New surgical procedures: can our patients benefit while we learn?

Several forces have combined to encourage gynecologic surgeons to acquire the skills they need to perform new endoscopic procedures. Pressures from health care institutions, industry, and, most important, from patients lead to increased demand for less invasive approaches to the treatment of gynecologic conditions. This demand may outstrip the profession's ability to demonstrate the safety and effectiveness of new procedures through rigorous clinical trials. Early on, the benefits expected from laparoscopic surgery may be limited by harms resulting from surgical inexperience. Physicians will struggle to achieve a balance between their ethical obligation to benefit patients while avoiding harm to them and their professional expectation of continued learning. Acquisition of new techniques involves a learning curve, across which complications and operating time decrease while the potential for benefit rises. To minimize harm to patients during the surgeon's learning process, peer review should play an expanded role. Surgeons should discuss their own surgical experience and level of skill openly with their patients as part of the process of informed consent. A relationship of trust is vital when one engages patients in a cooperative educational venture.

[1]  W. Harris Uterine dehiscence following laparoscopic myomectomy , 1992, Obstetrics and gynecology.

[2]  K. Hatch,et al.  Laparoscopic para‐aortic lymphadenectomy in gynecologic malignancies , 1993, Obstetrics and gynecology.

[3]  R. Leach The learning curve , 1992 .

[4]  J. Hulka,et al.  Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. , 1993, The Journal of reproductive medicine.

[5]  A. Viste,et al.  Complications during the introduction of laparoscopic cholecystectomy in Norway. A prospective multicentre study in seven hospitals. , 1994, The European journal of surgery = Acta chirurgica.

[6]  Richard W. Kobylinski,et al.  Increased cholecystectomy rate after the introduction of laparoscopic cholecystectomy , 1993 .

[7]  E. Steinberg,et al.  Costs and charges associated with three alternative techniques of hysterectomy , 1996, The New England journal of medicine.

[8]  W. See,et al.  Predictors of laparoscopic complications after formal training in laparoscopic surgery. , 1993, JAMA.

[9]  T. Falcone,et al.  Excision of ovarian dermoid cyst by laparoscopy and by laparotomy. , 1995, American journal of obstetrics and gynecology.

[10]  J. Dwyer Primum non tacere. An ethics of speaking up. , 1994, The Hastings Center report.

[11]  M. Hatlie,et al.  Climbing 'the learning curve'. New technologies, emerging obligations. , 1993, JAMA.

[12]  F. Nezhat,et al.  Laparoscopically assisted myomectomy: a report of a new technique in 57 cases. , 1994, International journal of fertility and menopausal studies.

[13]  T. Dent Training, credentialing, and evaluation in laparoscopic surgery. , 1992, The Surgical clinics of North America.

[14]  R. Orlando,et al.  Laparoscopic Cholecystectomy: A Statewide Experience , 1993 .

[15]  J. Olsson,et al.  A randomised prospective trial comparing laparoscopic and abdominal hysterectomy , 1996, British journal of obstetrics and gynaecology.

[16]  R. E Richardson,et al.  Is laparoscopic hysterectomy a waste of time? , 1995, The Lancet.

[17]  D. A. Johns,et al.  The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital. , 1995, American journal of obstetrics and gynecology.

[18]  Harris Bc Retrospective comparison of outcome of 100 consecutive open cholecystectomies and 100 consecutive laparoscopic cholecystectomies. , 1993 .

[19]  C. Mcsherry,et al.  Initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center. , 1992, Surgery, gynecology & obstetrics.

[20]  A. Jonsen Watching the doctor. , 1983, The New England journal of medicine.

[21]  John V. White,et al.  Gallstones and Laparoscopic Cholecystectomy , 1993 .

[22]  S. Guerriero,et al.  Treatment of Nonendometriotic Benign Adnexal Cysts: A Randomized Comparison of Laparoscopy and Laparotomy , 1995, Obstetrics and gynecology.

[23]  John G. Hunter,et al.  A prospective, randomized comparison of laparoscopic appendectomy with open appendectomy , 1995 .

[24]  F. Nezhat,et al.  Hospital cost comparison between abdominal, vaginal, and laparoscopy‐assisted vaginal hysterectomies , 1994, Obstetrics and gynecology.

[25]  J. Satterfield,et al.  Credentialing physicians for new technology: the physician's learning curve must not harm the patient. , 1994, The American surgeon.

[26]  E. Morreim Am I my brother's warden? Responding to the unethical or incompetent colleague. , 1993, The Hastings Center report.

[27]  A. Senagore,et al.  What is the learning curve for laparoscopic colectomy? , 1995, The American surgeon.

[28]  J. C. Lee,et al.  Use of alternative techniques of hysterectomy in Ohio, 1988-1994. , 1996, The New England journal of medicine.

[29]  B. Lo Resolving Ethical Dilemmas: A Guide for Clinicians , 1995 .

[30]  Imperato Pj,et al.  Serious complications of laparoscopic cholecystectomy in New York State. , 1992 .