A surgical life by Henrik Kehlet
16 June 2023
I finished my medical education at Copenhagen University in 1968 followed by clinical training at Gentofte University Hospital Copenhagen where I was introduced to research in endocrinology under the direction of Dr. Christian Binder and after 2 years as a research fellow completed my doctoral thesis on “Pituitary-adrenocortical function in surgery”. Subsequently, I rotated between all surgical specialties at Rigshospitalet Copenhagen University, becoming head of gastrointestinal surgery at Hvidovre University Hospital Copenhagen and Professor of Surgery at Copenhagen University in 1991. In 2006, I was offered a special position as a surgical scientist in perioperative medicine at the newly established “Section of Surgical Pathophysiology” in Rigshospitalet receiving a new professorship in Perioperative Therapy, which I presently maintain. I stopped doing surgery about 10 years ago, to focus totally on clinical research in enhanced recovery across surgical procedures.
What made you decide to become a surgeon?
When I was 12 years old, I was hospitalized for nephritis for 5 months and for some unknown reason that stimulated me to go into medicine and where surgery was attractive combining the possibilities for “active” intervention combined with the many challenges in technical issues and surgical pathophysiology influencing surgical risk and recovery.
Who were your influences?
Initially based on my doctoral thesis, I became interested in the endocrine-metabolic responses to surgery followed by several visits to many international prominent scientists in surgery as well as a number of anesthesiologists. Based on discussions with these prominent thinkers, my focus was initiated to combine the pathophysiological knowledge within pain physiology and treatment and surgical endocrine-metabolic responses into the multidisciplinary concept of fast-track or enhanced recovery after surgery. This concept began when I was a young surgeon and had performed major operations where the technical aspects went well, but the patients developed medical complications and died due to pulmonary embolism and liver insufficiency. These observations started my repeated questioning on “why had this happened?”, Subsequently, this led to a step-by-step analysis on pain management, fluid management, nursing care and the other processes that are now included under the heading of enhanced recovery..
What were your training highlights?
My life in surgery and research has been a continuum even until now due to a constant flow of clinical and scientifical challenges. The obligatory rotation for my surgical training iparticularly noting variations in length of stay length of stay in most surgical specialties was enlightening. I became increasingly aware of the different challenges facing different surgical patients, but always summarized into the question about perioperative care and those surgical traditions not based on scientific evidence.
Tell me about a surgical triumph
My memory on surgical triumphs is not related to a special patient or procedure, but mostly to experience the recovery of patients after major abdominal and orthopaedic and later other surgical specialties when implementing the concept of enhanced recovery. Initially, in colonic resection we decreased the need for hospitalization to 2-3 days which at the time was widely about 10 – 12 days and with a reduced risk of medical complications. It was a huge surprise to see those patients recovering so fast together with acceptance and satisfaction among all the professionals involved, including surgeons, nurses, anesthesiologists and physiotherapists.
Tell me what you learned from a “surgical” disaster
As mentioned above, the initial observations of major complications and death despite technically successful procedures was the major stimulus for me to continue to ask questions about what we are doing in perioperative care. Otherwise, there have been major disappointments in my career. First, the initial rejection of my enhanced recovery concept paper on multimodal care therapy published in British Journal of Anaesthesia in 1997, where the comments from major US journals stated that it was preliminary without any evidence and “offered little more than hope and speculation”. A lot of time has been spent arguing about the need to change traditions in perioperative care, despite available scientific data. This problem continues, but is easier to handle now than in the first phases of enhanced recovery. Finally, a career “disaster” was that the hospital administration fired me as chief and professor of surgery, when I argued against a reduction of the department budget despite having saved an enormous amount of money after introducing enhanced recovery programmes. Thankfully, the next day I was re-instituted in my duties due to uniform support from all the senior hospital colleagues. Nevertheless, 24 hours with much turbulence!
What was your proudest achievement?
To develop the documented success of enhanced recovery programmes across surgical procedures in a fantastic multidisciplinary collaborative effort. Also, to establish the world-known Danish Hernia Database, since at that time surgical careers were mostly based on expertise in major surgery like pancreatectomy, liver surgery, etc., while hernia surgery was not considered similarly important. We showed on nationwide data that major improvements could be obtained, but still with many challenges. Subsequently, the scientific results led to many honorary awards all of which I treasure..
What are your hobbies outside surgery?
I spend a lot of time playing tennis several times a week. Otherwise, music and especially opera. My wife and I are especially fond of Wagner.
What advice would you give a young surgeon?
Beside the challenging technical aspects and continuous developments in surgery, to continuously ask about the components in surgical care. Are they evidence-based? Why do complications (medical or surgical) occur? Why is the patient in hospital? Then think of ways to improve these features..
What would you be, if you had not been a surgeon?
Probably a psychologist or politician – but I don’t know where that interest came from in the beginning.
Of course, there are memories of patients where unexpected complications occurred that personally affected me as a surgeon being in some way responsible. Otherwise my memories are extremely positive from a long surgical career where the special conditions in Denmark with relatively short working hours have allowed an academic career leaving time for clinical research and multidisciplinary collaboration between surgical colleagues in different specialties, anesthesiologists, nurses and even administrators in the health care system.
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