Is the Size Appropriate for the Procedure?

Michael R. Dayton

While recently performing joint arthroplasty with the assistance of an orthopedic resident and medical student, I alternatively queried each about the identification and function of anatomic structures encountered during the approach to the hip. Although it was apparent that my assistants generally knew the structures, their ability to correctly identify anatomic landmarks was most hindered by an inability to see into the relatively small skin incision, a fact made apparent by the awkward positions they placed themselves in to respond to my questions.

As I generally attempt to maintain a relatively small incision size for total joint arthroplasty, I understood the difficulty in visualization of anatomy. This fact led me to revisit a question I have long considered. What is the precise role of minimally invasive surgery (MIS) in the teaching environment? It is often difficult enough to demonstrate to assistants the essential portions of a case with a larger hip incision, for example, let alone for cases where the incision size is barely large enough for protrusion of the femoral head.

The potential advantages of MIS have been well demonstrated in recent years. Lower blood loss, improved pain control, and rapid recovery are appealing features. Unfortunately, the advantages are accompanied by some disadvantages that have become apparent in peer-reviewed literature and manifested by postoperative complications. There is a well-defined role for minimized deep soft tissue disruption; however, as a clinician educator, I also feel the necessity to responsibly convey the visual portion of teaching to those around me as well.

The field of orthopedics is currently immersed in new technology and courses designed to allow surgeons to learn developing techniques, many of them less invasive. A question is henceforth raised: how much training in a course is enough? How many courses, cadaver or live-surgery based, are enough prior to introduction of a technique into clinical practice? The presence of such courses would suggest that the basic knowledge and ability to perform an open procedure is included in all residency and fellowship training programs. The increasingly common existence of skill-intensive MIS procedures, however, may progressively exclude the fellow and resident trainee from the very environment in which they can learn the practical part of surgical training: the operating theater.

Physicians directly involved with medical student, resident, and fellow training are the guardians of future generations of orthopedists. As such it is imperative that appreciation is given to hands-on anatomy of the surgical procedure. No cadaver course, simulation, or on-screen observation can replace the appreciation of surgical anatomy that scrubbing into a case allows. Although MIS has a definitive role in orthopedic surgery, so does appropriately demonstrating open anatomy for those in a teaching role. As best summed up by a mentor and highly skilled hip surgeon when asked how large he makes his skin incision: “I make an incision size appropriate for the procedure.”

Author

Dr Dayton is from the Department of Orthopedics, University of Colorado Denver, Colorado.

Dr Dayton is a paid consultant for Smith & Nephew and has received educational financial funding from OREF.

Correspondence should be addressed to: Michael R. Dayton, MD, 1635 N Aurora Ct, Mailstop F722, Aurora, CO 80045 (michael.dayton@ucdenver.edu).

doi: 10.3928/01477447-20090922-01