How to Train as a VR Surgeon Outside a Formal Fellowship

Abstract

VR surgery is a complex procedure, requiring special training to optimize the surgeon’s decision-making process (“the brain”) and achieve the required dexterity (“the hands”). If the fellow has no possibility to be in a formal training program, he must identify experienced and accomplished VR surgeons at other institutions – often in other countries – who are willing to take them on as “unofficial” fellows. These visits are typically rather short but extremely useful as long as the mentors (tutors) honestly share their experience and the fellow is able to process all the new information and consciously build on it. Repeated visits, including to different mentors, even after the fellow has started his own career, are indispensable mileposts on the road to becoming a well-trained surgeon.

Ophthalmology residents who decide to become a VR surgeon have at least some experience in performing anterior segment surgery, mainly cataract extraction. Such a background provides a good basis for specializing in posterior segment work – but no more than a foundation for it.

Training for VR surgery is a long, indeed never-ending, process. If the ophthalmologist is fortunate enough to live in one of the few countries in which formal schooling (fellowship) is available, his path to becoming a trained VR surgeon is charted. Most residents, however, will not have access to such tried-and-tested programs and must design their training program themselves. This chapter provides guidelines for such an endeavor.¹

FormalPara Pearl

For someone aspiring to become a VR surgeon, the importance of proper training cannot be overemphasized. Without such training many operations will end in failure for the surgeon and visual loss for the patient. Repeating the same erroneous intravitreal maneuvers will predictably result in the same tragic outcome. Facing failure after failure, these surgeons will eventually give up VR surgery, at the cost of blind patients and the loss of self-confidence.

1 The “To-Do” List

Taking notes throughout the entire training process is crucial, for two reasons. (1) The human brain is not a storage facility. Instead of trying to memorize the received information, whether major strategy-related issues or useful surgical tricks, it is best to preserve them electronically, in an organized system that best suits the fellow’s own logic and allows searching. (2) There is a huge difference between active and passive knowledge; taking notes makes the learning process active, as opposed to just listening or reading, both of which are passive.

The fellow should do all of the following:

• Select an experienced and willing VR surgeon² at the fellow’s institution, who will serve as a mentor for the entire training period (see the Appendix, Part 1).

• Read the most important books and articles on VR surgery – the mentor should help with the selection process.

• Attend meetings where peers, preferably from the international community, discuss the latest development in the VR field.³

• Spend the maximum possible time with the mentor,⁴ examining patients in the outpatient department. Many a pathology will be seen and you should understand how the decision whether the condition in that particular patient is amenable for surgery is made.⁵

  • Follow the patient after PPV, preferably long term. This helps recognizing complications and their treatment, and also, in retrospect, to see whether the decision to go to surgery was correct.

• Assist in surgery as often as possible.⁶ Assisting, again, must never be spent by passively staring at the microscope or monitor (see Table 2.1). As always, the more experience gained, the easier and more useful such observing/assisting becomes.⁷

  Table 2.1 The rules of assisting/observing in VR surgery^a

• It is highly advisable to learn from more than a single surgeon, however good he is. Different surgeons have different approaches to the same problem, and, optimally, the fellow is exposed to a variety of options. Even when the fellow sees something “horrifying,” it is helpful: he now definitely knows that he will never do this in his own practice.

• The best possible scenario is to visit numerous surgeons/institutions over time.⁸ The fellow does not have to spend a lot of time with/at each; a week or 2 usually suffices. Ideally, he arrives with lots of questions, gets answers, goes home, and continues the learning process in his own practice; with time he will have more questions and then visit another surgeon for answers and for a different experience.

Q&A

Q:

How should the fellow select which other surgeons to visit and observe?

A:

The surgeon should obviously be knowledgeable – but it is equally important for him to be willing to help, answer all questions, and explain things; in short, he must not only be an experienced surgeon but also be a decent person.

• The process of observing is not restricted to what is happening inside the eye. It is also crucial to take note, among others, of the following:

  • The surgeon’s posture and seating arrangement (see Chap. 16).

  • How he holds the instruments with three, not with two, fingers (see Sect. 20.1).

  • How he hands instruments to, and accepts instruments from, the nurse while he never looks outside the microscope (see Fig. 35.1).

  • How he supports the actions of the hand performing the maneuver with his other hand (see Fig. 2.1).

• Watching unedited videotapes of surgeries performed by the fellow himself as well as by other surgeons is a great teaching tool (see Sect. 11.3).

• Once you gained some experience performing surgery yourself, find a mentor who is willing to observe you (ideally, assist you), serving as your coach. Nothing is as valuable as an experienced surgeon who shares his practical expertise with you this way – as long as he does it in optimally (see the Appendix, Part 1).

Fig. 2.1

One hand supported by the other. The surgeon is performing maneuvers in the AC: the probe must be inserted through a temporal paracentesis because it has to be held in the horizontal plane. In this particular case it means that the probe is held in the surgeon’s nondominant hand; his dominant hand is used to provide extra stability and increased precision for maneuvering with the probe

Table 2.2 provides a brief summary to help the fellow design his own training program.

Table 2.2 The elements of a self-designed VR fellowship program*

2 A Word of Caution

Those who are outside a formal fellowship program have less supervision and scrutiny over their progress assuring that they always take the next step gradually (see also Sect. 11.1). This laxity may lead to a dangerous chain of events.

• Failures, some resulting in blind eyes, accumulate. To compensate, the fellow may choose to operate on more and more such cases, which lead to more failures, which seems to reinforce the need to do more cases, a vicious cycle.

• A corollary to this rule is a fellow who is forced to take on complex trauma cases, which are way above his level of expertise, because nobody else at the institution is willing to do them (see Sect. 63.12). The fellow will (have to) try operating in these cases not because he wants to but because he is told to.

  • With each successful surgical maneuver,⁹ the fellow’s ego gets a boost, and the motivation to do more and more complex maneuvers grows.¹⁰

  • Successful completion of surgical maneuvers can subconsciously make the fellow view VR surgery as a sum of surgical maneuvers. This is normal but very dangerous and must be consciously fought, not the least by the fellow himself. VR surgery is much more than the sum of individual surgical maneuvers – it is strategy first, and tissue tactics only second (see Table 3.1).