the concept of surgical insight.
The development of advanced surgical skills is not easy and requires significant training but also the capacity to be somewhat flexible in approach and able to deal with changing and unforseen circumstances as they arise.
If our trainees operate with the belief that surgical back up is always available then I strongly believe we will not be training them appropriately for the future. Their surgical skills will not advance to the level required for exceedingly difficult cases. Decreasing risk by early recourse to surgical back up may have the perverse effect of potentially increasing risk to even more patients in future by decreasing surgical skill levels.
I admit these concepts are somewhat “messy” but I believe they are real.