The surgeon’s solitude

Have you ever felt lonely? I’m not talking about lacking company.

I mean facing nothingness head-on.

Nothingness – by Julio Mayol

It’s that feeling of emptiness and silence, when guidelines, clinical sessions, and even the opinions of the most experienced colleagues no longer matter.

It’s the solitude of an individual who must make a decision about another person’s life in a matter of seconds, when the unthinkable happens. When you’re terrified but know you can’t walk away.

Whipple Procedure.

I slip a clamp behind the pancreas, detach it from the portal vein, and…

«Damn! I’ve broken something!»

Everything fills with red fluid.


I try to clamp it shut to make it stop.


But it tears further.

«Damn it all!» – fear makes me shout.

A viscous lake starts to emerge from the laparotomy, visible even to the anesthetist, who keeps administering more crystalloid solution to the patient because the blood pressure drops abruptly.

He looks at me.

Eyes filled with fear.

Agitation and nervousness.


And deep inside me.

«I’m sorry. I know. I’m sorry!»

Here, evidence-based medicine doesn’t hold its ground anymore.

«I have to handle this,» I think.

  • «It’s going to bleed a lot!» – I softly whisper – «A lot! Keep it steady, no matter what! I’ll hold it!»

But within oneself, everything starts to accelerate.

And you’re alone.

Your ears are ringing.

Your legs are trembling.

But you’re alone.

You can’t tell anyone.

And they can barely support you; they’re weak.

The heart races.

Very fast.


Breathing is almost painful.

The air burns.

Now they don’t ring, they just buzz. Your ears.

Sounds from anywhere but your head are inaudible. They’re like senseless whispers.

You’re alone.

You either control it or everything ends.

You’re there. But alone!

That’s the solitude I’m referring to.

That exhausting black hole.

In that void, some learn to distinguish what’s essential from what’s accessory.

Others might even see my heart pounding through my chest.

Surgery and LLMs

Large language models have recently emerged as powerful AI technology with many potential applications. Surgical practice might benefit from its use. Therefore, I decided to investigate what two widely available chatbots, ChatGPT and BingGPT, based on GPT3.5 and GPT4 respectively, had to say.

Surgeons. Digital art by Julio Mayol

My prompt to ChatGPT was: Why and how can LLM be used in surgical practice?

Its response:

Large Language Models (LLMs), such as GPT-3 and GPT-4, can be used in surgical practice in a variety of ways to support surgeons and enhance patient care. Here are a few reasons why LLMs can be valuable in surgical practice:

  1. Knowledge retrieval and decision support: LLMs have access to vast amounts of medical literature and information. Surgeons can use LLMs to retrieve relevant research articles, guidelines, and clinical data to support decision-making during preoperative planning, intraoperative situations, and postoperative care. LLMs can provide up-to-date information on surgical techniques, complications, and treatment options, assisting surgeons in making well-informed decisions.
  2. Education and training: LLMs can be valuable educational tools for surgeons in training. They can provide access to a wide range of surgical knowledge, case studies, and procedural guidelines. Surgeons can interact with LLMs to ask questions, practice virtual simulations, and receive feedback, which can help enhance their surgical skills and knowledge.
  3. Natural language interfaces: LLMs can serve as natural language interfaces for surgical documentation and reporting. Surgeons can dictate operative notes, postoperative reports, and other clinical documentation, and LLMs can transcribe and format the information accurately. This can save time and effort for surgeons, allowing them to focus more on patient care.
  4. Clinical decision support systems: LLMs can be integrated into clinical decision support systems that provide real-time recommendations and alerts based on patient-specific data. By analyzing patient information, LLMs can assist in predicting surgical outcomes, identifying potential complications, and suggesting personalized treatment plans.

It is important to note that while LLMs can provide valuable support in surgical practice, they are not meant to replace the expertise and judgment of surgeons. They are tools that can augment and assist surgeons in their decision-making and knowledge acquisition process.

Additionally, the implementation of LLMs in surgical practice should consider factors such as data privacy and security, ethical considerations, and the need for validation and verification of the information provided by the models.

Overall, the use of LLMs in surgical practice has the potential to improve patient care, enhance surgical decision-making, and support the ongoing education and development of surgeons.

The GPT4 response to the same prompt:

Why and how can Large Language Models be used in surgical practice?

Large Language Models (LLMs) are artificial intelligence systems that can generate natural language texts based on a given input, such as a prompt, a query, or a context. LLMs can be used in surgical practice for various purposes, such as:

  • Providing pre-operative information and instructions to patients and their families, such as the risks and benefits of the surgery, the preparation steps, and the recovery process.
  • Generating operative reports and summaries based on the surgical data and images, such as the type and duration of the surgery, the instruments and materials used, the complications and outcomes, and the recommendations for follow-up care.
  • Enhancing surgical education and training by creating realistic scenarios and cases for simulation and assessment, such as the anatomy and pathology of the patient, the surgical plan and technique, and the possible challenges and errors.
  • Supporting surgical decision making and innovation by generating suggestions and alternatives based on the current evidence and best practices, such as the optimal surgical approach, the most suitable device or implant, and the potential improvements or modifications.

LLMs can be used in surgical practice by integrating them with other technologies and platforms, such as voice assistants, chatbots, electronic health records, surgical robots, and augmented reality devices. LLMs can also be customized and fine-tuned for specific surgical domains and tasks, such as orthopedic surgery, neurosurgery, or cardiac surgery.

LLMs have the potential to improve the quality and efficiency of surgical practice by providing accurate and timely information, reducing documentation workload, enhancing learning and skill development, and facilitating creativity and innovation. However, LLMs also pose some challenges and limitations, such as ensuring their reliability, validity, safety, ethics, and accountability. Therefore, LLMs should be used in surgical practice with caution and supervision, and in collaboration with human experts.

Invited post by Dr. Ameera AlHasan: #SoMe4Surgery, a global community for all

Non sibi sed omnibus- Not for oneself, but for all

As you may already know, SoMe4Surgery celebrated its first birthday on the 28th of July 2019. More than a year has now passed since the birth of this dynamic surgical community and yet it continues to grow and flourish. As 2019 draws to a close, we take the opportunity to briefly reflect on what this year has brought to SoMe4Surgery and what we have to look forward to next year.

Fabulous factions and stellar societies

In keeping with the global trend of subspecialization in surgery, SoMe4Surgery has seen a rapid proliferation in the number of subgroups dedicated to various aspects of surgical practice. These range from broad specialties such as colorectal surgery, trauma and hepatopancreaticobiliary to finer and more specific fields like peritoneal surgery and bariatrics. Whatever your passion may be, you are bound to find the right surgical family to adopt you and your ideas. Just add the prefix SoMe4 and prepare to be amazed at what you will find in the treasure trove of Twitter societies at your disposal; these include exquisite rarities like mechanical ventilation, artificial intelligence in surgery, and genetic risk in cancer. And if, for some reason or another, you cannot find your El Dorado, you have the liberty to create one yourself complete with the blessings of the bigger SoMe4Surgery family.

The road to SMSS19

Perhaps the most memorable accomplishment in 2019 was the realization of the first SoMe4Surgery Summit in Madrid, now considered the surgical world’s Santiago de Compostela. Surgeons from all around the world flocked to Hospital Clinico San Carlos to participate by presenting and promoting their SoMe4Surgery experience. For those who could not physically make it, geography was no deterrent as they joined the virtual pilgrimage via live transmission online in what was an enjoyable and productive scientific journey. To celebrate the success of the day, participants later convened to dine and propose a toast in an evening that was christened SoMe4Fun.

You yourself can catch up on the details of that magical gathering and relive the excitement by looking up the hashtag #SMSS19 on Twitter. The event was a true testimony to the feasibility of virtualizing and subsequently de-virtualizing scientific and social networks.

Strength in solidarity

If you cannot go to SoMe4Surgery, then SoMe4Surgery will come to you. As surgeons recognize the importance of collaborating and sharing information and experiences in the 21st century, we have seen the hashtag #SoMe4Surgery being used alongside other hashtags in numerous conferences around the world; to name but a few: the American College of Surgeons Clinical Congress 2019, the European Society of Coloproctology Congress 2019 in Vienna, the Mexican General Surgery Association and the AIS Channel’s live colorectal surgery event. From workshops in cities as brilliant as Barcelona, as hot as Kuwait and as distant as Manila, you will find tweets that boast an intimate connection with SoMe4Surgery. Such collaborations have amplified the impact these conferences exert and have taken surgical knowledge where it has never gone before.

Power through publishing

While we will not attempt to list here the individual publications that have transpired through collaborative efforts within the SoMe4Surgery community, it suffices to mention that what once started as a tweet can now be found peer-reviewed and officially published in a number of reputable surgical journals. Real science mandates communication and cooperation and SoMe4Surgery provides a fertile ground to do just that. The power of the written word should not be underestimated and to generate meaningful publications has always been one of our goals.

Bilingual beyond borders

What Latin was to medicine in antiquity, English has become today. However, while English may be the lingua franca of our trade, this should not put the millions of non—English speaking professionals in the world at a disadvantage. This is why SoMe4Surgery now tweets in both English and Spanish culminating in an exponentially growing Hispanic surgical community that avidly shares its expertise. We hope to transcend language barriers through the help of multilingual colleagues as well as AI powered translators online. In defiance of philosopher Ludwig Wittgenstein’s infamous statement, at SoMe4Surgery, the limits of our language are not the limits of our world.

To infinity and beyond

“You have done so much with SoMe4Surgery already, what more is there to do?” you may ask.

While we cannot physically turn lead into gold, nor do we possess a crystal ball to foretell the exact future, we can make you one big promise though, and that is to continue to support surgeons, healthcare professionals and patients all around the world. Our alchemy lies in our ability to amalgamate the knowledge and expertise of everyone in SoMe4Surgery to create an ideal model of safe and scientifically sound surgical practice. Wherever you are, once you use the hashtag #SoMe4Surgery, we will find you and we will endorse you in whatever way we can.

We will continue to engage in active mentorship, to host educational activities on Twitter, to recruit colleagues and to share our experiences and discoveries through publications or otherwise, for the benefit of all-non sibi sed omnibus. Finally, we hope to see you all at the SoMe4Surgery Summit 2020, SMSS20.

*We would like to thank everyone who has been a member of this magnificent community, our pioneer surgeons who have continued to enrich our careers online as well as offline (including Professors Kenneth Mattox and Steven Wexner) and all the surgical journals and societies that have supported us unconditionally this year. We wish you and your families a safe and happy festive season, and a prosperous 2020, with SoMe4Surgery of course!

Invited post by Vahagn Nikolian: Telemedicine in the Future of Surgery

As wide spread adoption of technology has increased in our daily lives, so too has the arsenal of options physicians have to utilize and implement technology to take care of patients. Telemedicine, or the “use of electronic information and communication technologies to provide and support health care,” has resulted in improved access to care, increased resource efficiency, and decreased costs associated with routine health care. Given the promise for this resource, it is expected that the telemedicine market will demonstrate annual growth rates ranging between 20-50% for the foreseeable future.

Vahagn Nikolian MD – @VNikolian on Twitter
Fellow at @NYPHospital @ColumbiaSurgery Comprehensive Hernia Center

            Surgeons have utilized telemedicine in a variety of ways over the last decade. Pre- and post-operative patient evaluations utilizing telemedicine has become common in private practice and academic settings. Without a doubt, the accomplishments of the US Department of Veterans Affairs (VA) stands as the most impressive implementation of telemedicine technology. Annual VA Video Visits exceed more than 1 million regularly, with continued growth and allotment of resources expected for the next few years. Within the surgical patient population, the VA has demonstrated safety and feasibility in applying telemedicine to patients undergoing general, urologic, neurosurgical, plastic, obstetric, and gynecologic procedures.

            When considering new technologies, one must consider all stake holders and understand the impact that a deviation from the norm may have. Multiple studies analyzing patient satisfaction, time away from work, travel time, etc. have shown that patients are pleased with telemedicine encounters surrounding surgical care. Further, health care systems have demonstrated cost savings associated with implementation of telemedicine programs. For surgeons, telemedicine can provide an efficient means of evaluating patients and coordinating care. As the technology develops, utility in both rural and metropolitan settings must be assess to identify who would benefit most from these encounters.

            For telemedicine to continue to grow, concerns related to ethics of the platform must be scrutinized and overcome. The system must develop in a manner to ensure that health care data breaches are guarded against such that patients and providers are confident in the privacy and security of programs. Beyond cyber-security, other barriers hinder the widespread adoption of telemedicine platforms. First, licensure and practice laws for health professionals must be adopted that allow surgeons to more easily interact and take care of patients across state and, eventually, international borders. Additionally, reimbursement strategies must be reformatted to allow for patients to be evaluated without physically being in the same place as their provider. At the national level, enthusiasm for telemedicine is increasing, and reimbursement related to origination site requirements and definitions of rural qualifications have been updated to make telemedicine encounters more broadly applicable.

            In conclusion, telemedicine in surgery has received significant attention as patient satisfaction, decreased wait times, cost saving for both patients and health care systems have been demonstrated. With an emphasis on the patient and physician experience, telemedicine stands as an expected and natural evolution of surgical care. Moving forward, barriers at the local, regional, and national level must be overcome to allow for widespread dissemination and implementation of telemedicine in surgery. 

Global Mentors – Mentores Globales

I was quite lucky. Not two, but three mentors I met along my training years.

  1. Jesús Alvarez Fernández-Represa
  2. Julio García-Aguilar
  3. Jeffrey B. Matthews

Being in the right place at the right time was the secret of my success. However, many others are not so lucky.

That is the reason why I have created a list on Twitter, which is directly related with the #SoMe4Surgery community: Global Mentors

Senior surgeons on Twitter who express their interest in becoming #GlobalMentors will be included in the list.

Surgical trainees just need to subscribe and connect with the #SoMe4Surgery mentors in the list.

No matter where in the world they are, trainees will find the right mentor to support their professional development. Mentors will find the right mentee.

With Jeffrey B. Matthews, J
ulio Garcia-Aguilar and Richard Hodin: the Boston’s Beth Israel Hospital/Hospital Clinico San Carlos Mentoring team

Global surgeons: Prof. O. James Garden

Edinburgh, 8th of June 2019, Prof. O. James Garden retires as chairman of the BJS Society.

Prof. Derek Alderson (left), president of the Royal College of Surgeons, and Prof. James Garden (right)

Looking back, I recall that on the 9th of May 2012, being Prof. O James Garden the honorary secretary of the BJS Society, I was appointed to the editorial board of the BJS. And over the following seven years I have had a meteoric career to become secretary of the BJS Society in June 2018.

Consequently, you might think that what I am about to say is biased, but I must warn you that you would be severely mistaken, because he has been the epitome of a global surgeon long before I even dreamed of becoming part of the BJS community.

Prof. O. J. Garden is an outstanding surgeon, researcher, educator and manager, but as you can read in The University of Edinburgh webpage, retired from clinical practice in the summer of 2018. Even so, he has remained committed to surgical research dissemination and global surgical training for longer.

Over the last two years, given my role as secretary, I have had the privilege of witnessing his chairmanship of the BJS Society. An extraordinary thinker and strategist, with a strong commitment towards the advancement of our two journals, BJS and BJS Open, and the promotion of global surgical training, James Garden will be deeply missed by all of us in the BJS Executive and Council, but be sure he will always be available if we need him.

Thanks a lot Prof. O.J. Garden. Live long and prosper.

Global surgeons

A brief reunion at #DDW19 in San Diego led me to give some thought to posting regularly about some surgeons who are currently in practice, no matter where in the world, and who I admire for their global impact on one or more of the following areas:

  1. Professional leadership
  2. Surgical research
  3. Education and training
  4. Technology and innovation
  5. Knowledge dissemination

So here I am, almost ready to start. Stay tuned for upcoming posts.

With Jeff Matthews, Julio García-Aguilar and Rich Hodin

What I’ve learnt on my second day at #SSAT19

Today has been an intense and long day at #SSAT19: plenary sessions, Foundation awards, presidential address, editorial board meeting, etc.

However, these are the things that come to my mind when I try to recall what I’ve learnt:

The SSAT must be transformed to meet new challenges and generate new opportunities for academic surgeons.

Obesity and bacteria are clearly linked. In mice.

IBD is linked to microbiota.

Bacteria have refined their genetic code for longer than humans. They may outsmart us.

Chemotherapy toxicity may be influenced by intestinal bacteria.

Microbiome may play a role in pancreatic cancer.

John Alverdy is THE expert surgeon in microbiome.

We must solve complex problems because the easy ones are already fixed (Marc Nivet)

Residents and younger surgeons include their Twitter handles in their presentations.

In order to achieve transformation one must challenge his/her biases, get comfortable with being uncomfortable, interrupt the usual, and be curious.

What I’ve learnt today at #SSAT19

On the first day of the #SSAT19 meeting, two of the most important take-home messages came from a a retired surgeon, Prof. Christopher Ellison:

  1. You’re only old once,
  2. You never retire too early.

Robin McLeod has reminded us that the role of women in surgery is… the same as it is for a man.

Alberto Ferreres has pointed out that surgery is a moral practice, guided by three values: self-sacrifice, altruism and unselfishness.

Sachiyo Nomura has showed us how it is possible to manage a perfect balance between workload and well being in Japan.

Finally, Bruno Silverstein has reflected on the moral injuries that surgery inflicts on surgeons and, subsequently, lead to burntout.

ESCP 2015

Hoy ha acabado el Congreso de la European Society of Coloproctology, que se ha celebrado en Dublín del 23 al 25 de Septiembre. Afortunadamente, tanto el contenido científico del congreso como el tiempo en Irlanda han sido muy favorables.


Científicamente, la combinación de nuevas técnicas para el tratamiento de los tumores rectales junto con los continuos debates sobre la preparación mecánica del colon para la cirugía electiva del cáncer colorrectal y su impacto en los resultados a corto y largo plazo ha sido la adecuada para mantener la atención de una nutrida asistencia de cirujanos colorrectales de toda Europa.

Resulta interesante observar el gran empuje científico y comercial por desarrollar técnicas y dispositivos que faciliten el abordaje mínimamente invasivo y transanal a los tumores rectales. TEM/TEO y TAMIS son las grandes opciones que se debaten, con indicaciones muy dependientes de la destreza del grupo que lo usa. Y en debate continuo con la resección en «sacabocados» de la endoscopia.

Sin embargo, seguimos con las mismas barreras en cuanto a la correcta estadificación tumoral y la estratificación del riesgo de los pacientes con este tipo de tumores. Los métodos de imagen tienen limitaciones importantes a la hora de ofrecernos información sobre la afectación tumoral de los ganglios linfáticos en el cáncer de recto. Y además, los cambios postquirúrgicos también dificultan la valoración de la recidiva.

El lugar de la plataforma Da Vinci en cirugía colorrectal sigue siendo objeto de análisis con resultados consistentes: no ofrece ventajas significativas a los pacientes.

La preparación mecánica para cirugía del cáncer de colon parecía clara, pero están surgiendo estudios que la cuestionan por los peores resultados de supervivencia a largo plazo en aquellos que se omitió. ¿La causa? Se desconoce. Es una mera observación. Sin embargo, en el cáncer de recto sigue considerándose necesario realizar preparación intestinal.

Interesante fue también el debate sobre la cirugía paliativa, al final de la vida. El análisis ético y humano resultó impecable, pero con escasas pruebas de calidad que ofrecer.

Además, y entre los eventos sociales, hay que destacar el nombramiento de Steven Wexner como miembro de honor de la European Society of Coloproctology. Steven Wexner es uno de los cirujanos colorrectales más prolíficos surgidos de la escuela de Stanley Goldberg en Minneapolis.


En resumen, puedo decir que he disfrutado del congreso y de algunas estupendas presentaciones, pero que vuelvo desilusionado porque los problemas principales no terminan de resolverse. Y ando un poco cansado de escuchar eso de «more research is needed». Por supuesto que se necesita más investigación. Pero si tu trabajo necesita más investigación es que no ha servido para responder a la hipótesis o pregunta científica que te llevó a realizarlo.

Y para empezar, o finalizar, la Hakarena, coincidiendo con el Mundial de Rugby