Bonneys Gynaecological Surgery, Tenth Edition

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The surgeon should also remember that he is on display and his ability to cope with adversity as well as his manner when the surgery is going well will be keenly observed. The surgeon should teach continuously, pointing out to assistants and observers the small points of technique as well as related facts to the case in hand. Bonney enjoined that the surgeon should not gossip; the present editors feel that day - to - day chit - chat is not out of place in the operating theatre and is to be preferred to the media view of an operating theatre as a place of knife - like tension fraught with grave interpersonal relationships.

However, the mark of the good surgeon and his team is that, at the time of stress, the noise level in theatre should fall rather than rise, as each member of the team goes about his or her task with speed and efficiency. It is inevitable that at some point the surgeon will come face to face with imminent disaster; even the most stalwart individual will feel his heart sink at such a moment. The operator should always remember that at such moments if basic surgical principles are applied quickly and accurately the situation will be rapidly rescued.

Hesitation and uncertainty will all too often terminate in disaster.

A sturdy belief in his own powers and a refusal to accept defeat are the best assets of a calling which pre - eminently demands moral courage. Before operating the surgeon should prepare by going over in his own mind the various possibilities in the projected procedure, so that there may be no surprises and he may all the better meet any eventuality. Likewise following the procedure it is valuable to go over in one s mind every step in the operation in order to analyse any deficiencies and difficulties experienced; it is only by this continuous self - assessment and analysis that the surgeon can from his own efforts improve his practice.

It is of increasing importance that the surgeon understands the need for meticulous record - keeping in order to build a comprehensive database for future analysis.

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The modern surgeon has to continually examine his and others work in order to practise to the highest possible standards. More and more guidelines are being generated; the surgeon has to be sure that his work meets the quality requirements of modern practice. Patients, purchasers and professional bodies wish to be able to access the best possible practices.

Transparency of standards is essential to modern medical practice. The high - quality surgeon has little to fear from the implementation of guidelines and should look upon these times as opportunities for developing the highest quality of care. Surgery is physically and mentally tiring. The surgeon should be sure to be adequately equipped in both these areas to meet the demands of theatre.

It is important to remember that driving the staff on for long, tiring sessions is counterproductive; there is little merit in performing long procedures with an already exhausted staff. The surgeon s hands and mind become less steady, his assistants less attentive and the nurses tired and disillusioned. It is under these circumstances that mistakes occur. It is important, however, not to be dogmatic about the ideal length either of individual operations or of operating lists. A full day in the operating theatre may suit one surgical team but be anathema to another. Speed in o perating Speed, as an indication of perfect operative technique, is the characteristic of a fine surgeon, as striving for after - effect is the stock - in - trade of the charlatan.

An operation rapidly yet correctly performed has many advantages over one as technically correct yet laboriously and tediously accomplished. The period over which haemorrhage may occur is shortened, the tissues are handled less and are therefore less bruised, the time the peritoneum is open and exposed is shortened, the amount and length of anaesthesia is shortened and the impact of the operative shock, which is an accumulation of all these factors, is lessened. Moreover, less strain is put upon the temper and legs 5.

However, this speed must be tempered with attention to detail, particularly of haemostasis, and by a conscious effort not to unnecessarily handle tissue. Operative m anipulation The surgeon should continually endeavour to reduce the number of manipulations involved in a procedure to the absolute minimum consistent with sound performance. If an operation is observed critically, one is struck by the vast number of unnecessary movements performed, the majority of which are due to the uncertainty and inexperience of the operator.

In older surgeons, unless care is taken to analyse these movements and eliminate them they will become part of the habits and ritual of the procedure. Minimizing trauma is of fundamental importance for uncomplicated wound healing. The art of gentle surgery must be developed Moynihan. Sadly, many surgeons achieve speed by being rough with tissue, particularly by direct handling. This must be avoided at all costs, and the temptation to tear tissue with the hands rather than to delicately incise and dissect with instruments is to be eschewed.

All operative manipulations should be gentle; force is occasionally essential but should be applied with accuracy, only to the tissue to be removed and for limited periods of time. The surgeon who tears and traumatizes tissue will see the error of his ways in the long recovery periods that his patients require and in the high complication rate. Moynihan spoke in at the inaugural meeting of the British Association of Surgeons on The Ritual of a Surgical Operation, stating that he [the surgeon] must set endeavour in continual motion, and seek always and earnestly for simpler methods and a better way.

In the craft of surgery the master word is simplicity. Further r eading Berkeley C, Bonney V. A Text - book of Gynaecological Surgery. London : Gassell and Company, See www.


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See Moynihan BGA. The ritual of a surgical operation. Br J Surg ; 8 :. Lord Gowrie Most gynaecological surgery is elective. Consequently, for most patients, there is no excuse for preoperative assessment and preparation for surgery not to be comprehensive. There should be a departmental protocol in place so that all staff involved with the care of the patient provide consistent high - quality care. A medical history, examination and relevant investigations are undertaken as part of preoperative assessment.

The patient is provided with appropriate information, often in conjunction with support from a nurse specialist, and an informed consent is taken. A review of all available information, including preoperative scans and laboratory tests, should be performed prior to surgery.


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Initial v isit Most patients will be first seen in the outpatient department, where a preliminary assessment and provisional diagnosis will be made. At this first visit, the clinician should obtain a comprehensive history, fully Bonney s Gynaecological Surgery, 11th edition. Once this information is collated, admission dates for surgery, if appropriate, are organized, or referral made to the appropriate specialist. In the UK, there is increasing pressure on clinicians to see patients rapidly, come to a definitive diagnosis and arrange appropriate management as quickly as possible.

Although this pressure is most acute in the diagnosis and management of cancer, it is being extended in a more limited fashion to the management of benign conditions. In order to attain targets, clinics have to be structured so that referral can be made by telephone, fax or online if necessary, and appropriate diagnostic facilities such as endometrial sampling, ultrasound and colposcopy are available at the one visit. This requires considerable collaboration with supporting services including radiology and pathology.

History - t aking and d ocumentation As the clinician progresses through training, every effort should be made to concentrate on developing a style of clear and concise history - taking. Initially, this process of meticulous systematic questioning may seem cumbersome. However, with constant practice, an abbreviated technique will develop which concentrates on the major fields of interest but also allows for peripheral areas of relevance to be included. Documentation of the history is vital for medico - legal purposes, for transmission of information to colleagues and for analysis in clinical research and 7.

The editors have over many years organized standardized questionnaires for all patients, the details of which build up a complete picture of the patient, her cancer and her progress through therapy.

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This huge database allows rapid access for office administration, audit, research and analysis. In an increasingly litigious world, the careful but not necessarily cautious doctor who keeps good records and takes the time to communicate and document all meetings will to a significant extent protect him - or herself from the very distressing circumstances of litigation.

Patient i nformation Gynaecological patients require considerable support and assistance when making decisions about treatment, particularly surgery. The most important factor is the manner in which the patient conceives the impact of the operation upon herself, particularly her sexuality. The surgeon must be prepared to spend a considerable amount of time discussing and explaining the content of any surgical procedure.

Megan Wasson, D.O., Mayo Clinic, Gynecologic Surgery

This important process is frequently aided by the use of literature and drawings, copies of which should be included in the medical record. Departmental websites and contact numbers are a great assistance. It is at this point that the clinician may feel the need to involve other areas of expertise, including a nurse specialist, psychologist, stoma therapist and dietician.

A factor that is often of enormous reassurance to the patient is to meet other patients who have been treated for a similar problem and experienced similar procedures.

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Clearly, such a detailed approach is not practical for all procedures, especially minor ones; however, it is important not to trivialize minor procedures, especially those involving anaesthesia, as complications can and will occur and warning of the possibility and appropriate consenting is vital for all operations, even those of a diagnostic nature carried out in the outpatient department under local anaesthetic.

It is important not to talk down to patients; always use accurate terminology with appropriate explanation and resist the temptation to use gross inaccuracies, which become perpetuated in the mythology of the subject, such as the vaginal hysterectomy being described as a suction hysterectomy. The offer to the patient to attend with her partner, a close family member or a friend is also of vital importance in providing support and reassurance to the patient and often contributes to the essential dialogue and communication which is necessary.

Patients take in and understand information at very varying rates; some are comfortable with a brief once - only visit, whereas others may need repeat visits or telephone calls to answer questions and seek reassurance. This wide range must be accommodated within a successful practice.

Clinic i nformation If at all possible, information in written form should be sent to patients prior to the first visit. This should not only include details of appointments, parking facilities, transport access, etc. This should include warnings about examination, time involved and the advisability of having a partner or companion present. For many specialist clinics, such as those for colposcopy, specific details of procedures can be outlined.

A list of contact telephone numbers and departmental websites should be included. Information s heets and d ocuments At the end of the clinic visit, it is of inestimable value to be able to give the patient and her accompanying person a sheet of information with an outline summary of what has been said and discussed in the clinic.

The type of document will usually have space for drawings and handwritten notes. If the sheet can be of a carbon copy type, the patient will be able to take home the original and an exact copy is stored within the clinical record. Locally or nationally produced leaflets or booklets regarding the specific condition and operation should also be given to the patient to take home and read.

Drawings Drawings of procedures indicating tissues to be removed with small annotations alluding to potential complications and future difficulties are of enormous value.

The drawings should be made in the clinical record or included in the information sheet mentioned above and the copy kept in the records. Such 8. Consent for s urgery In recent years considerable effort has been expended in trying to improve the whole process of consent. The main reason for this is the extensive publicity given when operations are allegedly performed without proper consent.

Bonney's Gynaecological Surgery

Patients must give consent for operation in the light of full knowledge of the procedure, the nature of the condition for which it is being proposed, any serious or frequent complications of the surgery, as well as any reasonable or accepted alternative treatments, including no treatment.

In the UK, four standard consent forms have been created for all categories of patients including for those with parental responsibility and use where the patient is an adult unable to consent. In gynaecology, most patients who are undergoing surgical treatments are able to give consent on their own behalf.