CHAPTER 3 Principles of surgery
Principles of surgery
To this point we have considered some of the matters that lead to the surgical decision. We have also discussed the general principles that apply to the surgical experience in its broadest sense. The patient’s point of view has been stressed. Here we wish to deal more specifically with the principles and practice of surgical technique itself (Box 3.1)1–3.
Good preparation
To be well-prepared requires knowledge of the desired goals, the patient, the materials used, the techniques employed and oneself (see page 34). It also requires practice, practice, and more practice. While every surgical episode is different from every other, there is, to all surgical events, a fundamental core. The great surgeon, like the great athlete or chef, must be able to perform these basic core motions so well that they are done unconsciously. In the midst of a surgical procedure, attention cannot be diverted from what is happening to consider how a knot is to be tied or how remaining lens cortex is to be removed. Those activities must be so fully mastered that they have become ‘second nature’. While it is true that surgeons in training can perform a surgery in a way that the results are satisfactory, it is also true that better surgeons tend to have better outcomes than those less competent4–6. More experienced surgeons tend to have better results than learning surgeons. Whereas visual acuity may be 20/60 shortly after an adequately performed penetrating keratoplasty, it is more likely to be 20/40 or perhaps even 20/20 when done by a superb surgeon who has ‘been there’ hundreds of times before. ‘Occasional’ surgeons rarely have results as good as experienced surgeons who continue to hone their skills with constant practice4–6.
One aspect of the well-prepared athlete is pre-game or pre-race visualization7–10: the course, the start, the way the opponent will perform, the rare but real mishaps that may occur, the quirks of the referees, the failure of the equipment, the need to focus, the finish line – all of these aspects are visualized from start to finish so that when they occur during the race, the athlete has anticipated them and knows exactly how to respond, so also for the surgeon.
