Criteria to select a surgeon

Surgery means knowledge and technical experience

Technical difficulty and levels of Endoscopic Surgery.

Laparoscopic and hysteroscopic surgery anyway require a specific training.
Basic training is sufficient for simple surgery as an adnexectomy of a cystectomy.
The first Level permits to perform an hysterectomie.Following performing LAVH’s for smaller uteri , gradually the experience becomes sufficient to do total laparoscopic hysterectomies up to (TLH) 700-800 grams
The Second level : means dissection and suturing and a solid knowledge of anatomy. It requires additional training after the TLH has been mastered, to perform pelvic floor surgery, promontofixations and lymfadenectomies for cancer. Most important for this surgery anatomy remains normal.
The upper level means that anatomy is distorted and that in addition other organs as ureters and bowels are involved. This obviously requires additional experience and training to do bowel and ureter surgery. Most importantly, however, this surgery often requires peroperative judgment about the risk of surgery which should be balanced agianst completeness especially for deep endometriosis surgery. The same applies to debulking of advanced ovarian cancer.
Also hysterectomies for a uterus of more than 1 kilo is situated on this level because of technical difficulty. It should moreover be realised that few surgeons can have experience in surgery for rare diseases such as Wertheim for cervical cancer, or a para-aortic lymphnode resection. This group moreover often faces the dilemma that only few of those with experience in this disease have a good endoscopic experience.

Moreover the actual subspecialties in OBGYN do not fit with these surgical levels. For this reason we believe that the ‘Pelvic Surgery’ should become a subspecialty.

Knowledge remains important : first a correct diagnosis then the therapy !

One might think that a perfect cooperation between a technician and somebody who makes the diagnosis could work. Practically, is is absolutely necessary to be able to judge technical difficulty and risk of surgery and the expected results. Moreover a series of decisions have to be made during surgery. The importance may vary with the disease.

Most problems occur with deep endometriosis surgery. If the level of training is insufficient surgery will often be incomplete. Worse is the actual tendency to do (unnecessary) bowel resections, since this is much easier surgery perfect by the surgeon. The worst is a bowel resection for artefacts without endometriosis. Fertility surgery is a problem since in reproductive medecine the surgical expertise overall is limited. The volume of difficult surgery indeed is low. Also in oncology, the volume of Wertheims and thus of experience is low, explaining why this remains often done by laparotomy. Only pelvic floor surgery has sufficient volume and is therefore the necessary step to advanced surgery.

How to choose a surgeon ?

1. Sufficient technical skills for the planned intervention. This means that a surgeon should not operate above his level.
2. Sufficient knowledge and experience of the pathology. It should be clear that for the combination of advanced surgery and rare diseases such as deep endometriosis or Wertheims only few surgeons will have the required expertise.

3. Judge the surgical team. Who is going to assist ? Who is responsible for the follow-up. Difficult and demanding surgery as deep endometriosis requires a good team, a good surgeon is not sufficient.

4. Honest Information. Of the indication and the method : Hysterectomy is the example : whereas many of us performed their last laparotomic hysterectomy more than 10 years ago, even today in the USA only 20% are performed by laparoscopy. Of the personal exprience, the results and whether videoregistration is performed.
5. Use pubmed and the internet to judge a surgeon As a rule of thumb expertise should be visible in the publications, or in presentations, live surgery etc.