Evidence based surgery

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• Evidence-based surgery (EBS) involves the integration of the best
clinical and scientific evidence to treat patients.

• Best evidence is derived from the research literature and can be

categorised into a hierarchy of levels

• Application of the knowledge derived from “best evidence”

results in enhanced care for patients and also improved
standards for surgeons and health care institutions
• Surgery has traditionally been considered a craft wherein
individuals adopted techniques didactically from their
teachers and performed each operation in a particular way
because “that is how it was taught” to them.

• Throughout history, surgical practice has been dependent on

learning through one’s own mistakes or those of others.
Although a handful of exceptions did exist, such as the testing
of medical effi cacy by the eleventh century physician
Avicenna, it was not until the late twentieth century that the
concept of evidence-based medical practice came into fruition
• The Oxford English Dictionary defi nes Evidence as “information or signs
indicating whether a belief or proposition is true or valid”

• As surgeons, we already apply this defi nition to our daily practice, so when
we assess patients clinically, we all rely on our ability to draw clinical
evidence from clinical signs and investigations, much in the same manner as
Hippocrates did two and half thousand years ago.
Hierarchy of Evidence
Definition and Values

The broad definition of EBS has been stipulated as “the integration of

• Best research evidence (clinically relevant research, basic science,
relating to diagnosis, treatment and prognosis) With
• Clinical expertise (skills and experience adapted to a particular patient)
and patient values (patient preference and attitudes to clinical entity and
its overall management)”

This broad definition can be divided into two subcategories:

1. Evidence-based surgical decision making – in which best evidence is
applied to an individual or afinite group of surgical patients.
2. Evidence-based surgical guidelines – in which best evidence is applied at
an institutional or national/ international group of surgical patients.
• In order to apply best-evidence, raw data need to be
processed by a number of different types of knowledge.
These indictments to the
surgical fraternity have come
about as surgical research has
historically relied upon
publishing data that are
deemed to be of the “weakest
evidence”, based mainly on
case series as opposed to
randomised trials and meta-
analyses. The root causes of
these have been assessed in the
literature
 Be specific in your question(s)
 Prioritise your questions
 Ask answerable questions
• When reading the evidence, it is important not to lose sight of scientifi c rationality,
so as to acquire best evidence for best patient outcomes. The concepts of
information validity need to be rigorously assessed. These include:
• • Bias
• • Sample and study sizes
• • Methodology
• • Relevance
• Applying these techniques to study networks has resulted in two
conjectures:
1. Any representation of the evidence network needs to account for
the fact that all the treatments have not been studied equally.
2. Any representation of the evidence network needs to account for
the fact that there are varying amounts of published data for
different treatment comparisons.
EBS is no longer only about doing randomised control trials and for senior
academic surgeons. It is for all surgeons, their colleagues and their patients. It
works on the principles that best surgical practice is achieved through best
surgical evidence. It is now inevitable and has the potential to address all the
primary needs of our patient-oriented surgical practice, namely:

• • Patient management
• • Patient care
• • Patient safety
• • Patient outcomes
• • Patient satisfaction
Terima kasih