Vascular Surgery for the General Surgeon: The Big Hurdle or the Way Forward?

As a general surgeon doing a laparoscopic hernia repair, we are all well aware of (and adequately warned to stay away from) the triangle of doom. But how many of us are trained enough to tackle any complication that we may cause with an unsuspecting placement of a tacker? How many times have we been witness to, or worse, advised an amputation in a diabetic foot case because we just ran out of options? These are just some of the avenues where vascular training could help a surgeon to become better at his/her work.

The reality of general surgery is that with too many areas of specialty under its cover and too many new gadgets entering the playing field, it has become more of “surgery in general.” Moreover with 70 to 80% graduates now seeking advanced courses, there are effectively very few real general surgeons left. In such a scenario, the general surgeon is left with a niche case load, which also includes trauma, and it is now more important than ever before that he/she learns skills which will enable him/her to stay on top of their game.

Vascular surgery provides one such avenue for both, the budding and experienced, surgeons alike. There is no organ without a blood supply and that just reiterates the fact that very general surgeon needs a “basic” level of vascular training, if not familiarity with the “advanced,” that is, endovascular procedures.

Vascular surgery was traditionally considered a component of general surgery. For example, the American Board of Surgery considered vascular surgery to be one of the nine “essential content areas” of general surgery and a general surgery trainee was supposed to “have knowledge and experience related to the diagnosis ... management, including management of complications in the essential content areas.” But that was years ago and multiple studies conducted the world over, in developing and developed countries, have shown that the “integrated training approach didn't add much to either side of the balance.” A few reasons for this may be (1) vascular surgery has grown into a vast field by itself and a few weeks of rotation don't necessarily “train” an individual in handling the complexities of blood vessels; (2) in a lot of places, endovascular work has overtaken open surgeries which again is near impossible to be understood in a short period of time and moreover, reduces the exposure to open cases; and (3) the sheer number of gadgets can be mindboggling. The list goes on and the bottom line is that one cannot train to be a surgeon without training and the same applies to becoming a vascular surgeon.

It wouldn't be wrong to say that vascular surgery enjoys a circuitry in series rather than in parallel with general surgery. In other words, vascular surgery will only broaden one's field of view. Imagine opening a case of mesenteric ischemia without the skill to tackle that superior mesenteric artery thrombus which may be a life saver for the patient or opening that gluteal mass which was reported as a deep seated collection on ultrasound without (1) the knowledge that this could be a persistent sciatic artery and (2) the skill to handle the situation. Moreover, practicing general surgery in a country like India, which is considered the diabetic capital of the world, brings on the responsibility of tackling the complications, as well as the diabetic foot, and more specifically, diabetic angiopathy. The morbidity and mortality brought on by this is something that very few of us are actually equipped to tackle.

I would like to conclude with what the famous cardiothoracic surgeon Dr. Michael DeBakey said, “You can never learn enough.” This stands good at multiple levels. For a surgeon, acquiring new skills can be a bad thing, whatever stage of life it may be. On a larger level, (1) the ratio of vascular surgeon to patients in India is appalling and this can only change by training more people and (2) we need to save the field for the sake of the surgical fraternity. The fast growing numbers of interventional radiologists and cardiologists involved in endovascular procedures, raises a lot of questions on the practice and this only can be challenged by adequately and appropriately training more surgeons.