REVIEW ARTICLE Theatre of paediatric surgery Craig A McBride 1,2 and Andrew JA Holland 3 1 Department of Paediatric Surgery, Stuart Pegg Paediatric Burns Centre, Royal Children’s Hospital, Brisbane, 2 Centre for Children’s Burns and Trauma Research, Queensland Children’s Medical Research Institute, University of Queensland, Brisbane, Queensland, 3 The Children’s Hospital at Westmead Burns Research Institute, Burns Unit and Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia Abstract: In the 50 years since the first edition of this journal, operative paediatric surgery has undergone radical change. Many of the most common instruments are unchanged, both as a testament to their utility and in recognition of past surgeons remembered eponymously. Surrounding that basic core of instruments, theatre has changed radically as new tools and techniques have arisen. Surgeons have come down from their pedestals, recognising surgery as a team sport rather than a solo performance. More than half of the current paediatric surgical trainees are women, a higher proportion than in any other craft group of the Royal Australasian College of Surgeons. The appearance, and rapid development, of laparoscopy is to many observers the most notable change in surgery over the last 50 years. Placed in its context though, it is simply the most prominent example of a frameshift in surgical thinking. The patient as a whole is now the focus, rather than just the disease. Recent developments are as much about minimising harm to normal tissues as they are about extirpating pathology. As a surgical maxim, ‘Primum non nocere’ is even more in evidence in 2015 than it was in 1965. Key words: history of medicine; minimally invasive; neonatal surgery; paediatric surgery; surgical procedures. I can practice in an honorary fashion the arts of surgery and medicine. Being temperamentally inclined to precision and a sharp edge, it might be thought that I should choose the surgeon’s role. Winston S. Churchill (1874–1965) The operating theatre is a stage, and operations are its perfor- mances. The initiated are comfortable in this performance, but it is an intimidating place for the novice. Like any complex envi- ronment, theatre is codified by routines. Familiarity with these routines draws one into the company. Paediatric surgeon Peter Jones was one of the two foundation editors of this journal (the other, paediatric gastroenterologist Charlotte Anderson). He was at home on this stage, but it is doubtful he would have been as comfortable in theatre now; such has been the magnitude of change in the last half century. Appendicitis is essentially unchanged compared with 50 years ago, and many common surgical instruments retain their name and appearance. Many retired surgeons would not now recog- nise some of the equipment, or the systems and technologies, that are a quotidian part of a contemporary operating theatre (Figs 1,2). Even something as seemingly immutable as anatomi- cal understanding has undergone change and challenge in the last half-century. 1 Systems and Personnel Changes Is there any way you can be of help in this operation, besides leaving the room? Michael E. DeBakey (1908–2008) Fifty years ago the surgeon was in charge in the operating theatre. The title ‘doctor’ in general, and ‘surgeon’ in particular, conveyed an unassailable infallibility. A surgeon’s demands were called ‘doctors orders’ for a reason: it was inconceivable they would be doubted or questioned by other members of staff. Hierarchies were precipitous. Surgery was practiced, and patients were practised upon. The grand tradition of ‘see one, do one, teach one’ was in ascendancy. Supervision was variable, and simulation had yet to appear. Instead, surgical doctors were Key Points 1 Contemporary paediatric surgery is overtly team-based, rather than an individual pursuit. 2 Advances in operative paediatric surgery are focused on mini- mising risk and harm. 3 Intra-operative advances are driven by increased demands from the ward, and in turn drive what is possible outside theatre. Correspondence: Dr Craig A McBride, Department of Paediatrics and Child Health, University of Queensland, Level 3, Royal Children’s Hospital, Herston Road, Herston, Qld. 4029, Australia. Fax: +61 7 3636 1977; email: craig_mcbride@health.qld.gov.au Conflict of interest: Each author has contributed to the manuscript as per ICMJE guidelines. Neither author has any affiliation with companies produc- ing any product mentioned in the manuscript. There are no financial or other interests to declare. Accepted for publication 22 February 2014. doi:10.1111/jpc.12810 Journal of Paediatrics and Child Health 51 (2015) 98–102 © 2015 The Authors Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians). 98