whither craftsmanship?

When I was a pelvic surgery fellow, I was doing a bowel resection with a general surgeon who was an older, distinguished Persian gentleman with an old world sensibility to him. When it came time to do the reanastomosis, I asked the scrub nurse for a surgical stapler and was stopped by the surgeon, who asked why I wanted to use a stapler to reconnect segments of bowel. I indicated that this is how I had always done it, and it was a faster method overall. The surgeon preferred that I do a hand-sewn anastomosis. When I asked him why, he said “Why do I drive a Mercedes rather than a Ford Taurus? Both will get me to my destination, right? But the Mercedes has craftsmanship.” His point: a technician can use a mechanical device to connect bowel back together. A craftsman takes the time to do it the long way, with artistry and precision.

So that’s how I came to learn how to do old-fashioned, hand-sewn bowel anastomoses. I still preferred staplers. But there’s something to be said for craftsmanship. In surgery, how you do something is often as important, or even more important, than the end result.

I was thinking back to that surgical experience during fellowship as I took stock of all the things in ob/gyn that are not representative of craftsmanship. Unlike any other surgical field I can think of, we as a profession have been oversimplifying and undoing years of craftsmanship. Sometimes perhaps for the better. But overall, for the worse. Examples:

  • Replacing the more difficult art of forceps deliveries with a much simpler (yet often more dangerous) technique of vacuum extraction
  • Replacing the art of hysteroscopic endometrial ablation with office-based nonresectoscopic endometrial ablation that does not permit visualization of the endometrial cavity
  • Replacing advanced operative laparoscopy with robotics
  • Replacing ureteral dissection with lighted stents
  • Replacing laparoscopic hysterectomy with laparoscopic supracervical hysterectomy

Why am I lamenting all this? Because rather than become fluent in advanced surgical procedures, either through fellowship training or extensive preceptorships, my specialty has tended to ”dumb down“ surgical procedures in order to make them more accessible to the ”average gynecologist.“ Years ago, when endometrial ablation came out, it was looked upon as a way to make a significant dent in the ridiculously large number of hysterectomies performed annually in the US (~600,000/year for benign disease). However, only about 20,000 ablations were done every year, because most folks either never learned the hysteroscopic skills required to perform the procedure, or else just didn’t want to do it. So in its place came an office-based procedure, erroneously termed ”global endometrial ablation (GEA)“ that is a blind procedure but often as efficacious as the hysteroscopic version.

Now, I have nothing but praise for moving appropriate surgical procedures to an office setting. It’s easier for patients and better from a cost standpoint. But it’s one thing to move a procedure to an office setting thanks to innovative medical devices in an evolutionary fashion. It’s quite another to create a new device and technique in order to make a procedure accessible to more gynecologists due to their lack of surgical skills.

I hate to sound like an old curmudgeon complaining about the lack of skills of a younger generation. But just consider what’s happened to gynecology over the years. Can’t dissect the ureter worth a damn? No problem-just ask your friendly urologist to place some lighted stents into the ureters so that you can see them during surgery. Mind you, the stents only serve to make the ureters a better target for inadvertent injury, and the additional procedure adds minor risks and costs to the overall surgery. But it makes some gynecologists feel better. If only they didn’t fear the retroperitoneum and took less than five minutes to identify the ureter, dissect it, and mobilize it out of the way without the need for stenting.

Same with robotics. Again, I’m all for medical advances. But robotics had primarily been adopted by urologists in order to do laparoscopy simply because urologists traditionally have not been laparoscopic surgeons, unlike gynecologists. But what happened? Robotics became not just an expensive marketing tool by some hospitals, but a crutch for some general gynecologists to perform laparoscopic procedures that they couldn’t have done the ”old fashioned way“ (that is, without a $1.5-$2 million robot helping to facilitate the procedure). Robotics may yet be shown to have a rational place in gynecology; I know of at least one colleague who has similar objections to robotics but feels it makes it much more possible to close the uterus in an anatomic fashion during laparoscopic myomectomy. But when I hear about gynecologists using/needing robotics for laparoscopic operations that many of us routinely performed without any robotic systems, I wonder what the future is for my specialty. Same with laparoscopic supracervical hysterectomy. In the absence of any good data supporting an advantage over total hysterectomy, many of my colleagues perform laparoscopic supracervical hysterectomy as a way to make the procedure easier. It does reduce the risk of ureteral injury, to be sure. But do we really need to dumb down gynecology?

Surgery is all about craftsmanship. And skill. While I applaud attempts to make difficult surgical procedures more accessible to a larger number of physicians, it makes me wonder why such a large number of my colleagues don’t feel comfortable with, say, operative hysteroscopy or laparoscopic hysterectomy in the first place. So many things seem to require simplification, but I am not aware of that many general surgery or cardiothoracic surgery procedures that have been simplified in order to make them more performable by the average general surgeon or CT surgeon, respectfully. And just consider the average CT surgeon; would anyone dare imply that he/she isn’t capable of doing a valve replacement or some intricate vascular procedure, and thus would require a simplified operation to be able to treat his or her patient?

We need to do a better job at producing gynecologic surgeons who are capable of performing the more complex approaches to certain operations and procedures. If such procedures can evolve and become simpler and cheaper to perform, then great. But let’s do it for evolutionary reasons. Not in order to make something accessible to surgeons who really should be able to do the original procedure in the first place. If there is a real advantage to ”GEA“ then that’s wonderful. But is there an evidence-based advantage or is it really a case of ”dumbing down“ endometrial ablations?