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 visualization 7–10: 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 control 11–13. Control refers to the entirety of the surgical event. The surgeon must be in control of the whole procedure, including what happens prior to the actual operative procedure, what happens in the operating room, including the surgical team, the nursing staff, the anesthetist and the appropriate surgical technique. This requires having the requisite knowledge of the patient and the patient’s disease.

In order to control the procedure, the surgeon must be observant as to what is happening on and around the operating table. Ensuring good visualization of the surgical field is an essential principle. Seeing clearly requires proper direction and intensity of lighting, proper positioning of the surgeon’s hands, skillful assistants, proper positioning of the patient, and competence in the use of appropriate optical aids. By and large, the lower the magnification that permits seeing detail adequately the better: the lower the magnification, the wider the field, in both the anterior–posterior and the horizontal planes. Many of the improvements in modern surgical technique have stemmed from the persistent demand of surgeons to see better.

A necessary part of surgical training is experience with complications and unexpected events 14–17. Good surgeons do not become flustered or shaky when problems develop. They know what to do because they are well-prepared. They know when an immediate step needs to be taken such as closing an open incision at the first sign of an expulsive suprachoroidal hemorrhage. Because they are alert and observant and in control they notice premonitory signs of concern, such as the patient moving, changes in blood pressure, wobbliness of the lens, or shallowing of the anterior chamber. In such cases they stop, decide what action is needed and then take the appropriate action. It is usually best to slow the entire pace of the surgery at such times. It is better to do nothing rather than the wrong thing.

Control requires steadiness of the hands as well as of the emotions. If the hands are not adequately steady, it is helpful to stop, figure out why, readjust the position of the shoulders, elbows and hands, rest the hands on the patient’s face or other support, and not proceed until control is adequate. P.R. McDonald was a magnificent example of the controlled surgeon. He came to each case totally prepared. In his operating room there was no music in the background, conversation was limited to aspects dealing with the surgery or the patient, and only necessary steps and motions were made. His pace appeared to be ‘slow motion’, but his operating time per case was minimal – less than for other surgeons – because he knew exactly what he planned to do, he had fewer complications, he did things the right way the first time (such as placing sutures), he did not need to try a second time or try to undo an incorrect step. Fifty years later the methodical McDonald method is still apparent in the careful, cautious, orderly way surgery is performed and taught in the Wills Eye Institute operating rooms.

Finally, the surgeon must be in control of himself or herself. This is probably the single most important surgical principle. Good surgeons, like good athletes, know their limitations and their abilities 18. They are not timid – cutting tissues too slowly and causing additional trauma, or placing sutures so superficially they fail to hold. They are not over-confident – trying to remove a dropped lens from the vitreous through the pupil or not referring to a more skilled colleague. They do not speed up because the operating room supervisor tells them they are taking too long. They insist that the first step is right before proceeding with the second. They do not overlook complications or deny them because they are afraid or emotionally insecure, but rather recognize them and take the necessary steps to correct them. They know they are in control of the entire surgical event, because they exercise control over it and themselves.

Minimization of trauma

A fourth surgical principle is minimization of trauma. Damage to the patient and to the patient’s tissues occurs in many ways (see Box 3.2). Ironically, operating with excessive caution may actually result in a greater degree of trauma. The prolonged procedure that often characterizes the timid surgeon subjects the patient to the irritating components of irrigating solutions, airborne infection, increased contact with possibly contaminated instruments, stresses of lying immobile, and the effects of increased amounts of anesthetic agents. Furthermore, tissues that are gingerly cut will be sectioned less clearly than is optimal. On the other hand, the excessively aggressive surgeon may inflict trauma by cutting more deeply or more extensively than required, by crushing tissue, by failing to utilize proper plans, by allowing bleeding to persist, and by being unrealistic regarding his or her own surgical ability.