Surgeons at Macquarie University Hospital who operate in pairs say that the model brings immense benefits to patients having complex procedures.

While Medicare recognises a surgeon having an assistant operator, it doesn’t recognise a model where two surgeons, literally, co-operate. Yet, for many surgeons, the idea of two experts working together – rather than a single expert and assistant or trainee – is one that they believe brings immense benefits to both patient and surgeon.

The point of difference with cooperating, says Professor John Cartmill, is that you’re not alone performing complex surgery. You have a colleague of equal training and experience, genuinely interested and taking the same high level of responsibility as you.

“Operating in pairs means an equal level of commitment and the ability to equally substitute at different points in a complex procedure,” said Professor Cartmill, Colorectal Surgeon at Macquarie University Hospital. “The shared position of leadership takes the pressure off a surgeon as the single, lone decision-maker. And this has to be a good thing in terms of patient outcomes.”

The Australian and New Zealand College of Surgeons recognises this co-operative approach, allocating Continuing Medical Education points when surgery is done this way.Several surgeons at Macquarie University Hospital have built their practices around being able to operate in pairs in particularly demanding

In the Macquarie University Hospital colorectal unit Dr Anil Keshava and Dr Matthew Rickard have operated together for some time. Professor Cartmill started co-operating with Dr Andrew Gilmore when he first came to the Hospital. Since then other pairingshave sprung up including Dr Sam Kuo and Dr Sameer Mihrshahi. Indeed almost all complex gastrointestinal surgery at Macquarie University Hospital is performed co-operatively between two experts.

Dr Gilmore, who is committed to surgical innovation, says that there is no denying that surgery can be stressful and that ameliorating this in difficult situations is worth looking at.

“Stress response comes from the amygdala in the brain and, if the amygdala is firing, then frontal lobe function is suppressed,” said Dr Gilmore. “Anything we do to minimise stress will enhance frontal lobe function and, as such, decision-making and planning. “Family worries, running late, fatigue, patient bleeding – these are all things that add to stress. Operating with a colleague you respect in a co-operative manner undoubtedly lowers this stress.”

Those surgeons who operate regularly in pairs are more than convinced that the outcomes for patients are better. They see everything from shorter anaesthetic times, to more adept tissue handling and better postoperative morbidity rates.

“I know that when I operated in Orange, the anaesthetists there liked this approach for the pure time-related efficiency of the procedures,” added Dr Gilmore. “They felt great ease by seeing two surgeons working together. This worked very well for ruptured abdominal aortic aneurysms (AAA) in particular in Orange and the survival rate is very good there for this reason.”

The key to the success of this model is the essential respect that the two surgeons must have for one another.

“The way John and I work at Macquarie University Hospital, we have two surgeons who respect each other and recognise each other’s expertise and enjoy the combined creative learning experience,” explained Dr Gilmore.

“I feel so much more relaxed knowing I have a built-in decisionmaking and checking mechanism standing opposite me in the room. The quality of the surgery is excellent, efficient and, ultimately, to the patient’s great advantage.” Dr Rickard, who co-operates with Dr Keshava, also emphasises that the approach only works if you are with a colleague you like and trust.

“Anil and I know each other very well and we often switch back and forth as primary operators without any verbal communication. Together, you can better anticipate the postoperative outcomes for the patient when things get tough in theatre.

“An assistant who is there to get paid, or a trainee, frequently has a different level of interest and commitment to that patient’s outcome. More often than not, if you need to take over a case from a trainee, they stop actively assisting. This does not happen with another surgeon as assistant.”

Dr Keshava says that operating in pairs allows the second surgeon to provide an objective distance. “When we operate on people, we know about their families, their psychosocial situation, their expectations,” he said. “It is expected that these factors are pushed aside when we operate on people, but I don’t think it is a small thing. “I often tell Matt that I operate better on his patients than mine.

I think my movements are bolder, I feel that I think more clearly and possibly have more ‘guts’ in difficult situations when operating on his patients. Personally, I am reassured having Matt there if it is my patient, knowing he does not have the same emotional attachment with the patient.”

surgeons have done individually, they can benefit from assisting someone else who is also at the top of their game in doing an operation that they know well. Even at an advanced level,surgeons can pick up and develop new skills and techniques by operating on patients together.

“Certain motor movements need to be relearned and fine tuned,” said Dr Keshava. “This applies as much to us as surgeons as it does for an international batsman when they are out of form. Since working with Andrew last year, I have been re-introduced to the ‘right angle’, which I use a lot more now.”

Surgeon care and satisfaction are also part of the reason this approach is appealing.

“It is also extremely efficient for our work–life balance to be able to assist each other and do rounds for each other’s patients,” explained Dr Rickard. “It allows open communication and also does not allow us to ‘hide’ morbidity that may occur.

“Some of our colleagues finishtheir training and never see another surgeon operate. Since coming to MUH and operating with Anil, my work satisfaction has increased extraordinarily.” Associate Professor Tillman Boesel, an anaesthetist at Macquarie University Hospital, says that the two surgeon model is a major paradigm shift.

“I think that the synergies create a whole that is significantly greater than the sum of its parts,” he said. “Outside the technical and patient outcome aspects the most interesting thing is the change in decision-making and problem-solving. The sharing of responsibility seems to help a lot in this regard.”