The Independent of april 1th printed an article on the hidden dangers of endoscopic surgery, highlighting that quality of surgery increases with expertise. “Researchers from the Memorial Sloan Kettering Cancer Centre, New York, said that the findings suggested that patients were better off being treated in specialist centres, where surgeons performed a large number of the same operation.
They added that, if the results were confirmed to be correct, “surgeons should not switch between open and laparascopic [keyhole] procedures without a compelling reason”.
In a comment P. Koninckx stated that “the conclusions do not take into account the individual variability of surgeons and the fact that there is no quality control of the individual surgical intervention”
and that “Systematic videoregistration of the entire intervention with authentication to avoid any discussion, is easily feasible and inexpensive. Systematic videoregistration obviously would permit to judge the quality of the individual intervention. It could be used for accreditation and for eventual intermittent re-accreditation of the individual surgeon. Medicolegally, it could be used to judge complications. Moreover it would permit to judge the indication and the billing of a surgical intervention. In conclusion mandatory videoregistration of the entire intervention has the potential of increasing the quality of surgery while decreasing costs. Indeed surgeons will refrain from performing interventions without sufficient expertise.
Yet this concept has great difficulty to get accepted by the surgical community for several reasons. Besides the fear of medicolegal consequences, the mere concept of accreditation based upon quality instead of quantity is threatening. Especially in keyhole surgery quantity might not be a sufficient criterion as it is for many skills as tennis, football, or piano playing. That evaluation of quality might replace quantity is a revolutionary concept in training and recognition of surgeons and gynaecologists, since starting no longer is sufficient. Nevertheless it deserves carefull consederation for the benefit of the patient to establish what a ‘sufficient level’ will be.
Specifically in gynaecology this concept creates a major problem. The subspecialty training as conceived today with each subspecialty doing the a little bit of surgery, could/should be replaced by “pelvic surgery” as a subspecialty. With growing expertise first easy interventions as diagnostic laparoscopies and total laparoscopic hysterectomies would be done, then dissection surgery as pelvic floor surgery and lymph node dissection, to end with the most difficult as severe endometriosis. It is obvious that this sequence does not fit with the actual subspecialty programs.”