Looking at surgery

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Let’s face it. Surgery is scary. Whether it’s your first or your fifth. I think for those of us who have suffered for a long time, the unknown of “will they find anything, will it help, will it be worth it?” lingers in our minds. While surgery is not a magical fix-all, we want to feel as confident as possible when deciding on surgery.

First, it’s important to understand your disease and other related conditions that may be playing part of your symptoms. Start here to begin that learning.

Second point is to know your options for treatment and discuss the pros and cons with your provider.

Third is making an informed choice based on that knowledge. A little research can go a long way. When discussing surgery, here are some things to consider. We have many members on our Facebook group who have recommended surgeons to others based on their individual results. We can do our due diligence when asking others about a surgeon or asking questions ourselves. But what if this was taken a step further?

What is surgical vetting?

Surgical vetting involves peer reviewed assessment and feedback on video documented surgical procedures. For instance, a 2013 study looked at the different skill sets that played into surgical outcomes (Birkmeyer et al., 2013). The authors stated that:

“Clinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes.” (Birkmeyer et al., 2013)

In order to assess this, the study utilized this method:

“Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. We then assessed relationships between these skill ratings and risk-adjusted complication rates, using data from a prospective, externally audited, clinical-outcomes registry involving 10,343 patients.” (Birkmeyer et al., 2013)

Their findings?

“The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department. Although these findings are preliminary, they suggest that peer rating of operative skill may be an effective strategy for assessing a surgeon’s proficiency.” (Birkmeyer et al., 2013)

In 2016, a follow up article on that study noted:

“Recently, enthusiasm has been growing to tackle the challenges of directly evaluating and improving surgeon performance using intraoperative video. This work with practicing surgeons builds on the previous experience of using video to assess laparoscopic skills among residents…. While the use of video analysis to improve skill and technique is promising, one particularly important challenge must be recognized: building surgeon trust and social capital. In the bariatric surgery examples described above, this was accomplished over time through a spirit of collaboration that fostered relationships and a shared goal of quality improvement among surgeons in Michigan. For this process to succeed, these initiatives would first need to be piloted on a smaller scale through individual institutions or regional collaboratives to build social capital and ensure surgeon “buy-in”. Once established locally, a professional society (e.g. the American College of Surgeons, Society of Thoracic Surgeons, depending on the specialty or interest) could serve as a potential framework through which a program could be implemented more broadly. It will be necessary to clearly establish that skill assessment would be strictly for quality improvement purposes, ensuring complete confidentiality for participating surgeons. Through these steps, a collaborative infrastructure can be built to implement video-based analysis in a real-world practice setting.” (Grenda, Pradarelli, & Dimick, 2016)

Other studies have utilized similar methods. For instance, one done in 2010 to assess the skill accreditation system for laparoscopic gastroenterologic surgeons in Japan used “non-edited videotapes” that “were assessed by two judges in a double-blinded fashion with strict criteria” (Mori, Kimura, & Kitajima, 2010). Their study found that “surgeons assessed by this system as qualified experienced less frequent complications when compared to those who failed” (Mori, Kimura, & Kitajima, 2010). A similar approach was taken for urological laparoscopy with an 8 year follow up of the system (Matsuda et al., 2006; Matsuda et al., 2014). One article notes that “surgeons are under enormous pressure to continually improve and learn new surgical skills” and that the use of video technology can be useful to that means, especially as it is “becoming easier as most of our surgical platforms (e.g., laparoscopic, and endoscopy) now have video recording technology built in and video editing software has become more user friendly” (Ibrahim, Varban, & Dimick, 2016). The use of this technology may at one point lead to “future applications of video technology are being developed, including possible integration into accreditation and board certification” (Ibrahim, Varban, & Dimick, 2016).

How can this be used to help patients with endometriosis?

There are many dedicated, hard-working, and skilled surgeons out there, but it can be difficult for patients and other providers to connect with them. Not only can video vetting assist in surgeons being recognized for their skill, but it can also serve as a way for other providers and patients to find them! It can help connect patients and providers with surgeons with specific skill sets that a case may need. For instance, if a surgeon has demonstrated proficiency in working on thoracic endometriosis, then a directory could help providers and patients connect with not only that surgeon, but a multidisciplinary team to address that specialized care need. While there are no guarantees in life, surgical vetting can be another tool in our toolbelt to try to make the best decision we can.


Birkmeyer, J. D., Finks, J. F., O’Reilly, A., Oerline, M., Carlin, A. M., Nunn, A. R., … & Birkmeyer, N. J. (2013). Surgical skill and complication rates after bariatric surgery. New England Journal of Medicine369(15), 1434-1442. Retrieved from https://www.nejm.org/doi/full/10.1056/nejmsa1300625

Grenda, T. R., Pradarelli, J. C., & Dimick, J. B. (2016). Using surgical video to improve technique and skill. Annals of surgery264(1), 32. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5671768/

Ibrahim, A. M., Varban, O. A., & Dimick, J. B. (2016). Novel uses of video to accelerate the surgical learning curve. Journal of Laparoendoscopic & Advanced Surgical Techniques26(4), 240-242. Retrieved from https://www.liebertpub.com/doi/abs/10.1089/lap.2016.0100

Matsuda, T., Ono, Y., Terachi, T., Naito, S., Baba, S., Miki, T., … & Okuyama, A. (2006). The endoscopic surgical skill qualification system in urological laparoscopy: a novel system in Japan. The Journal of urology176(5), 2168-2172. Retrieved from https://www.auajournals.org/doi/abs/10.1016/j.juro.2006.07.034

Matsuda, T., Kanayama, H., Ono, Y., Kawauchi, A., Mizoguchi, H., Nakagawa, K., … & Referee Committee of the Endoscopic Surgical Skill Qualification System in Urological Laparoscopy. (2014). Reliability of laparoscopic skills assessment on video: 8-year results of the endoscopic surgical skill qualification system in Japan. Journal of endourology28(11), 1374-1378. Retrieved from https://www.liebertpub.com/doi/abs/10.1089/end.2014.0092

Mori, T., Kimura, T., & Kitajima, M. (2010). Skill accreditation system for laparoscopic gastroenterologic surgeons in Japan. Minimally Invasive Therapy & Allied Technologies19(1), 18-23.  Retrieved from https://www.tandfonline.com/doi/abs/10.3109/13645700903492969