RCSI SURGEONS SCOPE MAGAZINE is published annually by RCSI for surgical Fellows and Members. Issues are available online at www.rcsi.com/portal. Your comments, ideas, updates and letters are welcome. Please contact the Fellows and Members Office, 118 St Stephen’s Green, Dublin 2; telephone: +353 1 402 2116; email: fellows@rcsi.ie. RCSI Surgeons Scope is posted annually to Fellows and Members In Good Standing. To ensure you continue to receive your copy, please update your contact details via www.rcsi.com/portal. RCSI Surgeons Scope is produced by Gloss Publications Ltd, The Irish Times Building, 24-26 Tara Street, Dublin 2. Copyright Gloss Publications.
How the new system of surgical hubs will
Consultant General Surgeon Mr Martin Caldwell on his career, and life as a surgeon in Sligo
Robotic surgery, mentoring and the management of patient’s records – all part of the updated Code of Practice for Surgeons
RCSI’s mission is to educate, nurture and discover for the benefit of human health. Founded in 1784 with surgery at our core, we are an independent, not-for-profit, world leading
A LETTER FROM THE PRESIDENT, RCSI
PROFESSOR DEBORAH McNAMARA
uilding on our rich history and tradition, RCSI continues to be at the forefront of improving surgical care for patients, safeguarding standards of practice and providing leadership in the discipline of surgery. As surgeons, our unique longterm perspective is essential to the design and delivery of high-quality, evidence-based surgical services and training. Working with RCSI Council, and with the support of Fellows, Members and Trainees, I am leading the efforts to ensure that our College retains its strong role as the voice of surgery long into the future.
Over the last 12 months, I have been privileged to meet many surgeons across Ireland and around the world. Clinically, the challenges we face are very familiar: ageing populations with complex comorbidity, high levels of demand for surgical services and relentless pressures on emergency departments. What has changed, however, is the context in which surgeons are working. Public commentary about surgical practice has increased, often in ways that undermine the efforts of surgeons who are working hard to provide good care. Increasing misinformation and geopolitical instability have eroded the norms of civility, tolerance of difference and respect for expertise.
As a result, the surgical workplace is more challenging than ever before. The supportive role of our professional surgical community has never been more important.
EARLY CAREER SURGEONS
A key focus of my term as President is to support early career surgeons in their first years of independent practice. As many of us can remember, the initial excitement of consultant appointment can be quickly followed by rapidly escalating clinical demands, a steep learning curve and a variety of practical challenges ranging from the personal to the professional.
In the past year, RCSI has established the Early Career Surgical Network (ECSN). The network is an important way to increase connections between surgeons, and with RCSI, during the early years of consultant practice or while on international fellowship. Surgeons are eligible to join the network after successfully completing Part A of the Intercollegiate Fellowship in any surgical specialty.
As part of our efforts to foster connections among our community, we have also introduced a President’s Reception at RCSI which is held before each Fellowship conferring ceremony to welcome surgeons and their families to our Fellowship, and to spread the word about the network.
The ECSN provides an important way to tap into knowledge, connections and collaborations that will benefit not just the early career surgeon, but also their department and their hospital – please encourage your newer colleagues to take part. Teams across RCSI, from Fellows and Members to Surgical Affairs, are devoting time and energy to the network. It is important to all of us that our combined efforts are delivering the supports that Fellows need, so your
feedback on how we can improve is most welcome. You can read more about ECSN activities in Scope News (see page 4) and if you’d like to join the network, please email ecsn@rcsi.ie.
SAFEGUARDING SURGICAL PRACTICE, INNOVATION AND TRAINING
As technology and innovation become more embedded in our daily lives, the pace of change brings both challenges and opportunities. As new approaches are introduced, the safety of patients remains paramount. At the same time, the ability of surgeons to innovate in practice must be enabled and protected. Earlier this year, Council endorsed the Robotic Surgery Governance in Ireland: A Guide to Good Practice to provide additional safeguards for surgeons who are introducing this new technology into their practice. The framework provides a tangible way for surgeons to demonstrate their commitment to high quality surgical care and I commend Professor Barry McGuire FRCSI for his leadership in this area.
I also encourage you to read about our newly updated Code of Practice for Surgeons 2025 (see page 24 for more details). Led by Mr Dara Kavanagh
RCSI President, Prof. Deborah McNamara.
FRCSI, and supported by Mr Paddy Kenny FRCSI, RCSI Council Member and Chair of the RCSI Professional Development and Practice Committee, this update includes helpful links to the latest Irish Medical Council standards and highlights new legislation relevant to the practice of surgery. As our profession faces unprecedented scrutiny, the Code of Practice is recommended reading. More recently, we have established a short-life working group on AI and Digital Medicine. Its chair, Professor Micheál O’Ríordáin FRCSI, RCSI Council Member, has already reported to Council on how this diverse group is consolidating RCSI expertise in AI and other aspects of the digital revolution that are relevant to surgery. We look forward to updating you on our strategy and progress during the Charter Meeting.
MAINTAINING A VOICE FOR SURGERY
Meanwhile, more than 280 Fellows have contributed to the survey from the Expert Group on Best Practice in Clinical Governance for Surgery, chaired by Mr David Moore FRCSI, RCSI Council Member (see page 8 for more information). Over the last 18 months, we have reviewed best practice from around the world, as well as examples from closer to home. The critical role played by morbidity and mortality conferences and multidisciplinary team meetings is clear, but surgeons report a series of challenges including a lack of dedicated time and administrative support. The work of the Expert Group will support our call for greater resources to enable surgeon participation in essential patient safety activities. The results of the survey will be out soon, with the Expert Group Report to be published in February 2026.
Surgical practice is demanding. My ambition for RCSI is to remain a focal point for our surgical community as we navigate a rapidly changing world.
Another important way that RCSI ensures the voice of surgeons in our health service remains strong is through the National Clinical Programmes. In this edition of Surgeons Scope, you can read more about the work of the programmes. The National Clinical Guidance for Elective Care Facilities which will be published shortly, with thanks to the leadership of RCSI Council Member Ms Bridget Egan FRCSI, is especially important. This clinical guidance applies to every patient treated in a surgical hub, irrespective of specialty. Importantly, through this work, RCSI has successfully advocated for surgical hubs to be centres for surgical training. As the HSE elective surgical programme opens new ambulatory surgical hubs in Cork, Galway, Limerick, Waterford, North Dublin and South Dublin, this ensures that RCSI surgical trainees have access to all the training opportunities that arise from the ‘shift left’ of ambulatory care. Thank you to Professor Kevin Barry FRCSI, RCSI Director of the National Surgical Training Programme, for advocating for our trainees in these important conversations.
SUPPORTING SURGEONS
Surgical practice is demanding. My ambition for RCSI is to remain a focal point for our surgical community as we navigate a rapidly changing world. I hope to see you at the Millin Meeting on 14 November and the Charter Meeting 10-14 February 2026 to share ideas and, most importantly, to welcome a new generation of surgeons to our community. ■
Fellows and Members Conferring in Penang.
Launch of the Code of Practice for Surgeons
Prof. Deborah McNamara and her nephew at the Family Fun Day 2025.
SCOPE NEWS
Awards, networks and surgical appointments
The Early Career Surgical Network
The Early Career Surgical Network (ECSN) was officially launched by Professor Deborah McNamara, RCSI President, at the annual Millin Meeting in November 2024.
The purpose of the network is to increase and enhance the supports that RCSI offers early career surgeons as they navigate the career transition from training into independent practice. Chaired by Professor Christina Fleming FRCSI, the ECSN is a pan-specialty peer support community, which aims to provide a structured and tangible way for connecting surgeons at a similar career stage.
One of the key actions undertaken by the network was to showcase the impact of early career surgeons on practice and policy as part of the annual Charter Meeting in February 2025. Contributors to the symposium included Professor Helen Heneghan FRCSI, Ms Christine Buckley FRCSI, Professor Michael Kelly FRCSI, Mr Peter Lonergan FRCSI, Professor Joseph Butler FRCSI and Professor Philip O’Halloran FRCSI. Their presentations were followed by panel discussions that covered a range of topics, from mentoring to the importance of developing non-technical skills.
The ECSN has also developed a webinar and blog series. The first webinar, held in summer 2025, focused on the topic of ‘How to get a consultant job in Ireland’. The ‘Top 5 Tips’ from the webinar were the basis for the ECSN October Blog. A second webinar on the topic of the pathway to specialist registration with the Irish Medical Council will occur in winter 2025.
In addition to the practical supports and resources, the group has worked
to make peers aware of this unique support community. In July 2025, the ECSN attended the President’s Reception for newly conferred Fellows, where Professor Christina Fleming spoke about the value of peer support among younger surgeons as they take the next steps in their career. Future activities include a collaboration with the ISTG for a planned in-person event in December 2025 that will explore the topic of next steps for a surgeon once they secure a consultant position.
Learn more about the ECSN, how to get involved and the current committee via the Fellows and Members Portal: www.rcsi.com/portal.
SURGICAL BOOTCAMP
In July 2025, 100 surgical trainees participated in the 13th annual Surgical Bootcamp at the RCSI National Surgical and Clinical Skills Centre. The intensive course immersed surgical trainees in the technical and non-technical skills they will need as they begin their practice as surgeons. The programme was supported by over 40 faculty members from across a range of surgical specialties and emergency medicine, led by Ms Dara O’Keeffe, Simulation Lead in Postgraduate Surgical Education.
This innovative and hands-on programme is delivered by the Department of Surgical Affairs, RCSI SIM and consultant surgeon trainers. Technical skills, including suturing, excision of skin lesions, bowel anastomosis and laparoscopic skills, are taught by experienced surgical faculty in a high pupil-to-teacher ratio.
Non-technical skills including teamwork, communication for informed consent and crisis management are also taught using interactive discussion sessions and high-fidelity simulation. RCSI increased Core Surgical Training numbers from 80 to 100 trainees for the July 2025 intake, reflecting workforce demands across the healthcare system.
Launch of the Early Career Surgical Network.
Surgical Bootcamp.
RCSI National Clinical Programme for Surgery
Ms Bridget Egan FRCSI has been appointed co-lead of the RCSI National Clinical Programme for Surgery (NCPS). She follows Mr Ken Mealy FRCSI, pastPresident of RCSI, who held the role until his appointment to the Board of the Health Service Executive (HSE).
Ms Egan is an RCSI Council Member and Consultant Surgeon (Vascular) in Tallaght University Hospital (TUH). She also serves as Perioperative Clinical Director at TUH and Chair of the National Elective Care Clinical Guidance Group (NECCGG).
The aim of RCSI’s National Clinical Programme for Surgery is to provide a framework for the delivery of safer, timely, accessible, more cost-effective and efficient care for all surgical patients.
The RCSI National Clinical Programme in Surgery is a very important part of how RCSI collaborates with and supports the HSE to improve patient care and access to care. The programme works closely with the other clinical programmes, notably the National Clinical Programme for Trauma and Orthopaedic Surgery and Anaesthesia and the Acute, Emergency Medicine and Critical Care Programme. It also works with other clinical programmes, hospitals, health regions, specialty bodies, patient advocacy groups and relevant stakeholders across the health system.
EMERGENCY MEDICINE MODEL OF CARE 2025
The Health Service Executive (HSE) and RCSI have jointly launched the National Clinical Programme for Emergency Medicine (EMP) Model of Care 2025, the most significant update to Ireland’s strategy for delivering urgent and emergency care in more than a decade.
The new Model of Care is aimed at ensuring emergency care evolves in line with the needs of patients and the principles of Sláintecare. It builds on the original framework published in 2012, highlights a shift towards more proactive and patient-centred approaches to urgent and emergency care and emphasises the importance of ‘right care, right place, right time’ through four key pillars: organisation of care, patient pathways, infrastructure, and quality improvement. The new Model of Care also calls for stronger pre-hospital and community-based services so that patients can access care in the most appropriate setting, while also developing specialised services tailored to paediatric and older patients.
The document describes how multidisciplinary teams will play a greater role in delivering care, supported by expanded advanced practice roles and sustainable workforce planning, as well as the importance of data-driven tools and digital innovation in improving patient flow, guiding decision-making and supporting value-based care.
2025 PROGRESS Women in Surgery Fellowship
Ms Lauren V. O’Connell FRCSI is the recipient of the 2025 PROGRESS Women in Surgery Fellowship. This prestigious bursary, established to promote female participation in surgical training at fellowship level, is awarded by RCSI.
Ms O’Connell will undertake a fellowship in advanced colorectal cancer at the Peter MacCallum Cancer Centre in Melbourne, Australia, allowing her to gain international exposure in colorectal cancer surgery and further develop her expertise for the benefit of patients. Currently a Specialist Registrar in general and colorectal surgery at the Mater Misericordiae University Hospital, she graduated with honours from UCD in 2014. She achieved Fellowship of RCSI in 2024, receiving the Professor WAL MacGowan Medal as the top-performing RCSI candidate across all surgical subspecialties in Part B of the FRCS examination.
Ms O’Connell has also been awarded the Colm Galvey Educator Award (2019) for excellence in undergraduate teaching and has contributed to RCSI’s MRCS Preparation Course and surgical skills workshops for trainees. With over 35 peer-reviewed publications in leading journals, authorship of book chapters and presentations at major international conferences, her research focuses on early-onset colorectal cancer, functional outcomes post-resection, surgical education and minimally invasive techniques.
Ms Bridget Egan FRCSI.
Ms Lauren V. O’Connell FRCSI.
HSE Chief Clinical Officer Dr Colm Henry; HSE CEO Bernard Gloster; RCSI President Prof. Deborah McNamara; Minister for Health Jennifer Carroll MacNeill; Dr Rosa McNamara, Clinical Lead, National Emergency Medicine Programme.
that will enable healthcare institutions and surgeons to confidently navigate the rapidly evolving landscape of surgical technology. It provides clear, actionable recommendations for hospitals to integrate robotic surgery programmes, focusing on training, credentialing, and governance to ensure patient safety and enhance surgical outcomes. Professor Deborah McNamara, President of RCSI, said: “At RCSI, we are committed to supporting the professional development of surgeons while ensuring that the latest technological advancements are used responsibly. Our new guide is aimed at ensuring that hospitals and surgeons have the structured support they need to implement this cutting-edge technology while maintaining the highest standards of patient care and safety.”
Safe, effective robotic-assisted surgery
Earlier this year, RCSI published a new framework to support the safe and effective use of robotic-assisted surgery. As robotic technology continues to revolutionise the operating room, this new guide sets the standard for governance, empowering hospitals and surgeons to embrace the future of surgery with confidence while prioritising patient safety. The comprehensive guide, Robotic Surgery Governance in Ireland: A Guide to Good Practice, was published at the opening of Ireland’s first-ever Robotic Learning Village which took place during RCSI’s annual Charter Meeting.
The guide offers a structured approach to the adoption of robotic surgery
RCSI INSTITUTE OF GLOBAL SURGERY AND COSECSA
In August 2025, the long-standing collaboration between RCSI and the College of Surgeons of East, Central and Southern Africa (COSECSA) was recognised by the presentation of the Aspire to Excellence International Collaboration in Health Professions Education Award 2025.
The partnership between RCSI’s Institute of Global Surgery and COSECSA addresses the acute shortage of surgical care across sub-Saharan Africa by developing sustainable solutions to improve surgical and perioperative training and practice throughout the region.
Since 2007, more than 1,500 COSECSA surgical trainees have enrolled in training programmes across 20 member countries. The majority of graduates remain in the sub-Saharan region, where they go on to train the next generation of surgeons. Between 300 and 400 surgeries are performed by each COSECSA-trained surgeon annually.
The ASPIRE-to-Excellence judging panel chose the winner according to five specified criteria, including the collaboration’s mutually agreed goals, long-term collaborative and high delivery impact as well as shared responsibility and leadership structures. The panel said that the collaboration “clearly meets the spirit of the ASPIRE Award in International Collaboration”. They added
“This framework is not just a set of guidelines – it’s a vital tool for surgeons and hospitals to maximise the potential of robotic surgery while minimising risk,” explained Professor Barry McGuire, RCSI Professor of Postgraduate Surgical Education and Academic Development, and lead author of the guide. “Drawing from lessons learned in the early days of laparoscopic surgery, we are proactively addressing the challenges and opportunities posed by robotic platforms, ensuring safety and excellence in patient care.”
The guide was developed by the National Leads on the Robotic Surgery Committee in collaboration with the Irish Surgical Postgraduate Training Committee (ISPTC). This committee, composed of representatives from across surgical specialties, was founded with the mission of ensuring that the adoption of robotic surgery in Ireland is both safe and sustainable, safeguarding patient outcomes while supporting the professional growth of Irish surgeons.
that “the collaboration has had a demonstrable long-term tangible impact. Since its early years it has extended the benefit to other neighbouring institutions and the health education economy”, and that “the collaborators actively engage in processes to understand each other’s cultural contexts and acknowledge the role of cultural influences on decision-making, responsibilities and leadership”. ■
Prof. Deborah McNamara, RCSI President and Prof. Barry Maguire, Professor of Postgraduate Surgical Education and Academic Development.
Lucia Brocato, RCSI-COSECSA Collaboration Programme Manager, receiving the award in representation of the Institute of Global Surgery at AMEE Barcelona 2025.
FELLOW TRAVELLER
Ms Clare O’Connell FRCSI, is a Society of Urologic Oncology Fellow at University of Toronto
completed my Core Surgical Training and then my Higher Specialist Training in urology, mostly in Dublin, with two years in Cork. I finished in July 2024, and I’m now halfway through a two-year fellowship in Toronto in urologic oncology.
I work across three hospitals: UHN (Toronto General/Princess Margaret Cancer Centre), Mount Sinai, and Sunnybrook, where I’m currently on a four-month rotation. There is a great mix of complex open operations and robotic surgery.
I chose this fellowship because I wanted to do a Society of Urologic Oncology (SUO) Fellowship, but going to the USA did not appeal for a variety of reasons. I had my first child halfway through SpR training and my second right at the end of my time as an SpR. Carving out the time to do the USMLEs would have been a bridge too far.
Canada was an attractive option for many reasons. Two Irish trainees had done this fellowship before, and there was already a relationship established with the department. I had worked with both people since they came back as consultants and their skillset and knowledge were really impressive. University of Toronto is a centre of excellence for robotic prostate surgery, one of the important elements of the job that I’m going back to in the Mater Hospital. There is a lot of complex kidney surgery on this fellowship, both robotic and open, and it’s the regional centre of excellence for testicular cancer. We get exposure to all major urologic oncology operations.
A typical day starts at around 6am when my children wake me up and my husband and I both help them get ready for the day. I leave the apartment at around 7am and take the shuttle bus or an Uber to Sunnybrook, arriving at 7.30am.
On this fellowship, managing inpatients is mainly done by the residents, which is a huge change for me from SpR training – it’s nice to come in and go straight into your activity for the day. We usually start in theatre at around 7.45am. At the moment, I’m working with Dr Robert Nam who does a lot of complex open cancer surgery. We usually have two major cases per day, mainly for bladder and kidney cancer. On Wednesdays, I work with Dr Amanda Hird: we typically do two robotic cancer operations, such as partial nephrectomy or robotic prostatectomy.
We are usually finished in theatre by 5pm. One of the great things about urology is that you get to do complex surgery, but are often home for dinner. Currently I’m operating three days a week, and I have cystoscopy and minor cases two days a week. I do one weeknight call per month, with no weekend call.
This is a very good fellowship in terms of work/life balance. It’s been a great city to live in and it’s been relatively easy for me to maintain a good home life as well, which was very important for me when considering fellowships. My kids are small – one and three – and it’s a really critical time in their lives. My husband has been extremely supportive. I told him a long time ago what my career plans were and that we were going to have to go on fellowship and that if we had kids, he was going to have to come and take a career break. Everyone was on the same page and he was happy to do that. When we came here, our second baby was only eight weeks old and he looked after her full-time until she started daycare this summer. The first year of the fellowship is full-time research. I was a little nervous taking a full year away from clinical practice, but I really enjoyed it. I could do a lot of my research from home, which made breastfeeding much easier.
Toronto is a great city for kids, with good public parks, and lots of free activities. Daycare is heavily government-subsidised with full-time daycare for our oneyear-old costing the equivalent of €250 per month (if you can secure a subsidised daycare spot). That’s been hugely helpful – financially, it’s tough being on fellowship, as my salary is not great in relation to the cost of living in general. I had support from RCSI with Colles Travelling Fellowship funding, and I was awarded the David Thompson Fellowship from The Urology Foundation in the UK, which has been an invaluable financial lifeline.
We have some evening activities as a department. Our journal clubs usually happen in a restaurant downtown once a month, and we have occasional evening talks. A few friends are also here on fellowship and there are a lot of Irish Fellows in the city, including a few from my class in Trinity.
We live close to an urban trail called the Beltline Trail; you can walk for miles and miles and it feels like you’re not in the city anymore. At the weekends, we typically do a loop that leads to the Evergreen Brickworks where there’s a farmers’ market and little ponds with turtles. The baby is in a backpack, and the three-year-old walks it herself. In the afternoons we bring them swimming.
It’s great being in such a big academic centre. In Princess Margaret it seems like the rule rather than the exception that patients are on a clinical trial, which has been eye-opening. Obviously it’s very different back home in terms of resources. The philanthropic efforts the staff are involved with day to day is notable in that they are more directly involved in fundraising efforts than I’ve experienced in my training thus far. The staff here are easy to get along with and they’re all excellent teachers; the learning experience has been world class.
There are fewer women urologists here than in Ireland. There is only one female urologic oncologist at University of Toronto, and only six female residents out of 23. In Ireland, over 50% of urology SpRs are female. RCSI have made huge strides in addressing gender imbalances in surgery. It is heartening to see so many female trainees in urology in Ireland, and to have so many great role models in surgery. ” ■
Ms Clare O’Connell FRCSI.
ASKING THE EXPERTS
Professor Deborah McNamara, President of RCSI, has established an Expert Group on Clinical Governance in Surgery. The Expert Group, chaired by Mr David Moore FRCSI, RCSI Council Member, has been tasked with producing a report on Best Practice in Clinical Governance, which will be launched during Charter Meeting 2026
RATIONALE FOR THE ESTABLISHMENT OF THE EXPERT GROUP
The rationale behind the establishment of the group was to ensure a systematic approach to maintaining and improving quality of care for patients. “Good governance,” says Mr David Moore, “is paramount for both patients and surgeons.”
Mr Moore is joined in the Expert Group by RCSI Council Members Ms Ann Hanly, Mr Barry O’Sullivan, Mr John Caird, and Mr Keith Synnott, and by Mr Pat O’Toole FRCSI, and RCSI Director of Surgical Affairs, Kieran Ryan. The project manager is Daniel Howard.
“It was important for us to have representation from a wide range of surgical disciplines,” explains Mr Moore. “Within the group we have general surgery, neurosurgery, plastic surgery and orthopaedics. We report back to Council regularly through the Committee for Surgical Affairs and, following on from those discussions, other members of RCSI Council representing specialties such as cardiothoracics, general surgery, ENT and orthopaedics, have offered input and support, including Professor David Healy, Professor Ronan Cahill, Professor Laura Viani, and Mr Paddy Kenny.
REMIT OF THE EXPERT GROUP
The Expert Group has been tasked with producing a report on Best Practice in Clinical Governance
The key headings under which the group will report are: Patient Safety; Quality Improvement; Accountabilty; Standardisation of Care and Regulatory Compliance; Standards of Education and Training; and Data Management.
“Within the workings of the Expert Group,” explains Mr Moore, “we are studying the Medical Council’s rules to ensure that we understand and adhere to them to the utmost degree. We want to make sure that the standards of education and training for surgeons are appropriate, and that the management of data submitted, studied and used is appropriate. It is essential that people are confident in the anonymity and confidentiality of the process, as they need to be able to talk openly in order to improve what they are doing.
In preparing its report, the group is looking at differences in surgical governance globally. As the topic is vast, it is not possible for the group to cover every area exhaustively and where others have carried out extensive recent work – as, for instance, Professor Barry McGuire on Robotic Surgery and Mr Dara Kavanagh with his work on the Code of Practice for Surgeons – the group supports that work and has adopted those guidelines.
The Expert Group is focusing on perioperative meetings, morbidity and mortality conferences, multidisciplinary team meetings, audits on return
to theatre infection rates, and blood transfusion rates, as well as considering several technical issues and taking a view on the introduction of new practices and surgical devices.
“We are all aware of recent negative publicity surrounding conduct, complications and delays. It is our belief that much of this could have been avoided if there had been a clear understanding of what the standards in governance should be.
“These issues all fall within the remit of surgical governance and we are primarily looking at areas that have not previously been covered or in respect of which little work has already been done, so that we can set the guidelines,” explains Mr Moore. “Most importantly, we want to hear the opinions of surgeons; we need their views on what they consider to be best practice in their field. It is very important for us to get a sense of what they see as obstacles preventing best practice in surgical governance. We need engagement from within the surgical community around the country for this to be a valuable body of work. It is imperative that the voices of surgeons are front and centre. This type of review only happens once every decade or so, so it is vital that they make their voices heard, otherwise the opportunity to make changes will be wasted. Now is the time.”
A key element of the group’s brief is that it liaises closely with the Health Service Executive (HSE), and keeps it updated and informed.
“RCSI are the experts in this area,” says Mr Moore, “and clinical surgical governance is of vital importance to every organisation in our field. It’s essential to share our knowledge base, set the guidelines as care deliverers and keep the HSE as the care providers informed of our ongoing work in this area. We’re all on the same page when it comes to maintaining and improving quality of care for patients.”
ACTIVITIES OF THE EXPERT GROUP AND OUTCOMES TO DATE
The approach taken by the Expert Group was first to conduct a literature search, looking at best practice in other jurisdictions. This was followed by an initial survey, with the group contacting, in the first instance, surgeons working across public and private practice in Ireland.
The survey asked surgeons to respond to questions such as: What is important in surgical governance? Are you happy or unhappy with current standards of surgical governance? What do you need? What are your thoughts?
The group also contacted those involved in healthcare management, including the CEOs of all the hospitals, both private and public, the directors of the private healthcare providers and the Independent Hospitals Association. It also
approached HSE Regional Executive Officers, both clinical and administrative.
“We collated their responses,” explains Mr Moore, “and by taking what they had said we were able to start to understand what is important to these key people, to identify the most urgent and topical issues and to address the gaps that need to be filled.”
The Expert Group followed its initial survey with a second, more detailed, one, which asked questions about more specific issues in surgical governance, for example morbidity and mortality conferences: How often are they held? What is discussed? What KPIs do they look at?
“What we do at my hospital might be different to what happens in another hospital,” says Mr Moore, “and it’s important we know what those differences are so that best practice can be achieved.”
The group has also sought information about resources, to talk openly to improve what they are doing better understand what needs to be in place to deliver good surgical governance.
For instance: Are there sufficient, good quality IT facilities to have a successful meeting, when not everybody is in the room together?
“We need to be flexible and dynamic,” explains Mr Moore. “Surgeons are incredibly time-poor so it’s important that we meet people in ways that are efficient and do not waste time or resources. If we don’t, attendance will be poor. There are only so many hours in the working day, and we need to be sustainable rather than burdensome. Doctors need to be doctors, so there is an element of administrative support required so they have the information they need to hand rather than having to look for it. We can deliver good surgical governance if the tools and resources are provided.”
To date, Mr Moore says that the biggest learning has been that while the interest and motivation exists on the part of the surgical community to adhere to best practice in surgical governance, they question whether they have the time and resources available to them to be able to do so.
“While the College can advocate for this,” he says, “in practice it’s up to others to provide the resources, whether
that be the HSE or whoever else, because if we as surgeons are going to do this within the normal working day, something else has to give and that’s potentially reducing the time spent with patients. But this is important, and it needs to be done, so it needs to be managed.”
NEXT STEPS AND PRIORITIES MOVING FORWARD
The next task for the Expert Group is to collate the results of its most recent survey. Subsequently, the group will seek engagement with patient representatives and get their input. Following this, the whole group will meet to discuss its findings and begin to shape them into an initial draft document for circulation.
“Once that is finalised we will present our work to the College through the Committee for Surgical Affairs,” says Mr Moore. “Our aim is to launch our document on the Best Practice in Surgical Governance at Charter Meeting 2026 during a special session on surgical governance where we will have speakers and experts share their insights. This will involve plenty of time for discussion so we can hear from all those attending.”
In parallel to the Expert Group, newly developed guidelines relating to clinical governance in robotic surgery were drafted and launched in early 2025. These guidelines provide clear governance recommendations for this new and quickly evolving subspecialty. Furthermore, in recent months work to update the Code of Practice for Surgeons, originally published by RCSI in 2004, has been completed and the third edition of the Code was circulated in September 2025.
“We need engagement from within the surgical community around the country for this to be a valuable body of work.”
“Together with the work of the Expert Group, these documents bring a sense of timeliness to our focus on quality of care, which we are always trying to improve,” says Mr Moore. “It’s not about doing more surgery, but doing good and safe surgery and being able to benchmark ourselves against international centres. We need transparency to measure accurately and gain increased awareness as to where we stand. Every aspect of our work on this framework is designed to maintain a high standard of care and ultimately, public trust.” ■
Ms Ann Hanly FRCSI.
Mr Keith Synnott FRCSI.
Kieran Ryan.
Mr Barry O’Sullivan FRCSI.
Mr David Moore FRCSI.
Mr John Caird FRCSI.
Mr Pat O’Toole FRCSI.
A SURGEON IN SAUDI ARABIA
Dr Ameera Balhareth FRCSI is a Consultant Colorectal Surgeon at King Fahad Specialist Hospital in Dammam, Saudi Arabia. She specialises in the surgical management of colon and rectal cancers, advanced cases of chronic inflammatory bowel diseases including Crohn’s disease, and complex anal disease
grew up here in Saudi, mainly in the city of Dammam where I live now, which is one of the biggest cities in the Eastern Province. I went to school in Dammam and studied medicine at the Imam Abdulrahman Bin Faisal University, formerly known as the University of Dammam. After graduating I joined the King Fahad Specialist Hospital for my residency in general surgery.
I did five years of general surgery training, and then sat the Saudi Board examinations. After that, in July 2013, I applied for a fellowship in Dublin and I went and completed a two-year MSc in Leadership and Innovation in Healthcare at RCSI and a three-year specialised Fellowship in Colorectal Surgery at Beaumont Hospital. In Dublin, my main trainer and mentor was Professor Deborah McNamara.
I returned to Saudi in January 2018 and six months later, after I had finished my paper for the Saudi Commission, I applied for a consultant post and was appointed Consultant in General and Colorectal Surgery at the King Fahad Specialist Hospital in Dammam.
Subsequently I was appointed Head of Physician Training at the hospital, within the department administering academic affairs. In that role I had responsibility for the local programme for all specialties, including internal medicine and general surgery, at the residency level and for local fellowships.
After that I was Head of the Scholarship Office, and then Director of Training Affairs. I stayed in that post for two and a half years. Although it was an administrative role and involved a lot of paperwork, I found it very satisfying seeing the doctors progress through their training. I almost felt they were my babies because I was part of that process! Since 2022 I have been the Director of the Colorectal Surgery Fellowship Programme.
Throughout this time, I have continued full surgical work. The King Fahad has 365 beds and is focused on oncology and transplant. I don’t do general surgery, all my work is oncology-oriented. In my clinical practice I treat colon cancer, rectal cancer, inflammatory bowel diseases such as Crohn’s disease, ulcerative
colitis, and very complicated anal fistulas. I operate on men and women but, as I am the only female colorectal surgeon in the hospital, I am in demand as many female patients prefer to have a female surgeon. There are other female surgeons in the hospital; we have three breast surgeons and one thoracic surgeon.
Tuesday and Wednesday are my busiest days, and I do only clinical work on those days. On Tuesday I have a full day operating, and on Wednesday I have clinic. Sunday is the start of the week, and on Sunday, Monday and Thursday I have a mix of administrative work, rounds, and some meetings. Friday and Saturday are not working days. I do one weekend on call every month. Because we are not a public general hospital, we don’t get a lot of referrals. When you do get a referral, it is usually either a patient who is on treatment or patients who are at home but whose file is in the hospital. We are not a trauma centre and we do not get referrals for appendicitis and other small issues.
The population of Saudi is 35 million, with about seven million in the Eastern Province. Dammam is a busy city – I live 15 minutes by car from the hospital in a modern duplex apartment. The route is along a highway and my commute is not too bad.
Dr Ameera Balhareth FRCSI.
Dr Ameera Balhareth in surgery.
We start work at 7.30am each day. The temperatures and humidity are very high in July and August but all the buildings are air-conditioned and I’ve been living here for a long time, so I am used to it. I usually finish work around 5pm. In terms of work/life balance, it’s not always easy.
Right now, I’m focused on my leadership and potential. I know that there’ll be a lot of sacrifice, but I have goals and I want to work hard to achieve them at this time of my life. I try to achieve balance but sometimes it affects family life, and I don’t see my mother, father and my six sisters as often as I would like. Work can be very hectic. A couple of months ago, after attending a professional meeting in Paris, I took the week off to spend time with my parents and sisters; I have a baby nephew who is six months old and we are all mad about him.
My working environment is very good. I have two teams, the admin team and the clinical team, and everyone understands we are working together for the benefit of all – for the patients, for the hospital, for the government. Both teams give me a lot of support. I feel we have good relationships and there is a good team culture because we share the same goals.
Currently the health service in Saudi Arabia is going through a very challenging time because we are changing from purely government-run to semi-private and there is a lot of pressure from the government to achieve Vision 2030, which is that healthcare will start to function independently in the same way that it does in many European countries and the US.
Until now, the government has funded everything, but Saudi is trying to move to an insurance-based model under which hospitals will be financially independent. To date, if you needed anything for the hospital you just emailed in a request and it would be supplied. Now we need to do more planning, and everything needs to be justified. These changes mean it is a critical time in healthcare in Saudi. But I think it is the right thing to do because the amount the government is spending on healthcare goes up and up every year. It will be difficult to change but it will happen in time. I think we will get there.
Because I have both clinical and administrative roles, I can understand the problems from the perspective of the patient and the physician, as well as that of the administrator. My leadership training has helped me look at the issues from both sides.
Although I love my patients and my clinical work, perhaps in the future I will choose to focus on a leadership role
Currently I have a part-time role as Assistant to the Chief Operating Officer, which is a huge responsibility. So I am involved in things such as HR, logistics, financial matters and recruitment... I love leadership. When I was little, my dad noticed this in me and he pushed me. Ever since I was a teenager, he asked my opinion on things. It gave me satisfaction that he took my opinions seriously.
I learned a lot studying for my Master’s in Leadership and Innovation in Healthcare. It had a very positive impact on me, and when you learn something you want to make the most of it and keep your skills up to date. Although I love my patients and my clinical work, perhaps in the future I will choose to focus on a leadership role. If I keep growing in my leadership positions and it gives me the same satisfaction as my clinical work, I might switch focus. But it’s a very difficult decision for a surgeon. Time will tell.
Outside of work, I love going to the gym. I usually go straight after work for about 45 minutes, three or four times a week. Sometimes I do a class: I find it gives me a bit of relief and keeps me fit for what is a very physical job. It’s important to show up; every time I miss it, I feel the negative impact, and it affects me badly.
The other thing I love is reading. All my reading is around psychology and
leadership. During the working week I try to meet up with cousins or friends at least once. We are a big family; a lot of nieces and nephews keep me busy.
None of my immediate family work in healthcare, but I have cousins who are radiologists and surgeons. My sisters saw what a struggle it was for me when I was a medical student and I think they were put off by all the books and study. But for me it was just something that was inside me, I had to do it.
Dr Prabhu Ramasamy and family.
I’m not much of a cook but I do like TV, it’s on all the time when I am home. Because I am so busy at work I tend to be a very quiet person at home. It’s calm and organised. I like to listen to music.
Every year I travel to attend the European Society of Coloproctology meeting – this year it was in Paris. I met a lot of friends, people I have known for a long time. In Saudi, we have an annual colorectal meeting in March and I try to go to that each year. At a local level, in Saudi and the Gulf, there are meetings for all the surgical oncologists. I mentor a lot of female surgeons. There are now three times as many as when I started. There are a lot of women who want to pursue careers in colorectal surgery.
My mom, Fatimah, and dad, Saeed, have always been very supportive of my career. When I started medical school in 2001, not all families felt it was acceptable to have a daughter embarking on a career in medicine but they encouraged me all the way. My grandfather, Hamed, on my mother’s side, who passed away two years ago, was very supportive too. I remember in school we had English classes, but studied all the subjects in Arabic so it was a bit of a hassle in university because everything was in English. He bought me a small device like a phone that you could use for translation. It was a big help.
My grandfather was involved first in Aramco, one of the companies involved in the oil trade with America since the 1970s. He was an excellent English speaker and a great advocate for women. I still remember when I got the scholarship to attend RCSI in Dublin. My dad wasn’t sure whether I should go, but my grandfather said, ‘let her go’, and it changed my whole career.” ■
Dr Balhareth at work at King Fahad Specialist Hospital in Dammam, Saudi Arabia; in her office, with her nephew.
BLAZING A TRAIL
Four surgical innovators describe new approaches to modern surgery and some of their incredible firsts
A NEW CARDIAC SURGERY UNIT
Building a complex service from scratch in Cork was an opportunity for DR NIAMH KEENAN, Consultant Cardiothoracic Surgeon, Mater Private Cork
Dr Niamh Keenan set up a new cardiac surgical unit in Mater Private Cork in November 2024. Prior to that she had been working in the Mater Private in Dublin since 2022. From the time she started there, it had always been the aim to start operating out of Cork, and for her first two years, she travelled up and down to Cork each week, seeing patients before and after their operations, and performing surgery in Dublin. She emphasises the positive impact patients experience when they are seen nearer to home.
Setting up a new complex service from scratch has involved a huge amount of planning and organisation, involving all the departments in the hospital. This has included opening an ICU to increase the acuity of the site.
“The collaborative teamwork has been excellent,” says Dr Keenan, “and as a result, we’ve done very well in our first year. In leading the service, my primary focus was patient safety and excellent sustainable outcomes. I honestly believe we are achieving those two aims, and that comes down to good governance, clear objectives, enhanced recovery protocols, and of course, a fantastic team.”
Dr Keenan’s cardiac surgical qualification is from the Australian training programme. She went to Melbourne in 2012 after she had completed two years on the SpR programme in Ireland.
“Initially I went over to do a year on total arterial coronary revascularisation but I liked working there so much that I stayed and did the Australian training programme,” she explains. “Afterwards I spent six months at Papworth Hospital in Cambridge focusing on mitral valve surgery.”
In Cork, Dr Keenan operates one or two days each week. “Because we are a new service,” she says, “we started carefully. Initially we did coronary artery bypass grafting and aortic valve replacements; we have done mitral valve surgery and are planning some ascending aortic procedures. But if I feel a patient needs a more complex operation, for example, I work with my colleagues in Mater Private Dublin.”
Dr Keenan credits her time working at RCSI as a Senior Lecturer, and her time in Australia, which she describes as having a ‘phenomenal’ culture, with her heightened awareness of human factors around how she and her team operate. “In starting the new service,” she says, “I have been very conscious that the leadership and teamwork aspects of how we perform are crucial to safety and excellence. I have focused on creating a culture that I feel will be conducive to excellent work, so that
each day every person brings as much as they possibly can to the team and to the patient. A flattened hierarchy means that anyone who has a concern or a question will speak up. From a safety culture perspective, I really value this. A high standard of governance is crucial, and the whole team in Cork is fully engaged in our outcomes, understands how we are doing, and how we can learn. People enjoy coming to work and enjoy working with each other every day. We’ve had fantastic feedback from patients about the environment and team. They say they know that we’re all working together on their behalf, and they feel huge confidence in coming here to us, which has been really nice to hear.
“We’ve had fantastic feedback from patients about the environment and team...”
“As our department grows, I think we will continue to do more cases and indeed more complex operations, because I think there is huge scope for us here in Cork.”
Dr Niamh Keenan FRACS.
RE-MAPPING THE MESENTERY
A better understanding of the structure, led by PROFESSOR J. CALVIN COFFEY, Foundation Chair of Surgery University Hospital Limerick Group, has vastly improved outcomes for patients
Professor Calvin Coffey studied medicine at University College Cork (UCC), graduating in 1998, and obtained his PhD from the same university in 2005. He went on to Higher Surgical Training and obtained his FRCS in 2009.
“During training,” he says, “I was mentored by many eminent surgeons including Professor Ronan O Connell, Professor Deborah McNamara, Mr Gerry McEntee, Mr Joe Deasy, Professor Paul Redmond and Professor Liam Kirwan. They each inspired me to strive for excellence in my work. As a result of their influence, I developed a particular interest in general surgery and I made the decision to specialise in colorectal surgery.”
Professor Coffey completed his Higher Surgical Training with a fellowship in the Cleveland Clinic where he was exposed to high-volume, complex colorectal surgery using multiple platforms.
On his return to Ireland in 2010, Professor Coffey was directly appointed as the Chair/Professor of Surgery in University Hospital Limerick (UHL). Building on the work he had done in the US he pioneered robotic intestinal surgery in Ireland in 2016.
“We had a number of firsts that year,” he recalls. “We did the first robotic resection for rectal cancer in Ireland. We also did the first robotic surgery for inflammatory bowel disease in Ireland.”
Professor Coffey also developed a new technique for surgery for Crohn’s disease which is progressing internationally towards becoming standard surgical practice. Crohn’s disease is incurable, with high rates of recurrence, even after surgery. It is a condition for which at least 80% of patients will require surgery to treat at some point, with around 40% of those requiring repeat surgery.
“The new approach we pioneered at University of Limerick and UHL dramatically reduces the possibility that followup surgery will be needed to as few as approximately 4% of patients,” explains Professor Coffey. “The new surgical approach requires removal of mesentery adjoining the intestine. The mesentery is the organ in which all digestive organs of the abdomen develop and then remain connected to. It has been reclassified as a new organ as a result of our research. An international trial, recently published in Gastroenterology, validated our approach.
“In 2018 we were the first to designate the mesentery as
an abdominal organ. That work has changed our understanding of the human abdomen. It led to a complete revision of a chapter in Gray’s Anatomy that describes the content and organisation of the abdomen. The new foundation will be published in the 43rd edition of Gray’s Anatomy this year, and marks an important milestone in human anatomy.”
Professor Coffey has also developed a new technique to correct a complex abnormality of embryological development.
Professor Coffey has also developed a new technique to correct a complex abnormality of embryological development, called malrotation.
In recognition of his pioneering work, Professor Coffey has been awarded numerous visiting professorships to institutes such as St Mark’s Hospital, London and more recently, the Cleveland Clinic, Ohio, as well as several prestigious international lectureships.
He has received numerous awards both in Ireland and further afield, including an Alumni Achievement Award from UCC, and the Bengt Ihre Lectureship and Silver Medal. This year he is to be honoured at the Cleveland Clinic Awards with the Ian Lavery Master Clinician Award, one of the highest accolades in colorectal surgery.
Prof. J. Calvin Coffey FRCSI.
HELPING TO PREVENT SECONDARY CANCERS
A new approach to the recognition and treatment of anogenital neoplasia in Ireland was devised by MS PAULA LOUGHLIN, Consultant General and Colorectal Surgeon, Connolly and Beaumont Hospitals
Ms Paula Loughlin studied medicine at University College Dublin (UCD) and went on to do her postgraduate training abroad in Scotland, Australia and Northern Ireland. She undertook a post-CCT fellowship with Professor Eric Rullier at the University of Bordeaux, a large-volume centre specialising in the management of complex rectal cancer.
Having spent six years as a consultant in Northern Ireland, she returned to Dublin and was appointed as a consultant in Connolly and Beaumont Hospitals.
As part of her colorectal practice, Ms Loughlin has recently established an anal dysplasia service in Beaumont, the first of its kind in the country. “Most people are familiar with cervical cancer screening which is aimed at the detection of precancerous changes which can be treated to prevent the development of cervical cancer,” she explains. “However, there is much less awareness of the fact that similar pre-cancerous cells can develop around the anus, with both conditions largely being caused by human papillomavirus (HPV).”
Anal cancer is uncommon in the general population, with just 80 cases per annum diagnosed in Ireland. However, the incidence in high-risk groups, which include those living with HIV, men who have sex with men, and long-term transplant survivors, is increasing – the common denominator being immunosuppression and the prevalence of HPV.
“While it has been long established that treating cervical dysplasia can prevent the development of cancer, until recently there was a dearth of evidence in relation to anal dysplasia,” says Ms Loughlin. “This changed with the publication of the groundbreaking randomised control ANCHOR study (Anal Cancer /HSIL Outcomes Research) in the New England Journal of Medicine in 2022. Over 4,000 patients living with HIV and anal dysplasia were randomised to active treatment or monitoring. The study was stopped early because an interim analysis revealed that treating high-grade anal dysplasia lowered the risk of developing anal cancer by 57%.”
For pre-cancerous growth to be treated effectively, it has to be detected accurately and managed with the aid of high-resolution anoscopy. This was not previously available in Ireland where the standard practice has been to carry out random biopsies at interval with the naked eye, and to treat high-grade changes with topical agents which generally have a low success rate.
Ms Loughlin recently carried out a survey of Irish colorectal surgeons which confirmed most were seeing only a small volume of cases, with the majority using random mapping biopsies and topical treatments.
Before establishing the anal dysplasia service at Beaumont Hospital, Ms Loughlin trained with the International Anal Neoplasia Society (IANS) and its President, Ms Tamzin Cuming, the leading UK expert in the field, who works in Homerton University Hospital and St Mark’s Hospital in London, with whom she maintains close links.
“We are now able to offer what has been the standard of care
in the US and UK for some time,” explains Ms Loughlin. “With the aid of the microscope and the application of acetic acid, microscopic abnormalities can be more accurately detected and treated with electrocautery, the standard treatment used in the ANCHOR trial.”
“During my training, this condition was not well understood and was managed in a variable manner. We now have the evidence to diagnose more accurately, treat, and reduce the likelihood of anal cancer developing.” In the 18 months since the service started, approximately 70 cases have been performed under general anaesthetic. The plan for 2026 is to move to the outpatient setting with the procedure done under local anaesthetic, as is the practice in the US and UK .
“In addition to being able to offer this group of patients a more accurate diagnostic procedure, this will go some way towards alleviating pressure on our day surgery waiting lists,” says Ms Loughlin. “The patient can walk out of the clinic after the procedure. We also plan, with the support of the cervical screening laboratory, to start anal cytology, to stratify risk alongside the anoscopy procedure itself.”
Ms Loughlin says there is a need to develop an anal cancer screening programme for high-risk groups...
Ms Loughlin says there is a need to develop an anal cancer screening programme for high-risk groups, and that IANS recently published consensus guidelines to inform this process. “We will need to train current and future trainees in highresolution anoscopy. In the US, the practice is not confined to colorectal surgeons and includes infectious disease specialists, family practitioners, and nurse practitioners. More widespread implementation of the HPV vaccine, which has significantly impacted the incidence of cervical cancer, will hopefully do the same for anal cancer, but for now our focus is on providing those at risk with better diagnostics and treatment.”
Ms Paula Loughlin FRCSI.
SETTING UP THE NATIONAL SARCOMA SERVICE
In helping to develop the National Sarcoma Service
MR GARY C. O’TOOLE, Consultant Orthopaedic Surgeon at St Vincent’s University Hospital, Cappagh National Orthopaedic Hospital, St Vincent’s Private Hospital, and Beacon Hospital, Dublin, delivered tangible benefits for patients
Mr Gary O’Toole graduated from University College Dublin (UCD) medicine in 1996 and went on to the Basic Surgical Training scheme in St Vincent’s University Hospital for two years before being appointed to the senior registrar scheme in orthopaedics.
“The scheme at that time took somewhere between four and five years to complete. I achieved my FRCS (TR and Orth) in 2003 and St Vincent’s University Hospital appointed me to a proleptic position, allowing me to go away and train for the position to which I had been appointed. I undertook a fellowship in adult hip and knee reconstruction surgery in Sydney, Australia, before undertaking a second fellowship in musculoskeletal oncology in Memorial Sloan Kettering Cancer Center in New York.”
These fellowships were to shape Mr O’Toole’s future career, with a number of the techniques he was exposed to in Sydney still remaining part of his adult hip and knee arthroplasty practice.
“My fellowship in Sydney coincided with the early stages of computer-navigated knee replacement or what is now known as robotic-assisted knee replacement surgery,” he explains. “This technique has since evolved, mostly because of the development of the necessary support software computer systems. Unfortunately, due to start-up costs, it was not something I was able to bring back to Ireland at the time. The practice of robotic surgery for knee and hip replacements is now commonplace in Ireland and has changed orthopaedic practice. It continues to evolve, with companies continuously improving their software and surgical interface. In my opinion, a clear and thorough knowledge and understanding of a standard surgeon-led knee replacement is necessary for all orthopaedic surgeons before undertaking a robotically assisted knee replacement; the techniques are complementary rather than mutually exclusive.”
At the time of Mr O’Toole’s return to Ireland from fellowship, the country’s sarcoma service was delivered by an array of doctors who he describes as ‘medical luminaries’. These included Mr Brian Hurson and Mr Sean Dudeney (surgeons); Dr Fin Breathnach, Professor Des Carney, Dr Jim Fennelly and Dr Peter Daly (oncologists); Professor Peter Dervan and Professor Conor Keane (pathologists); Dr Denis O’Connell and Professor Stephen Eustace (radiologists); and Dr Michael Moriarty (radiation oncologist).
“The service was somewhat ad hoc, spread out over different hospitals and dependent on amazing Nurse Coordinator Margaret Cavanagh who orchestrated all interactions from Cappagh Hospital,” remembers Mr O’Toole. “On my return in 2005, we canvassed aggressively and eventually achieved some formal structure to the sarcoma service as well as official government recognition
through the National Cancer Control Programme (NCCP). Nowadays, while nominally based in St Vincent’s University Hospital, the National Sarcoma Service is a ‘hub and spoke’ model incorporating satellite hospitals including Tallaght University Hospital, Cappagh National Orthopedic Hospital, the Mater Hospital and St Luke’s Hospital in Rathgar. The majority of paediatric sarcoma cases are done at CHI at Crumlin. There is an institutionally supported multidisciplinary conference and what was once ad hoc now adheres to best international standards.”
For this reason alone, Mr O’Toole says the fellowship at Memorial Sloan Kettering Cancer Center in New York was by far the most influential period of his training as it shaped and defined his oncology practice.
“During my time in New York I was fortunate enough to work with my mentor Professor Patrick Boland and I will be forever indebted to him for his training and supervision.
Mr O’Toole says the fellowship at Memorial Sloan Kettering Cancer Center in New York was by far the most influential period of his training as it shaped and defined his oncology practice.
“The practice of orthopaedic oncology is often described as an orphan speciality, lacking the large numbers seen for other, more common, cancers. Despite the organisational progress with sarcoma services in Ireland we are deeply under-resourced in terms of personnel. In November 2025 we will welcome back our latest orthopaedic oncology surgeon, Mr Matthew Lee, who has been on fellowship in Australia and the UK. This brings the total number of orthopaedic oncologists to three, the same number of surgeons that served a smaller population in 2004 when I was first appointed. There is no other cancer surgical subspeciality that has similarly failed to grow and attract doctors during this time period. I hope this changes before I retire.” ■
Mr Gary C. O’Toole FRCSI.
SURGERY: THE SEPARATION
One of eight planned new surgical hubs is now operational with the others underway. Ciara Hughes, Programme Manager with the National Clinical Programme for Surgery, reports on this key programme to enhance surgical care capacity
he planned development of eight surgical hubs across the newly established health regions will provide much needed and very welcome capacity for surgical care in Ireland. This will be the largest investment in scheduled surgical activity in the history of the state. Through the existing Elective Surgery Model of Care, the National Clinical Programme for Surgery (NCPS) has advocated for increased capacity to allow the delivery of scheduled care in a timely and effective manner. This initiative sees the shift by the Department of Health and the Health Service Executive (HSE) to physically separate scheduled and unscheduled care. There are also future plans for four larger elective care facilities in Cork, Galway and Dublin.
The following data gives an indication as to the current status of the surgical waiting lists in Ireland as of August 2025:
• Outpatients 281,826 (surgery amounts to 45.2% of all outpatients waiting lists)
• Day Case 52,970 (surgery amounts to 73.3% of patients awaiting a day case procedure)
• Endoscope 15,270 (surgery amounts to 45.8% of patients awaiting an endoscopy)
• Inpatient 21,300 (surgery amounts 81.3% of patients awaiting an inpatient procedure)
• Overall 371,366 (surgery amounts to 49.2% of overall patient waiting lists: 754,849 + 21,540 suspended)
The demand for day case surgery in particular has increased by 44% between 2015 and 2025 from 36,850 to 52,970. This growing shift towards day case surgery allows the opportunity to safely separate scheduled from unscheduled care by creating elective day case facilities.
The surgical hubs are standalone, ring-fenced surgical facilities containing between two and four operating theatres, treatment rooms and other services necessary to deliver ambulatory, minor and day case procedures. They will provide day surgery for an agreed procedure list and with specific patient exclusion criteria, largely based on the American Society of Anasthesiologists (ASA) grade. The larger elective facilities will initially provide day surgery only but it is envisaged that the second phase will allow inpatient capacity.
The Elective Surgery Model of Care, published by the NCPS in 2011, went a significant way in supporting day case surgery as a means of treating more patients in a timely manner, reducing lengths of stay without compromising on safety. This document also went on to set benchmarks for day case targets for individual specialties. The success of this initiative, along with the Model of Care for Acute
Surgery, published in 2013, significantly reduced the number of bed days used while treating a much greater number of patients.
The British Association of Day Surgery (BADS) has also been promoting day case surgery as a method of improving efficiency, reducing overnight stays and helping reduce waiting list pressures. However, there is still variation in the National Health Service (NHS) between trusts and regions with regard to rates of day case surgery. A similar variation is also found in Ireland. Collectively RCSI and BADS along with GIRFT (Getting It Right First Time) and CPOC (Centre for Perioperative Care), have been urging trusts and health regions to consider ‘day case first’ pathways and reset some procedures to day case as the default.
To support specialties in making this shift from tradition, it is beneficial to have a list that is published and endorsed by the HSE. The NCPS initially undertook an engagement with all of the surgical specialties to define a list of procedures for these facilities. This had been initially carried out a number of years ago with approximately 500 procedures identified, but evidence of the shift in the ‘day case first’ policy was apparent when this number increased to over 750 procedures in 2025 with two further specialties being included, namely dermatology and oral and maxillofacial surgery.
Key to the success of these elective care facilities for both the patients that they serve, and for the staff that work in them, is quality and safety. In 2024, in her then role as Co-Lead of the NCPS, Professor Deborah McNamara, President of RCSI, published Clinical Guidance for Surgical Hubs, which outlined the need for standardisation across the hubs, including suitable procedure and patientselection criteria.
In 2024, Dr Colm Henry, HSE Chief Clinical Officer, commissioned National Clinical Guidance for the Elective Care Facilities. Ms Bridget Egan FRCSI, RCSI
Ms Bridget Egan FRCSI.
Council Member and Co-Lead for the NCPS, was nominated as the Chair of the project, bringing her experience and learnings from the already established Reeves Day Surgery Centre at Tallaght University Hospital.
Representation from surgery, anaesthesia, operations and nursing was sought from each health region. NCPS managed the project but was supported by the other National Clinical Programmes i.e. Trauma and Orthopaedic Surgery, Anaesthesia, Endoscopy, Critical Care and the national training bodies. Another key element was the input from our patient representative.
The following are some of the key topics discussed and agreed upon as part of National Clinical Guidance for the Elective Care Facilities project.
TRAINING
Further to stakeholder discussion, it was unanimously agreed that training should be accommodated at the elective care facilities in order to support the future surgical workforce. In this regard, it was also recognised that the design of the elective facilities, which deliver high-volume, low-complexity care to ambulatory and day surgery patients, provides excellent training opportunities for all healthcare professionals.
GOVERNANCE
It was previously determined that the governance of surgical hubs would lie with a specifically named hospital (either Model 3 or Model 4), but in respect of the elective hospitals other governance options were discussed by the relevant stakeholders and the following was agreed:
• National oversight: That a national governance approach be implemented to ensure consistency, equity of access, activity-based funding approach and to deliver oversight of the national network of elective care provision.
• Regional governance: From an operational and clinical governance perspective, that each elective care facility will sit within a specific health region and will leverage resources and structures at a regional level, including corporate and clinical services.
• Link to Model 4 hospital: Within the given health region, the elective care facility will have a link to an acute Model 4 hospital(s) in order to leverage resources, processes, allow for staff rotation and enable patient pathways.
• Regional implementation: That it will be a matter for each health region to establish the links and arrangements between the elective hospital and the respective Model 3 or Model 4 hospitals in the region, acknowledging this may be constructed differently depending on the circumstances particular to each health region.
PATIENT SELECTION/ESCALATION
In developing the guidance, the requirement to keep the patient’s perspective and safety to the fore necessitated the inclusion of defined patient selection criteria. The National Clinical Programme in Anaesthesia provided patient exclusion criteria in order reduce the risks of either an adverse event at the time of the procedure or postoperatively necessitating a transfer to a Model 3 or Model 4 hospital for admission or in an emergency. A list of exclusion criteria is included in the National Clinical Guidance document. Also included are criteria for when critical care may be required and how, with the support of the National Ambulance Service, patients may be safely transferred.
INFECTION PREVENTION & CONTROL
The Antimicrobial Resistance & Infection Control (AMRIC) team played a significant part in developing the recommendations in the guidance. It is so important that this is embedded in all the elective care facilities from the beginning as this will support Ireland’s third National Action Plan for Antimicrobial Resistance (iNAP3) which is due to commence soon.
SHIFT LEFT
There is an important balance to be found between assuring patient safety while also avoiding delays in patient flow. Learnings from established day surgery facilities outline how patient communication and consent can be optimised and the importance of managing patient expectations from the start. For example, some of the day surgery facilities in the NHS promote the use of chairs rather than beds pre and post-operatively where appropriate. Psychologically for the patient, a bed can evoke that feeling of a hospital stay whereas a chair suggests a much shorter visit and reduces stress for the patient. The new elective care facilities provide the opportunity to change the culture and move away from how things have traditionally been done.
The guidance aims to support the philosophy of ‘day surgery first’ as opposed to an inpatient stay for agreed procedures. Further efficiencies can be found by moving some procedures from theatres to Minor Ops rooms and Minor Ops procedures to outpatient treatment rooms.
One major source of waste is the requirement for patients to change into hospital gowns. As well as compelling patients to spend more time in hospital than necessary, there are concerns that it reduces patient autonomy and dignity and also occupies valuable nursing and support staff time. From a sustainability and infrastructure viewpoint, it increases consumable use, laundry and adds to floor space waste. To the maximum extent, patient autonomy should be supported by enabling patients to wear their own clothes where appropriate. The National Clinical Guidance document promotes this shift by listing the procedure, the appropriate place, whether a chair or bed is needed, and the appropriate attire.
PATIENT FLOW
In learning from the experience of others, simple measures have been to identified to maximise patient flow. These include scheduling diabetic patients first; having staggered arrival times; and adopting the ‘SiptilSend’ policy where appropriate.’
In relation to the latter measure, it has been found that allowing people to sip water until they are about to undergo surgery means that they are hydrated and more comfortable with less nausea, fewer headaches and a lower chance of needing a postoperative intravenous drip. These are just some examples that are outlined in the National Clinical Guidance document.
Ideally the amount of time spent in an elective care facility should be kept to a minimum for any patient. There is no age limit for adult patients undergoing day case surgery. In fact day case surgery is of huge benefit to the older person as their procedure is much less likely to be cancelled, which mimimises the disruption to their routine and avoids prolonged fasting. Facilities need to be mindful of patients with neurodiversity or dementia. In order to minimise disruption and avoid stress this group of people should be scheduled earlier in the day.
CONSENT
Seeking consent should occur as an ongoing process rather than as a oneoff event as per the National Consent Policy (2023). As part of the project, the NCPS carried out a review of all available day surgery consent forms and
Prof. Brian J. Mehigan FRCSI.
also interviewed staff from several hospitals regarding the consent process. There was huge variation in both process and documentation from site to site.
To support standardisation, the optimum aspects of the various consent processes were identified and integrated into one agreed approach that can be adopted by sites. This standardised consent process will serve to support the management of scenarios where there may be an advanced healthcare directive or where there is a question of capacity. It is further recommended that all patients should be provided with a copy of the consent form at the point at which the decision to undergo surgery is made. No patient should be asked to sign a consent form on the morning of surgery having not had the opportunity to read it in advance nor to have any questions answered.
PERFORMANCE METRICS
The metrics and KPIs implemented by the elective care facilities need to align with the overall operational goals and strategy in order to demonstrate good return on investment and cost efficiency. This will be achieved by monitoring all aspects of the elective care facilities process in addition to patient reported outcomes. The work which has commenced as part of the National Perioperative Patient Pathway Enhancement Programme (NPPPEP) is focused on optimisation of current capacity. The NCPS is working closely with NPPPEP and the National Office of Clinical Audit (NOCA) to ensure that the establishment of the new elective care facilities enhances the goals and objectives of this process and is aligned with the best practice framework to support efficient use of new operating theatre capacity.
The National Clinical Programmes in the HSE seek to clinically design and innovate new ways of working, identify new successful initiatives and support knowledge-sharing of best practice, either through education or applying for funding. Two such initiatives are in operation in sites around the country and are suitable for implementation in the elective care facilities. The first such initiative is Patient Initiated Review (PIR), for which the HSE has already identified an implementation framework in the Patient Initiated Review National Guidance Document.
Patient Initiated Review, also known as Patient Initiated Follow-Up (PIFU), is a healthcare approach where patients or their carers can proactively schedule follow-up outpatient appointments as required, rather than waiting for a prearranged, fixed appointment. PIR aims to empower patients by giving them more control over their healthcare journey and allowing them to access care when they need it, rather than being tied to a rigid schedule. PIR will help optimise new patient appointment availability, reduce unnecessary follow-up appointments, enhance patient experience and autonomy and reduce need on administration.
The second initiative that is suitable for implementation in the elective care facilities is Criteria Led Discharge (CLD), which has been piloted and embedded in the NHS and is currently in use in some hospitals in the Republic
of Ireland.Key to the success of CLD is having a multidisciplinary team agree on a set of discharge criteria that is specific to the patient’s procedure. It then allows for an appropriately trained clinical staff member to discharge the patient once they meet the agreed-upon criteria.
Innovations in surgery have revolutionised patient care, making procedures safer, less invasive, and more effective. Advances such as robotic-assisted surgery, minimally invasive techniques, and enhanced imaging technologies have improved surgical precision and reduced recovery times. The integration of AI and machine learning into surgical planning and intraoperative decisionmaking is enabling personalised and data-driven approaches. Developments in 3D printing allow for custom implants and surgical models, enhancing preoperative planning and training. Additionally, breakthroughs in regenerative medicine and bioengineering are opening new frontiers in tissue repair and organ transplantation. These innovations are not only transforming outcomes but also reshaping the way surgical care is delivered across disciplines.
The integration of new technologies into the elective care facilities is essential for enhancing patient care. Implementing a unified digital health record system, integrating AI diagnostics and image-guided surgery platforms would improve data accessibility, operational efficiency, and ultimately, patient outcomes.
The New Technologies for Future of Surgery in Ireland Working Group Report, which was published by RCSI in 2024 outlines a series of key recommendations that will need to implemented in the elective care facilities as new and disruptive technologies continue to play a crucial part in the development of surgical practice.
Research and research methodologies will be required to evaluate how these new technologies improve the quality of patient care, improve outcomes, reduce complications and adverse incidents, support productivity and manage costs.
SUSTAINABILITY
The HSE is committed to achieving net-zero emissions no later than 2050, delivering healthcare which is environmentally and socially sustainable. The Sustainability Principles and Practice in Surgery Report published by RCSI outlines the means by which any new elective care facility can reduce the environmental impact of surgical care by interventions throughout the surgical care pathway.
These practices should be embedded in the development of the elective care facilities both from a process flow point and in the infrastructural design. The four Royal Colleges have produced a Green Theatre Checklist to support current best practice in delivering sustainable surgical care, before, during and after surgery which also should be adopted at all elective care facilities.
The whole patient perioperative journey can be streamlined by optimising the patient’s health preoperatively, reducing unnecessary hospital visits by digital-health engagement and appropriate use of ambulatory care.
LOOKING FORWARD
The Mount Carmel Surgical Hub in South Dublin opened earlier this year and the North Dublin Hub is scheduled to open by early 2026. Many of the new regional surgical hubs are already under construction. The second phase of the elective care programme will plan for the larger elective care facilities in Cork, Galway and Dublin. These facilities present the first real opportunities for over a decade to deliver more timely access to surgical care in Ireland which will benefit the patients and the staff who look after them. It is the time to embed the ‘day case first’ philosophy and shift the traditional way of doing things to a more efficient, but equally safe way of providing surgical care.
Ciara Hughes.
STRENGTHENING OPERATIONAL GRIP: A STRATEGIC APPROACH TO THEATRE TRANSFORMATION
NPPPEP provides local teams with an enhanced operational grip for operating theatres to increase access for surgical patients, says Charlie Dineen, RCSI Technical Lead for NPPPEP
The National Perioperative Patient Pathway Enhancement Programme (NPPPEP) was established to optimise the use of operating theatre resources to better serve patients. Based on the principles of the Transforming Theatre Programme design, which was rolled out as a pilot in the South/South West Hospital Group, NPPPEP integrates four foundational elements:
1. Management Structure – ensuring the presence of the right multidisciplinary team and governance framework.
2. System of Measures – providing a standardised baseline for improvement through bespoke metrics.
3. Management System – facilitating regular, structured meetings of the core improvement team to review measures for improvement, set direction, and track progress.
4. Improvement Methodology – driving and sustaining impact through a scientific improvement methodology.
At the heart of the programme is a robust measurement system known as the Theatre Measurement Model (TMM), developed by RCSI. This model uses standardised operational and technical definitions and is driven by five key timestamps along the patient journey: anaesthetic start, surgery start, surgery finish, anaesthetic finish, and theatre exit.
These inputs generate detailed outputs that offer a clear breakdown of theatre operating room capacity, access, flow, and usage. Metrics include on-time starts, interoperative intervals, underruns, overruns, patient volumes, percentage utilisation, and cancellations. Additionally, Gantt charts provide a dynamic visualisation of patient flow and session utilisation.
Together, the TMM outputs and Gantt charts form a powerful toolkit for theatre schedulers, enabling more accurate planning of elective care. This approach accounts for case length/complexity variation, scheduling load levels, and expected utilisation rates – ultimately supporting more efficient and patient-centred flow. The TMM enables bespoke modelling by specialty, allowing for the prediction of throughput levels that can be aligned with surgical waiting list demand. This modelling provides valuable insights into how theatre operating-room resources are utilised. Any unused capacity can then be reallocated to other specialties or patient groups as needed.
According to Professor Eleanor Carton, RCSI Clinical Lead for NPPPEP, “Being involved as Clinical Lead with NPPPEP has brought home the degree of frustration felt by surgeons across the
country that they are unable to provide the best care for their patients due to lack of access to and the inefficient use of theatre – where daily delays, cancellations and interruptions to lists create a difficult working environment and sees waiting lists grow – all made worse as their calls for improvement and arguments for resources are left unheard. RCSI responded to this need for change by developing the Transforming Theatre Programme design now incorporated into NPPPEP. Through this programme and the standardised data produced, a common language to describe how theatres are used has evolved. This facilitates clinicians in discussing theatre use in a factual manner with management and for datadriven decisions to be made.”
Professor Carton added: “Witnessing sites move through each stage of the programme and have their individual ‘light bulb’ moments where the data starts to ‘click’ and the opportunities reveal themselves is very rewarding. Everyone on the NPPPEP team takes great pride in seeing sites use their own data to make the case for the changes they need to drive improvement.”
NPPPEP follows a structured approach over a six-month implementation phase. The design builds progressively – from team formation and the implementation of the measurement system to the establishment of formal fortnightly touchpoint meetings. These meetings follow set agendas focused on reviewing and interpreting data, drilling down by room and specialty, generating models of potential capacity, and setting initial SMART goals. The local team then operationalises the required changes to drive impact and develops a plan to sustain and build on the gains made.
Central to the programme’s delivery are weekly informal and supportive interventions with the local core NPPPEP team, facilitated by the technical partner team from RCSI. These sessions focus on fully understanding the data and how the various balanced suite of metrics are calculated. They also explore the context and narrative behind the data—particularly constraints and barriers across the perioperative pathway that limit patient flow and theatre throughput. Scheduling operating rooms is inherently complex, as it depends on multiple interconnected processes such as bed availability, recovery capacity, preoperative assessment, diagnostic services, and patient flow from outpatient departments. Success requires a fully engaged multidisciplinary team – including surgery, anesthetics, nursing, business operations, scheduling, and site management – working collaboratively to ensure patient-centred care and efficient use of local skill sets and resources.
Central to the programme’s delivery are weekly informal and supportive interventions with the local core NPPPEP team, facilitated by the technical partner team from RCSI.
CHARLIE DINEEN
The programme has been implemented in 22 hospitals across five health regions, encompassing 135 operating theatre rooms. It is highly effective at assessing theatre operating room capacity at a regional level. It supports strategic alignment of waiting lists and demand across regions. The standardised measurement system used across all Model hospitals enables capacity and access data to be aggregated in a tiered structure, providing clear and actionable insights for both regional and local hospital decision-makers. ■ For more information on NPPPEP, contact charliedineen@rcsi.ie. RCSI is the Technical Partner for NPPPEP which is led from the HSE’s Strategic Programmes Office.
Charlie Dineen.
Prof. Eleanor Carton.
BACK TO THE BEGINNING
Mr Martin Caldwell FRCSI is a Consultant General Surgeon at Kingsbridge Private Hospital in Sligo, having retired from the HSE and Sligo University Hospital earlier this year
artin Caldwell was born in the Sheil Hospital, Ballyshannon, where his mother, Maura, worked as a nurse. He grew up in Donegal Town, the eldest of five children, four boys and a girl. His father Séamus worked with his own father in their local wholesale business. Maura had trained in Liverpool but took time out to raise her family. She returned to nursing in her 50s, her salvation after Séamus died in 1993 at the age of 52. Now 85, she continues to live independently in Donegal.
Martin attended Hugh Roe Boys National School in Donegal Town. He was a sporty youngster, running with the local John Bosco Athletic Club, and won two All-Ireland silver medals in the 800m at Under 13 and Under 14.
“When it came to secondary school, I got a scholarship to board at St Macartan’s in Monaghan, and it was there I got into Gaelic football,” he recalls. “I competed at Ulster Senior Schools’ level right up to the MacRory Cup, and also played handball, competing nationally. I wasn’t stuck to the books but I always seemed to manage to do enough to get by comfortably. I wouldn’t describe myself as academic, but I wouldn’t have struggled with school either.”
Martin planned to study electronic engineering at the National Institute for Higher Education (NIHE) in Limerick, but a couple of months before he sat the Leaving Cert, the President of St Macartan’s College asked him if he had ever thought about medicine. “I hadn’t,” says Martin. “We didn’t get much career guidance in those days. I ended up submitting a change of mind form, with medicine at Trinity College Dublin at the top. We had a maths teacher at school who was fascinated with Trinity and wanted to go back and study dentistry, and while I was in the School of Medicine, he did go back as a mature student.”
Martin started in Trinity in 1981, and lived in Castleknock, sharing a house with a friend from Donegal, later living in rooms on campus. “Trinity was great,” he remembers. “Being from the country, I liked how central it was. A lot of my friends from Dublin lived at home and were always travelling in and out of the city centre, but the people from the country just went exploring. At first you’d get lost, but eventually you’d find your way around.”
At Trinity, Martin played football and represented the GAA Club on the University’s sports committee. He spent his pre-clinical years on campus, and was assigned to Baggot Street Hospital for most of his clinical years. “When I
Mr Martin Caldwell FRCSI, with Alfie.
was doing my finals I didn’t really know what I wanted to do,” he says. “I thought I wanted to be an obstetrician. But during my intern year, I was under Mr David Lane who didn’t have a lot of junior staff. As his intern, I got a lot of exposure in theatre, which was unusual. I decided surgery was the career path for me.”
In the summer of 1988, immediately after his intern year, Martin worked for two months as a locum surgical SHO at the Ibn al-Bitar hospital in Baghdad.
“The hospital was run by an Irish company, PARC, on behalf of the Iraqi government, and a lot of Irish doctors went out there. Baghdad was a very interesting city; you just had to be careful where you went or where you pointed your camera. The people and the country were beautiful. I got to see Babylon and the area between the Tigris and the Euphrates, and some of the golden mosques. It was about three years before the Gulf War, when it all changed. I feel lucky to have had that experience.”
On his return to Ireland, Martin demonstrated anatomy in Trinity for a year, got married to his wife Dawn, sat the pre-Fellowship exam and applied for and was accepted onto RCSI’s surgical training scheme.
“The old pre-Fellowship scheme was a three-year programme, and I completed two years as an SHO in Dublin between the Adelaide, the Meath and St James’s, and then a year as a registrar in Waterford.
“My senior registrar in my first SHO job in the Adelaide and Meath was Mr Ronan Waldron, who was a great teacher. At the time, laparoscopic surgery was just starting and Professor Frank Keane had us in on Saturday mornings with an upturned cardboard box, using the instruments to skin a chicken for practice.”
Martin and his wife had their first child, Adam, in 1991 and he decided to do his research at home rather than go abroad.
“A lot of my peers went to the US to do their research, but during the year I spent teaching anatomy in Trinity, I had got involved in a research project in Professor Tom Hennessy’s department. Following my year in Waterford, I spent two years in Trinity doing full-time research, mostly in upper GI, which turned out to be quite a productive period. I completed a doctorate in medicine in 1995.”
“During my intern year, I was under Mr David Lane.
As
his intern, I got a lot of exposure in theatre, which was unusual. I decided surgery was the career path for me.”
After his research, Martin spent a year as a registrar in Cheltenham General Hospital in the UK. “You had to go abroad and experience a different system. Cheltenham was the equivalent of what we now call a Model 3 hospital in that there were experienced surgeons doing complex work, but also had the generality. There was a vascular surgeon called Keith Poskitt and an upper GI surgeon called Tony Goodman; they were very good to me and taught me a lot.”
Throughout his career, Martin has operated on children as well as adults, thanks to the training he received in both Waterford and Cheltenham.
“During the year I was in the UK, I applied for Higher Surgical Training and started the programme in July 1995. For the first year I was in Beaumont Hospital with Mr Brian Lane and Mr Henry Osborne, both sadly now deceased. They were two very good teachers, and important mentors to me.
“For my second year I went to the Upper GI unit in St James’s under Professor Tom Hennessy. Professor John Reynolds also started as a consultant in the unit the same year. My third year was spent in the Adelaide and Meath with excellent mentoring from Mr William ‘Bill’ Beesley, Mr Martin Feeley and Professors
CLOCKWISE FROM LEFT: Mr Martin Caldwell in theatre; with his wife Dawn and three children Adam, Kate and Jack; with Dawn; with his mum Maura; taking part in the New York City Marathon in 2009.
Arthur Tanner and Professor Frank Keane. Two weeks before finishing, we moved out to the new Tallaght University Hospital. For my final year, I was back in Beaumont Hospital, mainly with Professor Paddy Broe and Mr Henry Osborne. This final year of Higher Surgical Training set me up well for the future.”
At the end of the year, consultant posts were thin on the ground. While he would have been happy to work anywhere, Martin had ‘a hankering’ to live by the sea, and so when a job came up in Sligo he applied and sat the interview in June of 1999. Once he heard he had the job, he was able to take the summer off and started in post in October.
“At that time,” Martin remembers, “the hospital had about 330 beds and I was one of two surgeons. The on-call was busy, but a lot of the registrars had come from abroad and were quite experienced, so we had a lot more back-up than we did later.
“When I retired from the HSE earlier this year, I was on a one in four, and that was busier and more stressful than the one in two ever was. That’s down to population growth and people living longer, because older people have more complex problems. The hospital changed hugely over the 25 years I was working there. There were fewer beds but, like every hospital in the country, it has become very busy from a medical point of view with emergency admissions. When I started, there were two surgeons and one emergency department consultant, and when I finished there were four surgeons and eight emergency department consultants.
“When I started in Sligo I would have been doing a lot of surgery that now would not be within the realm of the general surgeon. We operated comfortably on the thyroid, upper GI tract, stomach, and colon, and dealt with vascular emergencies and varicose veins. We had more operating time, with access to the operating theatre at least two days a week. But gradually, as specialties developed, some of those treatments became more finessed and better left to the specialists in those areas, although we retained the colon cancers throughout.”
“Some would find working and living in a smaller community claustrophobic but I enjoyed being able to give something back.”
In 2001, a day unit with two dedicated theatres opened within Sligo Hospital. For years that worked very well, as Martin and his colleagues were able to move many of the cases that would previously have involved overnight stays to day cases. But reducing the number of overnight beds had an impact on planned surgeries and there were many cancellations.
“Some would find working and living in a smaller community claustrophobic,” he says, “but I enjoyed being able to give something back. Every patient was either a neighbour, a friend or had some personal connection and fortunately most things worked out well.
“Because I had the training, in Sligo I was able to operate on children over the age of one. It was mainly routine surgery, procedures such as hernias, circumcisions, orchidopexy, emergency appendicitis, and the torsion of testes.”
Having retired from the HSE earlier this year, Martin now works two days a week in a small private day hospital in Sligo. None of his three children – Adam (34), Kate (30) or Jack (24) – has followed him into medicine.
Martin currently lives between Strandhill and Dublin with his wife, Dawn, and is enjoying the extra free time that partial retirement has brought. He completed the Chicago Triathlon in 2004 and the New York City Marathon in 2009, and has taken up cycling again. He works on improving his golf game at Strandhill Golf Club, and is in the enviable position of having a good friend who has a boat between Sligo (summer) and Howth (winter); he enjoys racing.
“I go up and down to Dublin often, and most weekends are long weekends. I plan to keep up my private practice for a few more years. One of the problems with the system is that in the smaller hospitals there’s no opportunity to stay on and mentor without having to do the busy on-call. But once you’re over 60, the on-call wears you down.
“In the UK, between 55 and 60 you can come off the on-call rota but keep working and do the complex surgery. But in the smaller hospitals here, there are not the staff to facilitate that. If everybody over 60 had gone off call in our hospital, there would have been one surgeon left to do the on-call.
“All the studies suggest that if you have an emergency department you can’t run an acute hospital without general surgery, and you should have eight surgeons. The problem is trying to fill their work day because elective surgery has been reduced so much that it’s hard to keep everybody happy. The new surgical hubs may help, and Sligo has been approved for one; that will be protected surgery.”
Martin was involved in surgical training at RCSI for many years at RCSI for many years, served as an examiner, taught on Advanced Trauma Life Support courses, and still teaches on the Care of the Critically Ill Surgical Patient course.
“I’ve been involved in the College reviews of paediatric surgery outside of the children’s hospitals. When you work in a smaller unit and you’re busy with oncall, it’s nice to go to courses where you’re teaching, meeting peers and getting away from the day-to-day work, but still stimulated and giving back.” ■
CLOCKWISE FROM TOP LEFT: Receiving his degree at Trinity College Dublin; with his wife Dawn; meeting a monkey while travelling.
KNOW THE CODE
As surgical care continues to be delivered in a complex and rapidly changing environment, the recently revised Code of Practice for Surgeons provides a set of principles that every surgeon can refer to
n September 2025, RCSI launched the third edition of the Code of Practice for Surgeons as an articulation of a straightforward set of principles that surgeons may use to inform their own practice. Updated to have regard for several legislative and regulatory changes, the process of revising the Code involved significant consultation with the wider community of Fellows and Members.
“The first edition of the Code was published in 2004 and a further edition issued in 2018,” explains Mr Dara Kavanagh FRCSI, Head of Surgical Policy and Practice Development, RCSI, who authored the latest Code. “The publication of the updated ninth edition of the Guide to Professional Conducts and Ethics for Registered Medical Practitioners was the impetus for the review while we were also mindful of the commencement of legislation including the Assisted Decision-Making (Capacity) Act 2015 (2022) and the Patient Safety (Notifiable Incidents and Open Disclosure) Act 2023.”
THE REVIEW PROCESS Working closely with colleagues in the Department of Surgical Affairs as well as the members of the Professional Development and Practice Committee, the Committee for Surgical Affairs and RCSI Council, Mr Kavanagh spearheaded a comprehensive review process. “We adopted an iterative approach to the review, allowing for continuous feedback and refinement of the draft guidelines,” says Mr Kavanagh. “The first phase was to undertake desk research, and it was particularly useful to look at the commentary arising from the change to the Guide to Professional Conducts and Ethics for Registered Medical Practitioners. This led me to engage with stakeholders including Medisec Ireland, which had published a series of summaries on the Medical Council’s Guide.”
After gathering valuable insights from several stakeholders, Mr Kavanagh and his team commenced the process of making amendments to the text of the second edition of the Code. “Throughout the drafting phase we were very grateful to have the input of the members of the Professional Development and Practice Committee, led by Mr Paddy Kenny FRCSI, RCSI Council Member as well as the Committee for Surgical Affairs, led by Professor John Quinlan FRCSI, RCSI Council Member,” Mr Kavanagh acknowledges.
By March 2025, after nine months of review, Mr Kavanagh and his team were able to share a draft with Fellows and Members and sought feedback via a survey that allowed the community to share their opinion on the suggested amendments to the text.
“We received very constructive feedback that prompted a lot of discussion,” shares Mr Kavanagh. “It was interesting to see one school of thought that proposed that the Code should be drafted to have regard for the wider surgical team rather than focused on the individual surgeon. It’s an understandable approach when you consider the realities of multidisciplinary teams, but at the same time we did not want to dilute the concept of the individual surgeon’s responsibilities as well as their ability to make an informed professional judgement.”
The recognition that surgeons must at times exercise their own judgement
is something that is clearly stated within the Code. “I think it was important to call this out,” explains Mr Kavanagh. “In drafting this Code, we constantly referred to the need for a set of principles rather than a codified rulebook. This is reflected in the language throughout the edition. There was plenty of discussion around the use of ‘must’ versus ‘should’.
“We also felt it was crucial to strike a balance between general guidance and addressing specific scenarios. As part of the survey of Fellows and Members, we did receive suggestions to include additional amendments but after much consideration it was felt that these could better be addressed via further contextspecific guidelines, and I know work is ongoing in this regard,” said Mr Kavanagh.
THE REVISIONS In addition to incorporating revisions arising from legislation, such as the Patient Safety Act (2023), the amendments to the Code reflect wider changes in society, in technology and indeed in surgical practice.
“For instance, in relation to surgical practice, the revised Code recommends that doctors commencing robotic approaches to surgical care should read Robotic Surgery Governance in Ireland: Guide to Good Practice. It also calls out the fundamental importance of mentoring, going so far as to state that a surgeon must avail of mentoring when using new operative procedures or technology for the first time until signed off as competent to complete independently,” explains Mr Kavanagh.
“The recommendation that surgeons should also offer a chaperone when they are required to perform an intimate clinical examination has evolved such that they must now offer a chaperone whilst also documenting this offer as well as acquisition of patient consent in the medical notes, which is a new addition to the Code also,” Mr Kavanagh advises. “The concept of establishing and maintaining trust with patients also extends to advice that surgeons should consider how their relationship with patients might be impacted by comments or images made on private social media accounts.
“Practical advice in relation to telemedicine and the management of the patient’s record including matters such as consent to and storage of video or photography are also new in this edition. These considerations reflect the rapid pace of change that has occurred since 2018 when the second edition was published and is in no small part influenced by developments precipitated by COVID-19,” Mr Kavanagh observes.
COMMUNICATING THE CODE The Code has been published on the RCSI website and circulated via various newsletters. Mr Kavanagh is keen to ensure that the community takes the time to read and familiarise themselves with the publication. “It contains principles that are of relevance to everyone from medical students to trainees to established surgeons. Additionally, while the legislation and regulatory requirements are specific to the Republic of Ireland, I do feel the guide will be of use to all Fellows and Members, regardless of their country of practice.” ■ A copy of the Code is available at rcsi.com/dublin/news-and-events.
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THE COLLES Q&A
PROFESSOR MICHAEL E. KELLY FRCSI
This Consultant Colorectal Surgeon addresses some Proustian questions
rofessor Michael E. Kelly is a medical graduate of Trinity College Dublin (2010). Following Basic Surgical Training, he obtained his MCh from RCSI in 2015. He completed the Specialist Training in General Surgery Programme (CCST) in 2021 and obtained his PhD in Medicine from University College Dublin in 2022.
Subsequently, he worked as a Locum Consultant Surgeon in St James’s Hospital before undertaking an Advanced Pelvic Cancer Fellowship at the Peter MacCallum Cancer Center in Melbourne, Australia. He returned to Ireland in July 2023 as a Consultant Colorectal Surgeon with a special interest in advanced pelvic malignancy at the Trinity St James’s Cancer Institute. More recently, he has been appointed the Chair of Surgery at Trinity College Dublin and St James’s Hospital.
He has a strong research portfolio with over 300 peer-reviewed publications centered on collaborative research in colorectal surgery, focusing on outcomes and survivorship.
When and where are you happiest?
The likely version: Away with my wife, Giao, and my boys, Dillon and Darragh. Ideally, at a beach, where I can swim at 6pm and not get burnt like a lobster. Less likely: Sitting in Croke Park watching Armagh win a third All-Ireland Final with my father. What is your ideal evening?
Dinner with my wife, finishing with a nice whiskey or two.
If you could research and write a book on any subject, what would it be?
I love history, especially Irish history related to the North of Ireland and the Troubles. We are in a time when many people involved in this important part of Irish history won’t be around much longer, and there’s still so much we don’t know.
What relaxes you most?
A run, especially when it’s lashing rain. What is your greatest fear?
Heights, despite my father’s best efforts to correct this.
Had you not decided to become a surgeon, what other career might you have chosen?
A pilot… one would wonder. When did you decide you wanted to become a surgeon?
In 2003, shortly after my late brother Stephen was diagnosed with a glioblastoma.
Prof. Michael E. Kelly FRCSI.
“Over the years, I’ve learned how NOT to do things from many people, including myself. These are the best lessons. ”
Do you have a mantra to live by?
This too shall pass.
What do you consider your greatest achievement?
Like my proudest moment… my two sons. What living world figure do you admire?
Our Uachtarán (Michael D. Higgins), who is a great orator with an even greater sense of social justice (soul).
What is your favourite childhood memory?
Summer holidays as a kid with my parents and my brothers in the south of France, playing badminton well into the evening.
Name your favourite writer.
I don’t have one. Unfortunately, I am one of those people who don’t read fiction. I read non-fiction, mainly history and autobiographies. But one of my favourite books is How We Die by Sherwin Nuland. If you could invite any historical figure to dinner, who would it be?
So many... Michael Collins, JFK, Abraham Lincoln, Martin McGuinness... much of history is a sanitised version to fit into the narrative that follows. I want to know the truth.
Would you have any advice for your younger self?
Enjoy training more: remember, it’s a marathon, not a sprint.
What has been your proudest moment? The birth of my two sons… nothing else can compare.
Who have you learned the most from in your life?
It’s a tough lesson. Over the years, I’ve learned how NOT to do things from many people, including myself. These are the best lessons. How does a surgeon in 2025 cope with pressure?
Work in a team that supports each other. Having great colleagues who collaborate makes life easier. What is your greatest extravagance?
My whiskey collection.
Which talent would you most like to have?
To play hurling at a competitive level or to be a polyglot.
What is the wisest thing you have ever said?
Don’t drink the Kool-Aid… decide for yourself. How do you have fun?
It depends on whether the kids are with us or not.
Name one virtue all surgeons ought to have.
The ability to work as a team.
Name one vice no surgeon should have. An infallibility complex… you are not God.
Name three things you would like in your future?
Watching Armagh win more All-Ireland Finals. Watching my boys grow into adults and build their lives. Travelling the world in retirement. ■
FAVOURITE BOOK: How We Die by Sherwin Nuland.
FANTASY DINNER GUESTS: Michael Collins, JFK.
HAPPIEST: Watching Armagh win at Croke Park.
ADMIRING: President
FAVOURITE MEMORY: Summer in France.
SCOPE EVENTS
WINTER AND SUMMER CONFERRINGS AND PRESIDENT’S RECEPTIONS
RCSI welcomed over 900 healthcare professionals into its global community of Fellows and Members at Winter and Summer conferring ceremonies held at its historic St Stephen’s Green campus. In surgery, the awards conferred included Fellowship of RCSI (JSCFE; encompassing Ad Eundem, Cardiothoracic, General Surgery, Ophthalmology, Otolaryngology, Plastic Surgery, Trauma and Orthopaedic Surgery, Urology and Vascular Surgery), and Membership of RCSI (including ENT and Ophthalmology). RCSI’s highest distinction of Honorary Fellowship was awarded to Sr Orla Treacy, Director of the Loreto Mission in Rumbek, South Sudan and Professor Dato’ Dr April Roslani, Professor of Colorectal Surgery and former Dean of the Faculty of Medicine at Universiti Malaya for their outstanding achievement in surgery and in other areas. Before both ceremonies, RCSI President, Professor Deborah McNamara hosted receptions for newly conferred Fellows and their families, to congratulate them on their incredible professional achievement and celebrate their commitment to furthering the field of surgery. In the last 12 months, RCSI welcomed a total of 82 Fellows, representing nine specialties, to the Fellows and Members community.
Dr Bisola Salaja and Dr Faryal Faryal.
Dr Gavin Dowling and Dr Claire Stenson.
Mr Andrew McCanny and Aideen McCanny.
Mr Abinash Panda with Godhuli Patri and Amaya Panda.
Mr Ken Patterson and Gráinne O’Reilly.
Mr Mohamed Albagir, Ms Emer O’Connell and Ms Lauren O’Connell.
Ms Ailbhe White Gibson and Ms Stefanie Croghan.
Ms Christine Kiernan with children Aoibhínn and Serena Bergin.
Dr Abdelrahman Mohamed and Dr Sathiyaraj Subramaniam.
Dr Fred Kenny and Mr Paddy Kenny.
Dr Eman Hamza and Prof. Deborah McNamara.
Dr Aisling Moriarty and Mr Brian Moriarty.
Mr Joshua Hayes with Ciara Hayes and baby Tommy.
Mr Muhammad Ajmal Khan, Ms Carolyn Cullinane, Mr Paul McCarroll, Mr Mudassar Riaz, Mr Jameel Rehman.
Dr Emily O’Hanlon, Dr Fergal Moran, Dr Tiarnán Daly and Dr Larissa Manojlovich.
Ms Olwyn Lynch and Mr Killian Daly celebrate with family including Prof. Thomas Lynch and baby Ellis.
PENANG CONFERRING
In June, 25 new Members joined our community in Penang, Malaysia. Professor Deborah McNamara, RCSI President, Professor Cathal Kelly, RCSI Vice Chancellor and CEO, Professor Tracy Robson, Deputy Vice Chancellor for Academic Affairs, and Judith Gilroy, RCSI Associate Director for Academic Affairs, travelled to Penang and joined Professor Karen Morgan, RUMC President to recognise and celebrate their achievements at the annual RCSI Fellows, Members and Diplomates Conferring Ceremony.
Dr Kuhan Ambikapathi and his guest.
Dr Harison Sevenathan, Dr Pavin Kaur Bal, Dr Kumanan Perumal, Dr Nazurah Binti Jaafar Sidek and Dr Yugaraj Thangavelu.
Dr Yiek Siew Hong and daughter with Prof. Tracy Robson and RCSI President, Prof. Deborah McNamara.
RCSI Members, Penang 2025.
FAMILY FUN DAY In February, the Fellows and Members Office hosted the first ever Family Fun Day for Fellows and Members and their loved ones. From fun-filled activities to great conversations and shared moments, it was wonderful to see our community come together. Families enjoyed face painting, arts and crafts, giant Lego, sports challenges, storytelling, and learning time at RCSI SIM Centre, courtesy of Simulation Technician Robyn and student volunteers.
MILLIN NETWORKING BREAKFAST
Almost 400 Fellows and Members, surgical trainees, NCHDs and researchers focusing on surgical research and training, attended the Millin Meeting on 8 November 2024. At the start of a busy day, the Fellows and Members Office organised a Networking Breakfast which provided attendees with an opportunity to connect ahead of an exciting programme of events. ■
SCOPE DIARY
Fellows, Members and Affiliate Members of RCSI are warmly invited to mark your calendars for the year ahead and be sure to register for the following events
RCSI Millin Meeting
Friday 14 November 2025 | RCSI Dublin | Paid event, registration is open.
Fellows and Members Networking Breakfast, Millin Meeting 2025
Friday 14 November 2025 | RCSI Dublin | Free to Millin Meeting attendees.
RCSI Fellows, Members and Diplomates Conferring Ceremony, Dublin
Monday 8 December 2025 | RCSI Dublin | Free for eligible candidates.
RCSI President’s Reception for newly conferred Fellows of RCSI and their guests
Monday 8 December 2025 | RCSI Dublin | Free for eligible candidates.
RCSI Charter Meeting
Tuesday 10 February - Saturday 14 February 2026
RCSI Dublin | Paid event, registration not yet open.
Fellows and Members Family Fun Day, Charter Meeting 2026
Saturday 14 February 2026 | RCSI Dublin | Free event for Fellows and Members, registration not yet open.
RCSI Alumni, Fellows and Members London Reception Friday 20 February 2026 | RCS England | Paid event for RCSI Alumni, Fellows and Members, registration not yet open.
Sylvester O’Halloran Perioperative Symposium
Thursday 26 February – Saturday 28 February 2026
CERC Building, University Hospital Limerick and the School of Medicine, University of Limerick | Paid event, registration not yet open.
RCSI Alumni, Fellows and Members Lunchtime Talk Thursday 12 March 2026 | RCSI Dublin | Free event for Alumni, Fellows and Members.
RCSI Fellows, Members and Diplomates Conferring Ceremony, Penang Sunday 14 June 2026 | RUMC Penang | Free for eligible candidates.
RCSI Alumni, Fellows and Members Lunchtime Talk Thursday 25 June 2026 | RCSI Dublin | Free event for Alumni, Fellows and Members.
RCSI Fellows, Members and Diplomates Conferring Ceremony, Dublin Monday 6 July 2026 | RCSI Dublin | Free for eligible candidates.
RCSI President’s Reception for newly conferred Fellows of RCSI and their guests
Monday 6 July 2026 | RCSI Dublin | Free for eligible candidates.
RCSI Alumni Gathering 2026
Thursday 13 - Saturday 15 August 2026
RCSI Dublin | Paid event for RCSI Alumni, by invitation only.
RCSI Alumni, Fellows and Members Lunchtime Talk Thursday 1 October 2026 | RCSI Dublin | Free event for Alumni, Fellows and Members.
American College of Surgeons (ACS) Clinical Congress
Saturday 26 September - Tuesday 29 September 2026 Washington, DC, USA | Open to RCSI Fellows and Members, cost associated.
REGISTRATION & QUERIES
As a benefit of membership, RCSI Fellows, Members and Affiliate Members In Good Standing receive either discounted rates or free attendance to RCSI events. To ensure you are notified by email when registration opens, please ensure your communication preferences are set to ‘Opt-In’ via the Portal. Additionally, if you would like to arrange your own on-site meeting in RCSI, Fellows and Members In Good Standing are also entitled to discounted room booking rates. To avail of discounted venue hire, or for any further queries, please contact fellows@rcsi.ie.
