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There is a global interest in and growing knowledge about how best to select residents in surgery. In 2010, Paice et al claimed that selection was “the missing link in patient safety work”1. The starting point for collegial discussions on the matter and opinions about selection are things we know and have experience of; and we know that there is a spectrum running from excellent to unsuitable surgeons. Some continue to ask, are surgeons “born or made”, i.e., is it innate talent, or their training that matters? Is competence-based education better than the apprenticeship model?2,3.  Further, it is well-established that all facets of competence matter for patient outcomes, not only technical skill4-6. The detrimental effect a less competent or even dysfunctional colleague can have on patients and the workplace environment is also widely recognised7. Attrition from surgical residency programs has been reported to be up to 20%, reflecting bad investments of resources8. Another challenge is that surgery accounts for most adverse events in health care, and that up to 15 % of patients in elective surgery suffer a treatment-related injury9,10. We all want the next generation to be better than us. Selection is thus a foundational factor in raising the standard level of treatment and care, reducing adverse events, improving workplace collaboration and heightening the reputation of the profession.

There is a global interest in and growing knowledge about how best to select residents in surgery. In 2010, Paice et al claimed that selection was “the missing link in patient safety work”1. The starting point for collegial discussions on the matter and opinions about selection are things we know and have experience of; and we know that there is a spectrum running from excellent to unsuitable surgeons. Some continue to ask, are surgeons “born or made”, i.e., is it innate talent, or their training that matters? Is competence-based education better than the apprenticeship model?2,3.  Further, it is well-established that all facets of competence matter for patient outcomes, not only technical skill4-6. The detrimental effect a less competent or even dysfunctional colleague can have on patients and the workplace environment is also widely recognised7. Attrition from surgical residency programs has been reported to be up to 20%, reflecting bad investments of resources8. Another challenge is that surgery accounts for most adverse events in health care, and that up to 15 % of patients in elective surgery suffer a treatment-related injury9,10. We all want the next generation to be better than us. Selection is thus a foundational factor in raising the standard level of treatment and care, reducing adverse events, improving workplace collaboration and heightening the reputation of the profession.

Some characteristics have been found important for surgeons to be successful, such as having a strong academic background and commitment to lifelong learning; possessing sufficient manual dexterity and fine motor skills to reach proficiency; displaying emotional stability; extroversion and conscientiousness; good communication skills and ability to work in teams; critical thinking ability; situational awareness; robust decision-making and problem-solving skills11-14. A more recent addition to the list is “technical orientation”, i.e. willingness and ability to work in a technology-based environment15.

Correspondence to: Anita Balakrishnan (email: ab2031@cam.ac.uk)

Department of Hepatopancreatobiliary Surgery

Cambridge University Hospitals NHS Foundation Trust

Nearly thirty years ago Paul Sugarbaker first published the classification and description of the techniques of peritonectomy procedures and organ resections as part of cytoreductive surgery1. Since then, Paul Sugarbaker has published numerous manuscripts, books and book chapters and produced videos on peritonectomy procedures. Some of these have been improvisations of the previous descriptions while others have been descriptions of new peritonectomy procedures that he had devised2,3,4. The description of the hepatic bridge and the clearance of the peritoneum in the tunnel created by it, clearance of peritoneal disease in an inguinal hernia, clearance of the foramen of Winslow and peritonectomy of the sub-pyloric space are some of the techniques published subsequently5,6,7,8,9,10. The most recent addition to the list was peritonectomy of the colonic mesentery published in 202111.

Paul Sugarbaker started working on the treatment of peritoneal malignancies in the early eighties and coined the term cytoreductive surgery for a surgical procedure that involved resection of all macroscopic tumor, including electrosurgical removal of the peritoneal tumor deposits, combined with administration of intraperitoneal chemotherapy12,13. The body of publications by Sugarbaker on peritonectomy procedures is the most comprehensive resource on these procedures in the literature, both in terms of the included procedures and the technical descriptions of these procedures. In 2016, Grey’s anatomy, for the first time, included a chapter on the anatomy of the peritoneum by Paul Sugarbaker14. Paul Sugarbaker has set the bar for the quality of operative surgical images published in these manuscripts. Cytoreductive surgery addresses different regions of the peritoneal cavity, and organ systems, and can appear disjointed and unstructured, especially in the setting of extensive peritoneal disease. The intraoperative images in his manuscripts are pristine, demonstrating each anatomical structure with great clarity15. This attention to detail underlines the importance of meticulous surgical technique, and the pursuit of perfection, which to those who have trained and worked with him, are his well-known hallmarks.

Paul Sugarbaker has over the years laid great emphasis on minute technical aspects of cytoreductive surgery, such as the incision and exposure of the peritoneal cavity, meticulous excision of previous surgical scars, use of high voltage electrocautery and copious lavage of the peritoneal cavity16,17,17. One of his most famous aphorisms ‘It’s what the surgeon does not see that kills the patient’ is a manuscript focusing on meticulous surgical technique to reduce peritoneal dissemination from colorectal primary tumors19. In current times, this aphorism incorporates , and underlines, the importance of ‘complete’ cytoreductive surgery which requires meticulous exploration of the abdominal cavity and identification and resection of all sites of disease. However, the original aphorism refers to another important concept that he introduced whereby he described the technique of centripetal surgery which involved starting the dissection far away from the tumor, and employing local peritonectomy procedures to contain the colorectal primary tumor19. While most of his work was on peritoneal metastases of gastrointestinal origin, the principles and concepts introduced by him are applicable to all surgical approaches for peritoneal malignancies. Another very significant Sugarbaker concept is that the peritoneum helps prevent retroperitoneal dissemination of peritoneal malignancy and is thus “the first line of defense” again peritoneal metastases20.

Undergoing an amputation can be a life altering procedure for many patients. Despite this, we know relatively little about how best to support these patients to help ensure their psychologically prepared for what is to come. The pre-operative period is often compressed, with the need for surgery to be conducted urgently This presents a challenge for clinical staff in how best to help patients with preparing for what is to come. Our team at De Montfort University recently completed a four-year study to explore the psychological preparation of amputation patients. The study- ‘PreAmp’- aimed to understand more about how preparation work is currently conducted, to explore the barriers and facilitators to psychological preparation of patients, and then to work with patients and clinical staff to co-design resources to help support preparation. We conducted an extensive range of research activities, including a survey of healthcare staff, interviews with existing amputees, ethnographic observations of preparation work in vascular wards as well as interviews with healthcare professionals and patients in those wards.

We found that both patients and healthcare professionals feel that preparation is very important, but at present this often does not happen in the ways that both patients and staff would like it to. Good psychological preparation for amputation requires the provision of clear information, staff need to include patients in conversations about their care and patients need time and space to work through any questions they have. Preparation is very much a multidisciplinary activity and teams working together- with the patient as a central part of the team- is a key way of ensuring effective preparation. There is a need to include people who work outside of hospitals, such as social workers/ social care services in preparing patients, though often that does not happen and delays in discharge are often as a result of this. Vascular wards are very busy, with staff under significant pressures, and as a result there is often not a lot of time to spend on the preparation of patients. Vascular services cannot routinely access psychological services for their patients, yet this is a major need for patients who experience anxiety and distress as a result of the need for amputation. Often it is allied health professionals who have to attempt to counsel patients despite it not being their area of expertise. Patients would also like to be able to talk to existing amputees as part of their preparation, those with lived experience of amputation are seen as helpful to people about to have an amputation. From this research we then created resources to help with preparation for having amputations. We co-designed these resources with amputees and healthcare professionals to make sure they were fit for purpose. The resources we developed are: