Nicholas Fogelson, MD
Grand Rounds at Baylor Dallas - A Few Lessons for the Residents
This week I had the honor of being invited to give Grand Rounds at Baylor Dallas, under invitation from the chair Dr Anthony Gregg. I spoke to the residents about endometriosis surgery, discussing what we understand about the origins of endometriosis, as well as the rationale for excision surgery. I also showed videos from a number of different excision sugeries, with cases varying from stage I endometriosis, stage IV pelvic endometriosis with bowel resection, abdominal wall endometriosis, and thoracic endometriosis. These sorts of talks are important we are exposing young doctors to something that they otherwise might never be aware of.
I also had the pleasure of working with the residents as we dissected a fresh cadaver, demonstrating the entire retroperitoneal anatomy. I took down the entire side of the pelvic sidewall and identified and demonstrated every named artery, vein, and urinary tract structure. We also demonstrated and dissected the path of the ureter from pelvic brim all the way to the bladder, and replicated technique for a radical laparoscopic hysterectomy.
Finally, I dissected all the pelvic neuroanatomy, including obturator, sciatic, pudendal nerves, as well as nerve roots S1-S4 on each side. We also demonstrated how one performs a pudendal nerve release, cutting the sacrospinous ligaments and coccygeus muscle to open up the pudendal canal to free pressure on the nerve.
I had a great question from one of the residents. She asked how a young doctor can become an endometriosis surgeon. My rather long answer was this:
1. Even at this early stage in your career, resist the urge to think about surgery as a series of steps. Many will do this. That is, when learning to do a laparoscopic hysterectomy many young surgeons will memorize and learn a series of steps that leads from the beginning to the end of the surgery. The problem with this is that while it may work in ordinary situations, one will inevitably encounter variations in anatomy or scarring and adhesions that will make your steps useless. And then you will be paralyzed, and either you will abort your surgery or you may continue and if unlucky, you will injure the patient.
2. Instead of learning a series of steps, focus on learning surgery as three legs to a stool. The three legs of the stool are knowledge of anatomy, knowledge of technique, and knowledge of intention.
Knowledge of anatomy means that the expert surgeon is the master of every anatomical structure in the vicinity of their operative field. Most gynecologists, probably 98% of them, would fail this criteria. The level of mastery required to truly excel means you understand the anatomy of nerves, arteries, veins, bones, and muscle structures, and the relationships between them. When a surgeon has mastered this leg of the stool, no anatomical variation is going to be scary, because they understand where everything is and where they can safely go to complete their task. Knowledge of anatomy does not come from operating under supervision and identifying anatomy as one learns. It instead comes from a specific intention to learn anatomy from all the resources available outside of the operating room, such as books, videos, and cadaver dissections.
The second leg of the stool is knowledge of technique. This means the ability to manipulate tissue and complete one's tasks without creating undue bleeding or accidentally injuring something, and the ability to successfully stop bleeding when it occurs. It also means a mastery of one's equipment, such as an deep understanding of the electrosurgical and other energy-based equipment that we use on a daily basis. Just using the settings your attending used is inadequate. One must truly understand why one sets a piece of equipment a certain way, and why one uses that equipment in a certain way, in order to deal with the situations where one might like to change those settings for better effect.
The third leg of the stool is the easiest one. It is the understanding of surgical intention. For example, the surgical intention of a hysterectomy is to remove the uterus from the body while leaving every arterial and venous connection between the uterus and the body secured and sealed, while preserving the support structure of the body. In many ways this is obvious. But in some cases it is more difficult to understand, such as whether or not one should remove a piece of bowel that appears involved in endometriosis. We call this surgical judgement.
Taking these three steps together and intentionally seeking mastery of each, one is bound to be an excellent surgeon. Once one is on this path, becoming an endometriosis surgeon is easy. There are a zillion patients with endometriosis around. Follow these principles and operate to remove the endometriosis. If you try to do endometriosis surgery as a series of steps you will fail miserably, because every surgery is different. But if you apply these principles, understanding anatomy, using good technique, and understanding that the goal is to remove all of the endometriotic tissue, you will succeed and your patients will benefit.
3. The third thing I said is that to be a strong surgeon, one should always cultivate a feeling of responsibility for your patient's outcome. I see too many surgeons experience complications in their surgeries and then strive to prove to themselves that they weren't at fault in what happened. This is fundamentally wrong. The surgeon is almost always at fault when something goes wrong. Ureters are cut in hysterectomies 1% of the time not because "it just happens sometimes", but because in 1% of cases the surgeon failed to apply proper surgical principles and to understand the anatomy of the surgery they were performing. Even the apparent faultless complication of a postoperative infection often originates in a failure of antisepsis or sterile technique, which are controllable factors. If one has a misadventure and chooses to externalize the responsibility for this event, one has lost the opportunity to grow from the error. And unfortunately, that means that if one operates enough, one will repeat that error one day again.
It was a pleasure to speak to the residents and faculty at Baylor Dallas and to teach anatomy to the residents, and I hope that a few of them go on to serve women with endometriosis. It all starts with the young.