Surgery

Jesse Ey, Guy J. Maddern

An older man with Crohn's disease underwent emergency laparotomy for small bowel perforation. A peri-incisional vesiculobullous eruption developed 5days later. Histopathology demonstrated viral cytopathic changes, immunohistochemistry was positive for herpes simplex virus and HSV-1 DNA confirmed by polymerase chain reaction test, representing the first reported case of localised herpes simplex following abdominal surgery.

Jessica S. Bulluss, Paul Chee, Matthew J. Verheyden

While representing less than 5% (6513 out of 138127) of the registered Australian medical practitioners (https://www.medicalboard.gov.au/news/statistics.aspx), surgeons are involved in the care of 2.8 million (out of approximately 11.6 million) hospitalisations yearly (https://www.aihw.gov.au/reports‐data/myhospitals/intersection/activity/apc). Surgeons and surgical care teams are intimately involved in how our health care system operates, from what type of care we receive, to how the public and private sectors interact (or are at odds at times) (doi: 10.5694/mja2.51844). Additionally, they are often at the forefront of innovations. Their cautiously optimistic approach to the introduction of new devices, techniques, and of late, artificial technology enabled tools, is important to ensure safety in care. The critical roles of surgeons and surgical teams in our health systems and technological development and assessment have meant that surgical research has expanded outside traditional laboratories and small scale clinical studies. Their wheelhouse now includes research areas with broad population level clinical and policy implications, including health services, comparative effectiveness, and health technology evaluation. In this issue of the MJA, we have curated high quality national surgical research, focusing on topics of critical national (eg, surgery in rural areas, national health technology assessment) and international (eg, artificial intelligence, evidence‐based care) significance. The issue was developed to highlight surgery research that can influence our health system and discuss challenges encountered by the discipline today. The contemporary narrative review by Paynter and colleagues discusses the role of surgeons in rural Australia where 29% of the general population, but only 20% of general surgeons, live (doi: 10.5694/mja2.52232). The authors expertly describe the rural surgical workforce, heterogeneity in care models, and workforce and training challenges. They argue that despite these challenges, several Australian studies have found rural general surgery outcomes are comparable to metropolitan centres. Another unique challenge nationally is raised in Ryan's thought‐provoking piece on TAVI procedures and their access (doi: 10.5694/mja2.52226). This article looks at the evidence base for technology implementation and recommends a coordinated national approach rather than the current federal v state (or public v private) approach, which can lead to inequity of service access. Research articles in this issue call attention to the increasing utilisation of implantable cardiac defibrillators (ICDs) in New South Wales, and the potential impact of upscaling a program that could prevent hip fractures, and therefore reducing emergency surgeries. In their study on ICDs, Zhu and colleagues suggest that the increases in ICD use seen in our most populous state are likely due to primary prevention (people at high risk of sudden cardiac death) and call for better guidance regarding their use (doi: 10.5694/mja2.52246). Discussing hip fractures, Jones and colleagues describe the potential fracture reduction benefits of scaling up the 29 fracture liaison services in place nationally since 2018 using a novel system dynamics modelling approach (doi: 10.5694/mja2.52241). With promising but modest results, the authors call for alternatives for secondary fracture prevention to continue to be explored. Finally, a perspective on the use of artificial intelligence in surgery and an invited editorial are evidence of surgeons’ balanced approach to the adoption of new technology. Kovoor and colleagues support the ethical introduction of artificial intelligence in practice, and optimistically suggest Australia can be a leader in its safe introduction (doi: 10.5694/mja2.52225). However, introduction of these tools in practice also requires an infrastructure for their ongoing monitoring and evaluation. This point is confirmed by the editorial by Darval and Richards (doi: 10.5694/mja2.52239), which while calling for more evidence‐driven surgery to address national waiting lists, also reminds us that rigorous studies and frameworks for ongoing evaluations can change the course of surgery, including demand, adoption, and outcomes.

Maria C Inacio · Francis Geronimo · Virginia Barbour

Johannes Mulder · Hans Sonneveld

In reply: We thank Cavazzoni and colleagues for their contribution on the legal aspects of voluntary assisted dying (VAD) and organ donation after circulatory death (DCD)1 in response to our article.2 Although it was true traditionally that no property existed in the dead body, the law has evolved, particularly in Australia concerning tissue donation, whereby property rights are now vested in relatives, for example with ownership of sperm from a dead body.3 Thus, contrary to the claim of Cavazzoni and colleagues,1 Australian law does indeed deal with the subject of ownership of procured tissues, which would extend to organs and would come into effect on the death of the person undergoing autonomous VAD. To support their argument that property rights over a dead body do not exist, Cavazzoni et al cite generally Quigley,4 with no specific detail. However, Quigley concluded that tissue or sperm obtained from dead bodies belongs to relatives.4 Moreover, in an article underpinning her book, Quigley concluded that “Recent legal decisions have seen a move towards the tentative explicit recognition of some property rights to biomaterials vesting in the source of the materials”.5 Thus, the traditional doctrine of “no property in the dead body” is outmoded and undergoing change. We believe it would be imprudent to ignore the rights of relatives from a legal point of view. From an ethical point of view, the rights of relatives — who, after all, have the duty to bury or cremate their loved one — must be considered. The relatives should be involved, as is the practice in the Netherlands with combined VAD and DCD, and in Australia with DCD. The last thing the whole process of organ donation needs is a legal challenge over organ procurement against the wishes of relatives. Difficult as it may be, those formulating guidelines should incorporate the consent of relatives into a guideline for combined VAD and DCD.

Jan Bollen · Neera Bhatia · James Tibballs