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Principle three



"Technique is only important until it is perfect – and it has to be perfect. Once[ it is] perfect, other factors are decisive in achieving surgical success."

Leslie H. Blumgart,
Professor of Surgery,
Memorial Sloan-Kettering Cancer Center, New York

Surgery is first and always a handicraft. The hands are the most important instrument of the surgeon. Only with them, he can work precisely, exactly, carefully and gently with good results for the patient, rapid healing from operations, without complications. As in every other handicraft, all manual abilities must first be learned, even by the most talented. As with a musician, music is only beautiful, easy and elegant after long years of studying, the development of one's own technique and permanent practice. Surgical technique is comparable with the art of painting. An empty sheet is covered with many lines – broad, narrow, long, short – until the eye can see a picture and the soul can recognise it. Surgical technique can be perfected only if the surgeon has carried out a large number of different operations in many areas and he personally knows the most variants of these operations intimately. The organs, their interactions, their location as well as the most appropriate accesses, are only recognised in correlation if one has experienced and taken part in various operations until all details form a complete whole. Virtuosity of the technique is a requirement for surgical activity. However, it is not an end in itself. The technique must be perfect. However, if it is perfect, it becomes irrelevant besides all the other factors in determining the success of an operation. If the technique is correct, then the announcement of the operation, the understanding of the patient's physical fitness and what he can physically and mentally withstand – all of these other factors are decisive. There is nothing worse in surgery than a soulless technician. Often we surgeons must go to great lengths to work with absolute concentration while staring at a small area, standing in the same place for hours and working with stern discipline without fading.

Technical perfection is the requirement for the predicate "good surgeon." It is absolutely necessary and must be practiced daily. In large operations which can be very difficult, the surgical art often consists of leaving open a way out in which an operation can be broken off, without immediate damage to the patient. Or the expert understands different ways of dealing with difficulties to get around operative problems at places where, for example, bleeding can occur, and to finally achieve the goal nevertheless.

As in every art, there are totally different artists, and not every surgeon can claim to achieve a higher level, if he is completely honest with himself. Also among surgeons, there are virtuoso masters with elegant performance and technical finesse. Unfortunately, in abdominal surgical procedures, this is often only recognised by the assistant who is present during the surgery. For the outside observer, who has only seen a superficial skin wound, it is practically impossible to assess the technical capability of a surgeon. Continuous advancement, comparison with other operating colleagues, visits from other internationally recognised centres, allow individual surgeons to form a picture as to where he stands and how to further improve his own technical knowledge.

If the technique is perfect, and it must be, only the correct selection of operative procedure determines the certain results of surgery in the long run.


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