Surgical news

Dhananjaya Sharma, MBBS, MS, PhD, DSc, FRCS, FCLS (Hon), FRCST (Hon)

Virve Koljonen MD, PhD

Virve Koljonen MD, PhD

Virve Koljonen MD, PhD

Virve Koljonen MD, PhD

Begum Pekbay

Virve Koljonen, MD, PhD

Virve Koljonen, MD, PhD
Department of plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

I am a big fan of Pokémon Go. I play it regularly and by that, I mean, every day. The inventiveness of the appearance of Pokémon characters and their witty back stories appeal to me. It is nice to look at a new character and try to find out its real-world counterpart. Further, the structure of the game is to collect as many as possible Pokémon or walking a certain amount of kilometers doing projects within the specified time, perfectly aligning with my competitive personality. Some time ago I was browsing through the medical literature. I am always trying to keep up with new literature, although nowadays it is very difficult. It has been estimated that medical knowledge doubles in just 73 days 1. I do really miss those golden old days when you just did a brisk walk to the library to find what you were looking for. I cannot overestimate my joy when I found out that my favorite leisure time hobby, Pokémon go was employed to expose predator publishers2! Pokémons have helped to reveal that predatory publications have no peer review, nor editing, and what is most choking, not even a reality check2. I am not going the reference these publications, since I feel that the journal gets undeserved glory for including them in the reference list. However, I will walk you through some of these genius publications. For the purposes of this article, I also made AI images in the Pokémon go -style.

Virve Koljonen, MD, PhD
Department of plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

I vividly remember when attending congresses was in real life only. Today that seems like another reality. I do remember the awkward moments, when I had like one microsecond to decide how to greet my congress acquaintances. Should I greet them with familiarity, or formally, or just casually wave my hand when walking by. As a person coming from a northern country, apart from choosing the right way to greet acquaintances, another custom of the continental Europe is causing me quite a lot of anxiety: air kisses. Which cheek comes first and how many are appropriate, because I don’t want to seem like a stalker, and what if I accidentally belch simultaneously. So many things to consider and be afraid of. Traditionally the success of congresses have been measured by the number of participants and by the number of abstracts 1. This obviously translates to money made by the organizing entity. Before the advent of internet, medical congresses were truly occasions where top scientific innovations were presented, new techniques were introduced, and with a chance to learn from experts 2. Nowadays knowledge is available for anyone at anytime and anywhere. Of course, I will not dismiss the value of face-to-face interactions, that has led to great innovations and is personally meaningful to those participating in such actions. What about the keynote speakers – superstars of their specialty. The more famous the keynote speaker, the more attractive congress is likely to be. In social media, there are events that are called meet-and-greet events. By definition, these events are arranged so that a famous person i.e. influencer can meet and talk to the people. Or is it vice versa actually. Meet-and-greet events are not quite the normal fan event, but almost. Well, to me it sounds a lot like inviting keynote speakers.

Virve Koljonen, MD, PhD
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

A little while ago, I was supposed to write an editorial. I had the perfect concept. Ideas cruised in my mind and the best ideas took parking lot in my left cerebral hemisphere and started having a life of their own. I booked time – the whole weekend for myself – psyched myself during the previous week, did reference search and even printed some articles. I had three litres of diet cola in the refrigerator. And then, nothing happened – zero, nix, nada, zip. I experienced a Nietzschean moment; I stared at the white document on my computer screen, and I swear to you, the white document stared back. I have been around the block quite a few times so to say by the Merriam-Webster definition. So, this was not a new experience to me. Everyone who writes, whether it’s scientific manuscript, thesis, grant application or some other forms of academic writing, has come across this potentially frightening situation. White paper syndrome, blank page syndrome, writer´s block, white page terror … Monochrome eponyms and all so negative. Syndrome, terror and block. This does not sound good. Writer´s block – the term – was invented by Bergler in 19471 and basically it means inability to write, either to start or continue writing. An important feature in diagnosing writer´s block is that it causes feelings of overwhelming anxiety. Let us familiarize with another term relevant to this topic: procrastination. The difference between writer’s block and procrastination can be traced back to sitting, translated as a continuous period of being seated, especially when engaged in a particular activity. A person experiencing writer’s block is sitting in front of the desk whereas a procrastinator is doing anything else but sitting at the desk2. This is the best definition I could find. Having said that I must acknowledge that standing desks and sit-stand working stations have many health benefits3, 4.

Virve Koljonen, MD, PhD Department of Plastic surgery Helsinki University and Helsinki University Hospital Helsinki, Finland @plastiikkaope

Since ancient Egypt and ancient times, there have been female surgeons.1  The earliest image of a female surgeon at work was found in the tomb of Ramses II.2  The papyri that survived to the present day show that medicine and surgery in ancient Egypt was systematic, although it was infiltrated with magic and religion. It has been suggested that in ancient Egypt  there were medical specialties and specialised physicians.3 Women surgeons played an active role in the development of surgery and medicine. Women surgeons operated on breast tumours, treated wounds, placed bone fractures in the correct position, performed births, and performed caesarean sections1.  So, everything was going pretty smoothly until the Middle Ages came. The Middle Ages were not a good time for women surgeons. Women were prevented from training as doctors and surgeons. This has been attributed to male-dominated church and state rulers, which led to a deterioration in the position of women physicians, surgeons, and women1 overall. Women, together with carpenters, smiths and weavers were banned practising surgery and taking part in the Company of Barbers and Surgeons.1 During the Middle Ages, however, there were a couple of exceptional cases when a woman was allowed to practice her profession as a surgeon; if they were found qualified by a “competent” jury.4  Hey, did we just accidentally find the basis for current competency-based specialisation? Another career path for women to achieve the profession of surgeon was death of surgeon husband. Widows of surgeons, were allowed to practice surgery.4  That is, inherit the profession. Fortunately, women continued to practice our profession.

Virve Koljonen, MD, PhD Department of Plastic surgery Helsinki University and Helsinki University Hospital Helsinki, Finland @plastiikkaope

Some 5 years ago, or was it 12 years ago I remember reading on the internet, or maybe it was in some chat forum, well anyway. So, I read a question from patient, that has echoed in my mind all these years. I cannot give you link or reference, so you just must trust me on this. The question was: “I thought my surgeon was fine gentleman, until I was in the OR, and he listened to country and western music. This ruined my experience; why didn’t he listen to classical music? Can I trust him?” For some reason, in the movies and tv-series, the OR is always portrayed with peculiar lighting – you know,  pitch dark room and only one spotlight to the operating area and classic music playing in the background. And the surgeons and nurses are talking about complex patient cases. Strangely enough in many of these discussions the surgeon and OR nurses seem to talk are about internal medicine patients and cases. We all know that this cannot be further from the truth. On second thoughts, maybe it’s good to keep it this way, to maintain the mystery of OR.   The idea of using music to relax anxiety in patients is not new. An article published in the year 1950,  states that as early as 1944, a portable radio was installed into plastic surgery operating and dressing rooms.1 The article continues that  after opening the radio, “the comfort and composure of our patients was  apparent immediately, their fears were allayed for minds were diverted and occupied by the music rather than the thought of the operation.”1 WHY don’t we write like this anymore! Nowadays this would be something like: the positive effect of music on the patient´s self-reported negative emotions were noted within an average of 3 minutes (range 0 – 30 minutes), by the Music Before Operation (MBO) Questionnaire (*I made this one up), that patients taking part in the survey completed whilst giving written informed consent before their surgery.

Recommendation and Article by Dr Ameera AlHasan, Specialist General and Colorectal Surgeon, Jaber Al-Ahmad Hospital, Kuwait, @A160186

“Banal prejudice. People are most unfair to doctors and to us surgeons in particular. Just think: a man does a hundred appendectomies and the hundred and first patient expires on the operating table. Is that murder?” Mikhail Bulgakov is better known for his literary masterpieces such as The Master and Margarita and The Heart of a Dog. However, this series of short stories is directly inspired by his experiences as a doctor, not as a writer. The main character, Dr Vladmir Bomgard has just graduated from medical school and is sent to work in a remote hospital in the geographically hostile Russian countryside. As the only doctor on premises, and with the help of a medical practitioner and two midwives, he has to navigate many challenges including his lack of experience, limited resources, snow blizzards and a generally uneducated patient clientele, all while filling in the shoes of his presumably more qualified predecessor. Struggling with feelings of imposter syndrome, he is particularly intimidated by surgical and obstetric emergencies, starting his account by establishing that a strangulated hernia is the epitome of all difficulties.   Through dedication, reading, support from his staff and sheer serendipity, he establishes a name for himself, eventually becoming a reference for colleagues who will follow in his footsteps. The book takes the reader through a rural doctor’s struggles in treating various emergencies and afflictions such as trauma, complicated labour, children with obstructed airways, syphilis and many others. It also touches on various other sensitive topics such as bridging the gap between medical school and real-world practice, having difficult conversations with patients who hold different values, and dealing with colleagues who suffer a drug addiction. 

Virve Koljonen M.D. PhD.
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

I read with great interest Post reproductive female killer whales reduce socially inflicted injuries in their male offspring in Current Biology.1 I was intrigued to learn that in only a few animal species apart from humans, females experience menopause, and live past it. Currently, only humans and toothed whales; killer whales and short-finned pilot whale females live, as it is called, a post reproductive life.2 To be brutally honest, I had not contemplated about the menopause in other animal species nor in humans. But now that I think if it, I have never heard of post-menopausal ants or menopausal lionesses. Another term linked to this is the grandmother effect, that basically means that older female kins can take care of the younger.3 Is this beneficial or not, results are contradicting?3 We should not focus on gender; thus I suggest that we talk about the grandparent effect in surgery. Surgical departments consist typically of surgeons of different ages. Every individual brings their experience, vision and  insight to benefit the community. It has long been the case that the views of senior surgeons are listened to and respected more than those of newcomers. Thus, as they get older, surgeons expect their opinions to be automatically respected more. Of note, I strongly disagree. Our profession is highly physical, and we use a lot of neurocognitive skills. Physical decline together with chronological ageing is a fact. We acknowledge this in our patients, but not with ourselves. Hearing, vision, dexterity, strength and reaction time usually tend to deteriorate with aging,4,5 although I must note that this is highly individual. Likewise, age-related neurocognitive changes such as processing speed, problem solving and adaptive thinking, and critical and analytical reasoning usually decline.5,6 Together these natural ageing-related phenomena pose a risk both to the surgeon and the patient.  Add to this that, in general, doctors take poor care of their physical and mental health and do not consult physicians,7 other than themselves. So, it is clear that older surgeons may be a serious risk factor for poor outcome.

Recommendation and Article by Teresa Perra and Alberto Porcu Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy

Anatomical knowledge is an essential asset for every surgeon. This book is a useful and handy guide for every student, surgical resident, or young surgeon. It provides a brief anatomical description for each site, followed by the surgical technique. The Editor-in-chief of this book, Professor Skandalakis, shares his experience in the field of surgical anatomy and technique. The result is a book that explains everything in a simple language and is full of beautiful illustrations to explain relevant anatomical details and fundamental steps of surgical procedures. The latest edition has been updated to include robotic surgery techniques and to reflect recent advances in surgery with the relevant anatomy. It is well-written and every chapter is well-structured. Why surgeons should read it: This handbook is a very useful resource for surgeons in the early stages of their career or medical students with an interest in surgery. Every anatomical region is described. The main basic surgical interventions are explained. In the latest editions, new chapters have been added. Whether you need to perform a simple skin biopsy or a complex procedure such as a pancreatoduodenectomy, anatomical knowledge is critical. This book opens your mind and highlights key points of anatomy relevant to performing surgery. This is a book that you can quickly consult to review the anatomy of a particular site and the key steps of a surgical procedure. It allows you to relate the anatomy to the surgery. It is a pocket manual and an online version is available.

Recommendation and Article by Dr Ameera AlHasan, Specialist General and Colorectal Surgeon, Jaber Al-Ahmad Hospital, Kuwait, @A160186

What do a surgeon, a taxidermist, a tailor and a magician have in common? The author, Roger Kneebone started his career as a surgeon operating on trauma patients in South Africa before deciding to return to England where he changed paths to become a general practitioner. He is now a professor specialized in surgical education at Imperial College London. In this book, he reflects on his journey to becoming an expert at each stage of his career, comparing and contrasting his own experiences with those of friends and acquaintances who are themselves experts in their fields. He divides the journey to expertise into three main stages namely Apprentice, Journeyman and Master. He then goes on to explain how one navigates these stages by making full use of their senses, deliberately putting in the time to repeat certain (mundane) tasks before going on to develop their own style of work as well as the ability to improvise in unfamiliar situations and finally becoming a master who is able to pass on the craft to their mentees. Professor Kneebone brilliantly demonstrates how, regardless of the craft, the principles remain the same and how there are no shortcuts to mastery. The professions cited in the book including those of surgeon, taxidermist, tailor, magician, hairdresser, pilot, musician, and many others, all share this common journey and all require a diligent and gradual acquisition of skill and good judgment combined with the ability to manage both people and risky situations. Every surgeon should read this book. It is written by a surgeon, someone who has known and lived the surgical experience first hand, but most importantly, it puts everything into perspective. Younger surgeons sometimes don’t see how having to do repetitive minor tasks adds value to their ultimate goal of becoming a master surgeon, whereas the author explains how “doing time” is inevitable. More experienced surgeons, on the other hand, upon wondering whether they have become masters or not might ask how would they even know when they got there? Professor Kneebone clearly explains how mastery is a journey and not a destination in itself; the learning process never stops but masters are able to innovate and educate.

Virve Koljonen M.D. PhD.
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

Today I am going to share you with my speech to newly qualified plastic surgeons, I have been thinking about the tradition of speaking in surgery and medicine, in general, and usually it involves Powerpoint slides, and bloody pictures. Personally, I have nothing against PowerPoints or blood, but I feel that we need to revive the art of giving speeches. A good speech is inspiring and captivating, a good speech has clear message and is supported by facts, a good speech is basically telling a story suitable for your audience. Based on this I would grade my speech 3/5 – there is always room for improvement. If your professor is not as eloquent as yours truly and you need reassurance, just imagine that this speech was made by your professor to you.  And here we go:   A specialist degree – including a specialist degree in  [insert your specialty here] surgery – is an exceptional university qualification.  The bulk of a specialist’s degree is spent in hospital working on what, at least in our hospital district, is irritatingly and dismissively referred to as service production or health-care production. In day-to-day work on the service-production side, one learns to perform specialty-specific procedures on specialty-specific patients through an increase in the number of n. And if you’re really, really lucky, you also learn to perform unusual and rare techniques on patients with unusual and rare diagnosis. That’s good. 

Virve Koljonen M.D. PhD.
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

We all carry along excellent medical examination tools constantly. Maybe you remember from pre-clinical physiology courses that human has five basic senses: sight, sound, smell, taste, and touch. Regarding examining the patient and assessing a patient with chronic wounds, I suggest that you use only four of your basic senses and discard taste, although our early colleagues made diagnostics by tasting e.g. urine for diabetes1. So, lets stick with our four senses. This is my take on examining the patient with a chronic wound and assessing the wound itself –  the person and the wound. The examination of the patient with a chronic wound begins when the patient enters the room. Inspect how the patient moves, briskly walking without any walking aids, with walking sticks or crutches, with the help of a rollator walker, in a wheelchair or on a stretcher. Also note how the patient moves to the examination table, easily or with help of others. On the examination table note if the patient can breathe easily lying supine or do you need to lift the backrest to ease the breathing. Why this is important, with a single glance, you can assess patients’ reserves for further treatment.

Recommendation and article by Begum Pekbay; Medical Doctor, and PhD-candidate in Surgical Education and Training; Rotterdam; The Netherlands; www.linkedin.com/in/begumpekbay; Instagram: @drs.begum

“The secret to managing the quality of our decisions is to learn to be wrong as fast as possible.” In Thinking, Fast and Slow, Daniel Kahneman illuminates a two-systems approach to human judgment and choice: the fast, intuitive System 1, and the slow, measured System 2. Errors result from relying too much on the faster intuitive decision-making process and not enough on the slower calculated process that applies rules and statistics. Kahneman further dissects different cognitive biases and systematic errors and explains how they affect decision-making. The content is based on extensive research and serves as a comprehensive guide to understanding human thought processes. It provides concrete, valuable tools for individuals in various fields, including surgeons, to enhance decision-making skills. Why surgeons should read it:

Recommendation and Article by Mr. Arindam Chaudhuri MS FRCSEd MSc FRCS; Consultant Vascular Surgeon; Bedfordshire Hospitals NHS Foundation Trust; @vascularis

Bailey & Love’s Short Practice of Surgery was the surgical textbook we were given to read from our time as 3rd year medical students. Despite the ‘short’ in the title, this is a comprehensive tome that has evolved through years and indeed generations of surgeons. Today, subspecialisation has somewhat eroded the generalist reading of our yesteryears, and with that comes the downside of that lack of surgical general knowledge which underpins the continued loss of general surgical training. The book has evolved into its current 28th edition from the one of my student days. There are multiple versions including more affordable paperbacks (typically for overseas trainees/surgeons) and digital versions. On a comparative basis, chapters that now exist such as ‘Basic Surgical Skills’, ‘Surgical Audit’, ‘Ethics & Law in Surgical Practice’, ‘Tissue and Molecular Diagnosis’ were not present in the previous versions we read, indicating that the modern nuances of current surgical practice have been incorporated yielding more than 80 chapters- compared to the 61 in my own historic 21st edition now held firmly by duct tape. Topics such as ‘Tropical infections and infestations’ add a global perspective. Nevertheless, the book continues to do what it has always done, present a vast amount of general surgical knowledge in an easily readable way. To that end, it promotes the value of knowing the history of surgery. It also provides insights into how surgery has evolved, ever-amusing and memorable aphorisms (‘When you have a new hammer, everything looks like a nail’) and footnotes (how Ramstedt’s family name had been misspelt). Why surgeons should read it:

Virve Koljonen M.D. PhD.
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

I was asked to give a little talk in the annual congress of Young Plastic Surgeons association in Finland. I was given a topic: Is it the duty of medical specialist to share information on social media and on what terms? This title didn’t frighten me at all. ICYMI, I have been active in social media (SoMe) for some time now. I manage a relatively popular educational account in Instagram,  where I share videos on how to do procedures, e.g. suturing, wound treatment, and of course I share my accumulated valuable wisdom on ethical and moral aspects of our profession1.   When I started my account, my target population was medical students and young residents. Very soon it became clear, that there was a demand for such content. I noticed nurses, doctors of other specialties and laymen starting to follow me. Another indication that content such as mine is needed is that I receive DMs in strange hours, usually during night shift hours, thanking for showing the procedure. There is actually a name for this: just-in-time learning2 or microlearning also known as heutagogy. There you have it: your word of the day. Heutagogy means self-determined distance learning using technological developments3.   To answer the first questions of the title: No. Rest assured, there is no obligation for anyone to start a SoMe-influencer career. Let’s face it, most people don’t have skills or messages to share. Interestingly, most active SoMe-influencers have a good academic track record based on H-index4-7, on Twitter/X that is. Different SoMe platforms have different profiles and Twitter profiles itself disseminating research and scientific content. Communicating science and highlighting accomplishments is never a bad idea in SoMe, besides gaining personal benefit by improved article citations8 it also benefits the whole surgical community9.

Virve Koljonen M.D. PhD.
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

I just love those self-help books! Two of my favourites apart from surgical literature are Simon Parke´s One-Minute Mystic – For those with only 59 seconds to spare, and Pessi Rautio´s  (my translation) Becoming a connoisseur of contemporary art in a quarter of an hour. Self-help books, oh the simplicity and inspiration…. And the empowering titles! Not to mention the effortless access from your smartphone or bookshelf as printed, e-books or audiobooks, just when you need emotional support or are ready for your personal growth spurt. Well then, why don’t we have simple and short self-help books for scientific writing? If I get enough encouragement from you dear readers, I will write a self-help book that is to be called: Mastering the art of medical scientific writing in just 10 short minutes. Why short minutes you may ask.  Are there minutes that are of different lengths? Of course not, it just sounded better and suits this literary niche. It has been said that research is not complete until it is published or “Science is not finished until it’s communicated” as Sir Mark Walport said in 20131; or “Nothing in science has any value to society if it is not communicated ” by Anne Roe; or “Publish or perish”2 by Case in 1928, I could go on and on, but I hope you get the idea, how important it is to do research and publish it.

Virve Koljonen M.D. PhD.
Department of Plastic surgery
Helsinki University and Helsinki University Hospital
Helsinki, Finland
@plastiikkaope

I have come to the point in my surgeon career, that is seems appropriate to look back and ponder some of the choices I have made. Therefore, it is time to warm up and dust off my trusty retrospectoscope. According to the title, I will inspect only things that I regret. And starting in  three… two…one… ignite!  Strange working hours, no I don’t regret that… high stress levels, challenge of being up-to-date …definitely not those… what about this; uncertainty in early career, nooh.. Now I found it! Here it comes. What I regret most in my career, is that when I started back in 1990s, there was no talk about ergonomics. And now I pay the price of it.  My both shoulders are worn out, some days it is nearly impossible for me to lift my arms over 90 degrees, I had bilateral golf or tennis elbows – not sure which, because I chose to treat myself. My feet are mess, my wrists hurt and I have back pains. Some of you may think, well it´s because of her genetics. No, I am not alone with these issues.

Recommendation and Article by Stephen J Wigmore; BJS Foundation Treasurer; Regius Professor of Clinical Surgery University of Edinburgh; Director Edinburgh Surgery online; Editor in Chief HPB; @ProfW_edinsurg

Lessons in Chemistry is a novel by Bonnie Garmus set in America in the late 1950’s to early 1960’s. It follows the extraordinary life and career of the heroine Elizabeth Zott and her dog Six-thirty. Zott is a scientist at heart, to be precise a chemist and is ruled by scientific principles and logic. The story follows the prejudices, misogynistic biases and innumerable obstacles that she faces as a talented woman scientist making life and career choices in what was an incredibly patriarchal society- scientific research. In spite of the serious subject matter and some sad elements to the story, the book is written with wonderful humour and there were some “laugh out loud” moments for me. Even when she becomes a TV celebrity hosting a cooking show Zott adamantly remains a scientist and refuses to compromise on her principles or to bend to the whims of the male TV producers. The character Zott has such a wonderful mind and the absurdity of the juxtaposition of her logic with the prevailing wisdom, patriarchal prejudice and culture is quite charming. Why surgeons should read it: This book has nothing to do, on the face of it, with the subject of surgery and yet I think all surgeons should read it. At the same time in history, surgery was almost exclusively a male preserve and the structure of training, service delivery and hospital culture excluded women. There have been changes and improvements in recent years which have made surgery more accessible to women but the playing field is probably still not as level as it should be. Lessons in Chemistry could equally be Lessons in Surgery.