Go back to article: A symposium on histories of use and tacit skills

Roger Kneebone: Recapturing a surgical past

My contribution considers how tacit, embodied forms of knowing might be made visible through re-enactment, and how objects might act as prompts for collective recollection by teams of professionals. The work is based on a research project (funded by the Wellcome Trust) in which I used physical simulation to recreate the conditions of surgery, bringing together teams of long-retired clinicians to reprise the kind of procedure they used to perform.

A word of introduction may be helpful here. After qualifying in medicine, I trained as a general and trauma surgeon in the 1980s, completing my specialist training at a time when almost all major operations were carried out by ‘open’ surgery under general anaesthesia. During an abdominal operation, say, an incision in the patient’s skin would give direct access to internal organs, allowing the surgical team to see and deal with anatomical structures and their abnormalities. In the late 1980s, however, an entirely different approach – minimal access or ‘keyhole’ surgery – was pioneered, radically changing how many procedures were performed. Here small instruments and tiny cameras were introduced through puncture sites, avoiding the need for large incisions and greatly reducing recovery time. Such techniques quickly became adopted, and now many procedures (such as removal of the gallbladder) are seldom if ever performed by open surgery.

The 1980s therefore provide an intriguing moment in surgical history, where one form of surgery was about to give way to another, and where many clinicians who straddled that transition point are still alive today. Yet accounts in the surgical literature are concerned largely with the clinical outcomes of new forms of treatment, giving little insight into how surgical procedures were actually performed or into the processes by which such innovations were adopted.

A major challenge is the difficulty of articulating those ways of knowing which cannot easily be captured in words. As in many expert domains, experienced surgeons develop a tactile awareness, a sense of the affordances of the materials they work with – in this case, living human tissue and the instruments and materials of surgery. This awareness is gained through long experience of operating and is almost impossible to describe.

After interviewing many long-retired surgical team members I realised that much of what I hoped to document defied verbal description. At the same time, I came to recognise that surgical knowing is not individually held but is collective, shared between surgeons, assistants, scrub nurses, anaesthetists and the myriad other members of any surgical team. I therefore designed a series of simulations, inviting retired teams (who had worked together for years or decades before retirement) to come together and re-enact surgical procedures using authentic instruments and materials from the time. Simulation is well established in clinical education, but is chiefly a means for clinicians to learn and practise current procedures and techniques. This project’s use of simulation as a means of documenting surgical practices from the recent past is a methodological innovation.

Figure 9

Colour photograph of a hospital surgery room diorama inside a museum exhibition

Lower Wellcome Gallery’s 1980s operating theatre

For more than three decades until 2016, the Science Museum’s Lower Wellcome Gallery included a life-size replica of an operating theatre, created in 1980 to show the latest in surgical technology at that time. Fully equipped with surgical and anaesthetic equipment, this ‘room set’ had remained all but untouched since its installation. The Museum gave me permission to invite surgical teams to re-enact procedures there. This provided an unusual opportunity to observe and film highly experienced teams as they went back in time. Much of what they did during these simulated operations took place beyond their conscious awareness, and on analysis of video recordings I was greatly struck by the way in which instruments were passed effortlessly between surgeons and nurse without the need for explicit requests.

Initial re-enactments with a long-retired surgical team (surgeon Professor Harold Ellis, anaesthetist Professor Stanley Feldman and Theatre Sister Mary Neiland) focused on removal of the gallbladder (open cholecystectomy), a commonly-performed operation which formed an essential part of every general surgeon’s repertoire. Post-simulation interviews with the participants showed that re-enacting this procedure, even after a gap of decades, prompted unexpected recollections of how they had once worked together and provided a glimpse into an otherwise undocumented past.

Further re-enactments focused on the early days of keyhole surgery, working with pioneers in the field (led by urologist Mr John Wickham and radiologist Dr Mike Kellett). In contrast to the team carrying out an operation that had remained stable for over fifty years (open cholecystectomy), the keyhole surgery innovators recalled having to improvise, to develop new instruments, to come up with creative solutions to unexpected problems and to develop a cohesive team of surgeon, scrub nurse, interventional radiologist and surgical instrument designer who worked together on equal terms – a radical change from traditional leadership models. Again, the process of physical re-enactment acted as a prompt to subsequent recollection, triggering memories which led from individual instruments and items of equipment to more general discussions about the events and challenges of the time.

A third exploration addressed some of the ‘dead ends and blind alleys’ of surgical innovation, the operations that were developed but never caught on because they were quickly superseded during times of rapid development, with new techniques emerging all around. For example, in the late 1980s Wickham worked closely with hepatobiliary surgeon Mr Chris Russell on the technique of laparoscopic cholecystotomy, or removal of gallstones while leaving the gallbladder inside. After performing a successful series of almost one hundred such procedures the team abandoned this approach when surgeons from France demonstrated that removal of the entire gallbladder by keyhole surgery was safe and effective (thereby eliminating the chance of gallstone recurrence). Yet the rapidity of innovation at that time meant that such approaches were little documented and rapidly disappeared from view. Simulation-based re-enactment proved effective in prompting the team’s collective recollections of that time, documenting perspectives that have eluded capture by other means.

Figure 10

Colour photograph of a simulation based reenactment of a surgical procedure carried out by numerous medical staff

Simulation-based re-enactment of open cholecystectomy with Prof Harold Ellis and colleagues

Figure 11

Colour photograph of a simulation based reenactment of a surgical procedure carried out by numerous medical staff

‘Dead ends and blind alleys.’ Re-enacting laparoscopic cholecystostomy with the late Mr John Wickham and colleagues

These simulations were designed largely for ‘insiders’ in surgery and medical history, allowing them to document the processes of surgical teamwork and record the histories of objects through use. Such objects included both established surgical instruments and emerging technology which at the time was entirely new. Leading on from these initial simulations, a subsequent project, the ‘Time Travelling Operating Theatre (TTOT)’ shifted focus from ‘insiders’ to ‘outsiders’ (patients and publics). This public engagement initiative invited members of the public to witness full-scale enactments of three ‘moments’ in surgical time – 1884, 1984 and 2016 – before taking part in discussion sessions with the clinical participants. Of course, only the second and third of these moments lie within living memory. The challenge of trying to recreate a sense of late nineteenth-century surgery from objects, contemporary accounts and written description threw into sharp focus the value of accessing professionals’ personal experience. Moreover, opening the world of surgery in this way brought additional perspectives and raised new questions which insiders had not thought to ask. These included ethical challenges around consent to undergo new and untried surgical procedures, the potential loss of valuable skills in the move from open to keyhole surgery, possible new directions shaped by developments in robotic technology, and questions about the nature and purpose of surgical instruments.

This use of physical simulation has brought into sharp relief the embodied knowing which lies at the heart of much expert practice, and the crucial role played by objects. Many of the objects in museum collections are of course too fragile or vulnerable to be used in simulations of this kind. However, there remain many that are sufficiently robust to be put to work, especially in the hands of experts accustomed to manipulating them. Such activities have a twofold effect. First, witnessing how objects are used in the context for which they were designed can provide important insights into the objects themselves, and how their form relates to their function. In the case of instruments and equipment tied to a particular historical moment, such information offers unique richness for historians, museum specialists and clinical professionals. Secondly, objects may act as prompts for recollection, either by individuals or (as in the surgical examples above) as members of a team. These recollections may ripple far beyond the activity itself, triggering deeper memories about conversations, events and insights. Yet such knowledge is vulnerable, as the people who hold it become old and frail. We have an opportunity to document this knowledge, using objects in museum collections to unlock rich stores of memory and chronicle their use, but this opportunity will not last indefinitely.

Capturing the tacit knowledge that underpins surgical practice is a daunting challenge. For experts, such knowledge has become so instinctive that they may not even recognise it. For those outside the field, the subtleties of this embodied knowing may be impossible to grasp fully. Yet such knowing lies at the heart of almost every professional domain. Objects offer a means of recognition, a way of bringing such knowing into view. Interacting with museum collections and documenting their histories through use presents an opportunity to capture what may otherwise remain unarticulated, hidden from insiders and outsiders alike.

Component DOI: http://dx.doi.org/10.15180/170808/004