Goal-oriented

The first principle for the surgeon is to know the primary goal of the surgery. The method of performing surgery is important, but the ultimate goal is a different consideration. We may become so involved with the process of the surgical technique that we sometimes forget the surgical result that we are trying to achieve. As technical skill has increased, so has the ability to choose between specific outcomes, some of which may be conflicting. For example, patients can now be offered the ability to have both distant and near vision following cataract extraction, without the need for glasses. But often this comes at the expense of superb clarity. Which takes precedence? As skills improve, the need for clearly defining outcomes actually increases.

Or consider the patient with an intraocular pressure of 55 mmHg. What is the primary aim of surgery in such a case? Clearly the answer to this would depend upon many factors. The primary goal in such an eye could be comfort, restoration of the anterior chamber angle, improved visual acuity, or lowering of the intraocular pressure. The procedures required to accomplish these goals are different. The surgeon must therefore decide first upon the primary objective. Subsidiary, or even conflicting, aims must also be considered, but the priorities must be distinguished clearly before a decision can be reached as to what course of action is wisest.

Good preparation

To be well-prepared requires knowledge of the desired goals, the patient, the materials used, the techniques employed and oneself (see page 34). It also requires practice, practice, and more practice. While every surgical episode is different from every other, there is, to all surgical events, a fundamental core. The great surgeon, like the great athlete or chef, must be able to perform these basic core motions so well that they are done unconsciously. In the midst of a surgical procedure, attention cannot be diverted from what is happening to consider how a knot is to be tied or how remaining lens cortex is to be removed. Those activities must be so fully mastered that they have become ‘second nature’. While it is true that surgeons in training can perform a surgery in a way that the results are satisfactory, it is also true that better surgeons tend to have better outcomes than those less competent4–6. More experienced surgeons tend to have better results than learning surgeons. Whereas visual acuity may be 20/60 shortly after an adequately performed penetrating keratoplasty, it is more likely to be 20/40 or perhaps even 20/20 when done by a superb surgeon who has ‘been there’ hundreds of times before. ‘Occasional’ surgeons rarely have results as good as experienced surgeons who continue to hone their skills with constant practice4–6.

One aspect of the well-prepared athlete is pre-game or pre-race visualization7–10: the course, the start, the way the opponent will perform, the rare but real mishaps that may occur, the quirks of the referees, the failure of the equipment, the need to focus, the finish line – all of these aspects are visualized from start to finish so that when they occur during the race, the athlete has anticipated them and knows exactly how to respond, so also for the surgeon.

Part of being well-prepared is the development of a well-conceived plan to achieve the desired result, keeping in mind the multiplicity of factors that are involved. During performance of the surgery, the plan may need modification; at this point the initial purpose of the surgery again must be carefully considered. The surgeon should not make the error of substituting the plan for the primary objective. Also, it must be recognized that events during the performance of surgery may make it necessary to modify the surgeon’s aim. Just as having a well-defined plan is essential, so also is the ability to abandon a plan and create a new more appropriate one, should events occur that demand a change, always remembering the primary objective.

Control

A central surgical principle is that of control11–13