The Art Of Surgery

Surgery is as much art as it is science. Surgeons use their scalpels and electro-cautery devices to make accurate incisions, and then skillfully bring tissues back together. They coordinate many tasks at once while maintaining the finest precision. There is no such thing as a routine or casual surgery, however. Complications can occur at any time, even in the simplest of all procedures. Surgeons have to treat every operation as unique. To perform surgery, you need patience, manual dexterity, and the ability to remain calm and composed under intense pressure.

Surgeons thrive on the immediate gratification of operating on patients.

When choosing a specialty, medical students who dislike the idea of having to wait weeks to months to see if a pharmacologic treatment works gravitate toward the fast-paced surgical specialties, where you can see the results of your efforts right away. The general surgeon relieves a patient's unbearable abdominal pain by resecting an inflamed appendix or by cutting intra-abdominal adhesions to relieve a small bowel obstruction. The vascular surgeon restores blood flow to a patient's cold, nonfunctional limb and saves it from amputation by performing a femoral-popliteal artery bypass operation. Trauma surgeons repair spleens lacerated during a motor vehicle accident, surgical oncologists resect tumors, and transplant surgeons place new kidneys. The list goes on and on.

Few people are born with the innate technical skills to perform surgery well. For the majority of us, learning how to operate requires repetition, self-awareness, dedication, and intra-operative teaching—all of which takes place in the setting of an apprenticeship during residency. From the first day of internship, new surgeons are taught the proper technique for performing procedures appropriate to their level. Usually this begins with placing a central line—a catheter inserted into large veins and threaded to the heart to obtain central venous access for administering fluids and drugs. For all procedures, whether this simple one or more complicated ones, residents can learn certain aspects from textbooks: landmarks, patient positioning, indications, and risks. But the actual art of the procedure must be learned as an ap-



✓ Has excellent hand-eye coordination and manual dexterity.

✓ Can think quickly and act decisively.

✓ Enjoys mastering new technology.

✓ Demands the highest level of perfection.

✓ Is an energetic, dedicated, and compassionate physician



Residency in general surgery requires 5 years of postgraduate training. There are currently 254 accredited programs. Some programs offer (or require) an additional 1 to 3 years of research— basic science, clinical, or other creative options including biome-chanics, robotics, and instrumental design. There is no argument that surgery is a tough residency. Residents arrive at the hospital


prentice. To ensure the development of good technique with minimal risks to the patient, senior physicians directly teach residents how to hold needles properly, take a stitch, tie a variety of surgical knots, use the electrocautery device, and maintain adequate hemostasis (minimizing bleeding). Obviously there are some tricks of the trade that no textbook can illustrate. Over the 5 years of general surgery training, every resident cultivates his or her own style, within the limits of being a safe and skilled surgeon. Although learning how to perform surgery may seem daunting, in reality anyone in a solid residency program and with a modicum of dedication can learn the technical aspects of surgery.

In the operating room, surgeons learn the proper use of hundreds of instruments, from scalpels and scissors to retractors and needle drivers. To give residents even more experience with these tools, surgical skills laboratories have become part of most residency programs. They incorporate inanimate models, virtual reality, animal labs, and cadavers into surgical training. For example, first-year residents often complete sessions on tying knots or performing laparoscopic appendectomy in pigs, while the senior residents learn to how to perform more complicated resections — colectomies and splenectomies — on the same animals. These components of the long, rigorous surgical training are necessary because the craft of operating continues to change. Today there is increasing em-

very early to round on their patients before heading to the operating room. Because patient care and consultations continue after finishing the scheduled operations, the days are long and physically demanding. The rigorous call schedules require residents to stay overnight every third or fourth night. In the first year, surgical interns spend little time in the operating room. They see patients in the hospital requiring surgical consult and master the essentials of postoperative care of patients on the surgical wards and intensive care unit. Operating room time increases throughout the year. Residents spend the first 2 years primarily in general surgery but also rotating through surgical subspecialties like neuro-surgery, urology, and orthopedics. The remaining 3 years are dedicated to improving operating skills through rotations in general, vascular, cardiothoracic, pediatric, and transplant surgery. Additional months of training include surgical intensive care and endoscopy. Residency in general surgery provides the gateway to a number of surgical subspecialties that require fellowship training.


phasis on minimally invasive surgery. This type of surgery seeks to provide alternatives to open surgery, including laparoscopic surgery and robotic surgery. La-paroscopy involves making small incisions and inserting ports to gain access to the abdomen or chest and to place cameras and instruments. By not opening up a patient, this approach shortens recuperation time and reduces potential postoperative complications. It also provides a different point of view from which to see the anatomy and attack the problem at hand. Learning the latest operative techniques, therefore, means a lifetime of constant reeducation and self-discipline.

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