Perspectives in gynecologic surgery: past, present and future
© Springer-Verlag Berlin / Heidelberg 2004
Published: 10 February 2004
As health systems around the world change and financial and social demands on physicians grow, surgical gynecology as all of medicine is at a critical juncture. Shrinking funds, cuts in staff, a tougher business environment and more demanding patients all pose important problems and challenges.
Innovation is the basis of everything else. All of endoscopy is based on the continuous improvement and perfection of existing technology as well as the invention of new devices and techniques. Better endoscopic instruments, better optical and electronic systems, better intraabdominal recovery mechanisms, better distention media: innovation is key. But innovation is a tool. It is not an end in itself; rather, it enables us to achieve what we really want to do.
Another example for the paradigmatic change towards minimal trauma and organ preservation in gynecology is the evolution of breast cancer treatment. Starting with Halstead’s radical mastectomy, we have now moved to breast-conserving surgery as the new gold standard: In more than two thirds of patients with breast cancer the breast can now be conserved. Here as in other fields, progress was possible only thanks to a multimodal and multispecialty approach: breast-conserving surgery, radiation therapy, neoadjuvant and adjuvant chemotherapy, hormonal therapy and more reconstructive surgical options with autologous flaps. Many specialists, one goal: to provide the best treatment for each individual patient. And the progress continues: The sentinel node approach further minimizes surgical trauma. Interventional diagnostic techniques such as vacuum biopsies are helping to further decrease surgical trauma, particularly with benign disease.
Vaginal approach, endoscopic access (Fig. 6—endoscopic colposuspension) and breast conservation: all these developments are no coincidence but the result of a profound respect for our patients. All of these techniques were pioneered in gynecology. Gynecologic surgeons have been at the forefront of the drive for minimal trauma in surgery. Not surprisingly, endoscopy is part of most, if not all, of these new treatment strategies.
Gynecologic surgery is stronger now than it has ever been. We are able to offer our patients a variety of comprehensive diagnostic and therapeutic options for all gynecologic problems. We are able to do so because of these three pillars of modern gynecologic care: innovation, multimodality and minimal trauma. The general condition of the patient, her personal expectations and wishes such as desire for future fertility, desire for plastic reconstruction, for sexual self-esteem; all these can be taken into consideration. The wholeness and bodily integrity of our patients can be preserved and the disease can still be optimally treated.
What must be done in the years ahead? (1) Further innovation is needed to further improve existing surgical techniques. (2) We must continue to integrate our surgery into multimodal and multispecialty therapeutic concepts. (3) We must further decrease both diagnostic and therapeutic trauma to ease the pain of disease and improve the quality of life of our patients. We have to continue to push ahead our specialty on the basis of evidence-based medicine. And there are many opportunities. Today, gynecologic oncologists collaborate with radiation oncologists and oncologic surgeons; tomorrow, we will have to integrate new immunologic and molecular-biologic therapeutic solutions in our treatment approach. Today, we are pushing the limits of endoscopy; tomorrow, we will have to integrate robotics into our field.
However, this multiplicity of opportunities, of what can be done, poses new challenges. On the one hand we are seduced by the technical aspects of our field and risk ignoring the human aspects of our daily work. Let us remember that, no matter how much technology we use to cure our patients, we are also expected to care, to comfort and to console. Curing and caring remain the basis of all medical science. On the other hand, as we are successful, the expectations of our patients and of society as a whole continue to grow exponentially. We know that some of these expectations cannot be met. What we could do is not always what we can do. And what we can do is not always what we should do. That is the conflict of all medical progress. Economically, we must ask: Can society afford it? Ethically, the new therapeutic options of genetic medicine raise the question: Should society allow these new techniques?
We believe that a humane and ethical medicine, high quality of medical care and a sound financial basis do not contradict each other. Innovation can bring costs down. Minimally traumatizing surgery can decrease time spent in the hospital and preserve the ability to work. Multimodal approaches can use synergies and can help to increase productivity, also in the health sector.
Gynecologic surgery and gynecologic surgeons can be proud of their achievements. So, despite the difficult situation of our health systems as a whole, we have every reason to look forward to the future with confidence. Every challenge contains opportunities and risks. The field of gynecologic surgery as the originator of minimal invasive surgery is ready for the challenge.