Scarless surgery: a warning for shortcut history-taking

Abstract

The examination of the abdomen from the end of the bed provides vital information to the medical student and the clinician alike. It can give a picture of the problems inside from its size, shape and sometimes even its colour before palpation. Since the first successful laparotomy in the early 1800s by Ephraim McDowell,1 the midline scar seen from the end of the bed examination of the abdomen has been a good indicator to the clinician that the patient has had a previous surgical procedure. The tell-tale signs of exact surgical procedures were apparent from the location of a scar such as the Kocher's incision for an open cholecystectomy or McBurney's incision for an open appendicectomy. As surgical innovation and technology advance,the skills involved in deciphering a patient's previous operations are going back to first principles. The first laparoscopic cholecystectomy dates back to 1985 over 100 years after the first open procedure.2 As we have just begun to be familiar with the locations of laparoscopic scars for various procedures, single incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) for common procedures have now come into play. The first NOTES procedure demonstrated that abdominal surgical interventions can be carried without abdominal wall incisions.3 Shortly after that the first transvaginal cholecystectomy was reported in 2007 by Zorron et al.4 Hence, the common scars once seen are now disappearing. The goal, especially for medical students and junior surgical trainees, is to understand the presentation of surgical disease.5 Medical students easily get distracted with the primary skill they are required to master is the physical examination. Without effective history-taking it is not possible to elicit the necessary signs to make differential diagnoses. Learning about patients as clinicians still comes from the history that we take which captures not only the physical problems but also sometimes the underlying psychological concerns. We naturally learn through story-telling when we present our patients to others or as we live our own lives. The history-taking and presenting forms an integral part of medicine. Data processing to make a diagnosis comes from taking the story and the history of the story. Our observational skills go hand in hand with the stories that form part of our life cycle. Hence, clinical reasoning can be challenging without a proper history. The history-taking is not only about making a diagnosis but also being able to communicate and build rapport with your patient. The multidisciplinary approach to patient care relies heavily on the history elicited by different health professionals and the communication between them is all about ‘story-telling’. Invariably, listening to the patient's story usually reveals the answer. The examination and investigation part of our management is guided by the story. History teaches us many things, once bitten with brief history-taking when examining a patient that has undergone a SILS or NOTES procedure the individual will not shy away from taking a full history next time. A change to medical history-taking is yet to come, till a chip-and-pin approach to medical notes becomes commonplace, clinicians have to rely on the patient's memory to recall parts of their anatomy removed. The evolution of operative surgery means the telling tales of the long lines of surgical incisions will be no more. Hunting the facts of human activity can lead to profound understanding.6 The approach to patient management will continue for a while yet to be in the traditional three-step approach of history, examination and diagnostic tests.7 Despite the sophistication and innovation of technology as scarless surgery and robotic surgical procedures become the norm in the future, taking the patient's history has no short cuts. The emphasis from clinical teachers should continue to be history before examination.