Poor assistants, poor equipment and no Mentor when performing surgery by laparoscopy.

In one of my earlier blogs entitled “12 reasons why laparoscopic surgery is not popular in Malaysia”, the 9th reason I stated was “You don’t get good assistants when performing surgery by laparoscopy

This is a common complaint by gynaecologist keen to perform laparoscopic surgery. Laparoscopic surgery is an instrument intensive procedure. You need nurses who can prepare all the necessary equipments to perform the surgery. Even if one item is missing, it will be difficult to perform the surgery. For example, recently I performed 2 total laparoscopic surgeries on very large uteruses measuring more than 1 kg. The suction irrigation system was not working properly and it took a longer time for me to complete the surgery.

The importance of nurses 

It is difficult for a gynaecologist to be present in the operating room to make sure that all the equipments are there before starting the surgery. This is the job of the nurses. Once the instruments are prepared, the next step is that we need good first assistants. In the government hospitals 2 surgeons can assist each other to perform laparoscopic surgery. However in the private hospitals, where all gynaecologists are solo practitioners, the first assistant is usually a nurse. First assistants must have good hand eye coordination and must understand the surgeon’s needs when assisting in these surgeries.

How Private Hospital work

Private Hospitals work for profit. They are not bothered to provide good assistants. Their job is to provide 2 or 3 assistants trained or untrained and it is up to the surgeon to get their job done. This is compounded by the fact that surgery by laparoscopy is not done often in most private hospitals. So nurses can never become good assistants. When few surgeries are performed by laparoscopy, private hospitals will not invest in good instruments. Many gynecologist give up performing laparoscopic surgeries because of poorly trained assistants and insufficient instruments. There is also this problem of trained nurses leaving for better pay to other hospitals or abroad.

How did I overcome these problems

This had been a recurring problem in my practice for years. Over the last 25 years, I must have trained several dozens nurses. Once trained they leave and I have to train more. I used to get anxious going to the operating room when I have a difficult laparoscopic surgery because I am unsure whether I will be getting a nurse who is good enough to assist me. Nurses who are good may be on leave or on nights off. I have on occasion postponed my cases because I could not find a good assistant. 

After struggling with this problem for years, I persuaded one nurse who had been assisting me for the last 15 years, to work for me. So for the last 8 years or so I have no anxiety when I go to the operating room because my “personal nurse” whom I pay the salary, is there to prepare everything for me. The day before the surgery we will discuss about the next day’s list. I perform a variety of cases such as single port surgery, vNOTES etc. She knows what to prepare for me for each type of surgery. She will assist me in all complex surgeries.  I will get other nurses to assist me in simpler cases and she trains them. In this way, we keep training new nurses. The hospital where I work, benefit tremendously from this arrangement. 

How can we solve these problems.

There are many private hospitals in Malaysia. In most of these hospitals only a few cases of surgery by laparoscopy are performed. As such, no single gynaecologist can become good at it.  How if there is a private hospital dedicated to performing surgery by laparoscopy where all the best instruments are available and all the nurses are well trained to assist.  How if this hospital also provides a mentor, a gynaecologist who is well trained in laparoscopic surgery who is available to give a helping hand if the operating gynaecologist is having difficulty in performing the surgery by laparoscopy? Is such a hospital a viable solution to all the problems currently faced by most gynaecologists? 

What will be the challenges to set up such a Private Hospital

  1. To find a mentor willing to partake in such an adventure
  2. Investors willing to set up such a hospital
  3. Willingness for gynaecologists to bring their patients to this hospital to perform laparoscopic surgery
  4. Private hospitals not allowing their gynaecologists to take the patients to another hospital to operate
  5. Suitable formula for reimbursement to the gynaecologist and the mentor. 

Conclusion

This blog is a thought exercise. I have dreamt of such a hospital for years. It will require courage to set it up, run and be profitable. It will surely benefit the public, many of whom are not given a choice of enjoying all the benefits of surgery by laparoscopy.

 

Dr. Selva
Sevellaraja Supermaniam
21/3/2020

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