Dr DiSciullo has an interesting view on surgical training in gynaecology, specifically vaginal surgery. His vision is quite encompassing and I think will be what happens in the future. Worth another look in the future.
Date: Mon, 18 Mar 2013 20:19:22 -0400
From: Anthony J DiSciullo <Gary_Frishman@BROWN.EDU>
Subject: Vaginal Surgery Education
Dr Marlow brings up several interesting issues around the broad topic of surgical education in gynecology. AAGL and AUGS have changed the landscape in gynecologic surgery. Well organized fellowships now supplement a training program that does not prepare our residents for independent surgical practice. These organizations give our patients well trained surgeons who can improve both outcome and quality of life.
If I had a crystal ball here’s what I think I would see in the future. Most if not all vaginal surgical training will come from the discipline of Urogynecology and Pelvic Reconstructive Surgery. Those fellowship trained surgeons will accumulate the caseload experience that will provide the best outcome. As MIS technology improves, vaginal hysterectomies for benign non-prolapse conditions will gradually move to MIS where visualization of anatomy and surrounding structures provides a level of precision difficult to achieve in vaginal surgery.
As nanotechnology advances we will see drone mini-cameras that will not require a separate port, cheaper and more sophisticated tele-manipulators (currently referred to as “robots”) and more versatile instruments with a larger spectrum of functionality. Many disorders now treated surgically will best be treated with non-surgical interventions, further reducing the caseload and concentrating referrals to experienced well trained surgeons.
Lastly, when the fellows now in my AAGL fellowship rotation are my age they will talk about straight stick MIS as an evolutionary approach that led to better multifunctional instruments and cheaper robots. Robotic consoles will reduce their risk of lumbar and cervical disk problems often associated with long hours in straight stick cases. They will leave the vaginal surgery to pelvic reconstructive surgeons as we now leave endometrial cancer to the gyn oncologist. They will concentrate on delivering excellent surgical care with skilled use of instruments designed for the best outcome. As bandwidth improves, tele-manipulative surgery will permit intra-operative consultation from experts around the world.
When I finished residency in 1972 everyone on my surgical faculty was doing at least one vaginal case a week. For people in my age group this is not an unusual background. We had access to a caseload that is no longer available for teaching. The laparoscope now allows us to see relevant anatomy and surrounding structures before something is cut or tied. I believe our teaching effort in the cases available for surgical education would best be spent on robotics and laparoscopy, not on increasingly rare vaginal surgery.
Anthony J. DiSciullo MD
Director of Gynecology, Mount Auburn Hospital
Boston Urogynecology Associates
Cambridge, MA
Disclosure: Olympus/Gyrus proctor; Endoshpere (technical advisor)
