Performing your first independent surgery is an experience you never forget. It is when you are handed the scalpel and tasked with operating on a patient alone for the first time. For every new type of procedure as an independent primary surgeon, this experience is a milestone in every surgeon's career.

The experience is a blend of readiness and anticipation. You have dreamt of leading a surgical team, making critical decisions, and staying calm under pressure—like the heroic surgeons on television. But alongside this excitement, there's often a significant amount of anxiety. Questions flood your mind: Are you truly ready? Can you recall every step of the procedure? The pressure intensifies when your consultant is no longer just a room away, in the coffee room or their office.

Your heart races, and your breathing quickens. The operating theatre can either be a chaotic, noisy hall. An enthusiastic or overconfident assistant might add to the challenge, expecting to do the procedure whether they have the knowledge or the skills to do it. Despite practising the procedure multiple times in simulations or under supervision, performing it as the primary surgeon elicits a unique blend of panic and excitement.

No matter how much you have prepared, read, or assisted, it is different when you are the ultimate decision-maker. Each new operation can feel like the first time, and overcoming the initial trepidation builds your confidence. With each successful surgery, your assurance grows, but new challenges continue to arise with more advanced cases.

Reflecting on these emotions is crucial. Learning to turn panic into excitement can improve our performance. The physiological reactions to fear and excitement are the same; it is the associated emotions that differ. Balancing cautious fear with tempered excitement is key—too much of either can lead to mistakes.

Managing the Known and Unknown

When preparing for surgery, it's helpful to think in terms of Johari's Window: known knowns, known unknowns, and unknown unknowns. The unknown unknowns are the most daunting because they encompass what you don’t know that you don’t know, leading to anxiety and self-doubt. However, you can never know everything, so focus on managing what you can.

Known Knowns:

1. Operation Steps: Familiarize yourself thoroughly with the procedure. Stick to what you know best for your first independent surgery.

2. Patient Details: Understand the patient's age, body type, gender, and overall health. The priority differs based on whether the surgery is elective or emergency.

3. Skill Set and Team: Assess your skills and those of your assistant. An experienced scrub team and a well-briefed assistant are crucial. Make sure the anesthetist is aware of any specific requirements.

4. Instruments: Ensure you have all necessary instruments ready.

Known Unknowns:

Assess the history and pathology. If there is a previous operation, expect some distortion of anatomy. There might be possible variations of the pathology also from the scan. Go through the differentials and prepare for those eventualities. It is those possible complications, that cause the fear.

Unknown Unknowns:

This is where your experience and ability to think critically come into play. There might always be some element, that we can not foresee. A systematic approach and logical thinking are the only way that can help manage these situations effectively.

Preparation and Execution

1. Develop a System: Create a consistent planning system for every operation. This helps you anticipate potential complications and determine responses.

2. Review Patient Information: Thoroughly review the patient's history, notes, scans, and test results before surgery. This reinforces your confidence and readiness.

3. Prepare Your Team: Discuss the plan with your team, especially the assistant. Explain your need to lead the surgery entirely to ensure things go smoothly. Put yourself first, the first independent operation is not the time to teach.

4. Visualization and Calm: Before the operation, visualize each step in detail, including positioning and potential issues. This mental practice can improve performance. If anxious, use breathing exercises or personal rituals. This familiarity will help you get into the zone.

5. Intraoperative Strategy: During surgery, let your training guide you. If encountering difficulties, consider moving to an easier task before returning to the problem area. When you are stuck, thinking aloud of all the options can clarify your strategy and decision-making.

6. Seek Help if Necessary: If you are truly stuck and it is more complicated than expected, then call for help. There is no shame in asking for help. It is about patient safety, not ego. But then reflect on the experience to understand why you needed assistance and learn from it.

The first independent surgery is a defining moment. Balancing preparation, visualization, and a systematic approach with the ability to handle the unexpected will help you navigate this critical experience. Embrace the mixture of fear and excitement, as both are essential in developing into a skilled, confident surgeon.