Tools of the trade
Vol. 17 No 4 | Summer 2015
There is a simple pleasure in using the right tool for the task at hand. Whether it is a sharp knife finely slicing a tomato, the smooth sweep of a well-tuned wood plane or the satisfying feel of a good needle holder as you place a suture, the proper tool makes the performance of any task safer and easier, and gives a better result. Conversely, the wrong tool, a poorly maintained one or lack of expertise in its use leads to frustration, struggle and error. Unfortunately, in medicine, the consequences of these things are more serious than an unevenly sliced tomato.
Obstetricians and gynaecologists are faced with adhesion-related problems daily. We are no strangers to challenging caesarean sections, lengthy gynaecological surgery and even inadvertent enterotomy related to pre-existing pelvic adhesions. Subfertility and tubal pregnancy secondary to tubo-peritoneal adhesions are not foreign to us either. Indeed, adhesions develop in 60–90 per cent of patients who have undergone gynaecological surgery. Nevertheless, the real extent of adhesion-related complications and financial burden on the healthcare system are still largely underestimated.
The use of suture materials to ligate bleeding vessels or approximate tissue dates back to the 16th century BC, as evidenced in the Edwin Smith papyrus, the oldest record of a surgical procedure. In the last decade, exciting suture and wound-closure technology, such as barbed sutures and absorbable staples, have been introduced. After millennia of experience, research and development, although the ideal universal suture material is yet to be discovered, we are edging closer.
‘Buxton’s law’ of investigation of a surgical innovation states: ‘…it is always too early for rigorous evaluation until, unfortunately, it’s suddenly too late.’ Adoption of new surgical techniques in gynaecology is vital for the improved care of our patients and the development of the profession. A pivotal positive example is the revolution of gynaecological care by laparoscopic surgery in the 1980s. New surgical procedures and devices can appear very attractive to surgeons and patients alike. However, the diffusion of surgical innovations into common practice raises serious questions about patient safety.
Every tradesperson needs a range of tools at their side and in medicine, particularly in obstetrics and gynaecology, surely one of the most valuable and powerful tools in our toolbox must be that of research synthesis, a process that underlies many of the principles of best clinical practice and evidence-based medicine (EBM).