BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 2. - Keyhole Surgery
RADIO 4
TUESDAY 16/05/06 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
MICHAEL BAILEY
BIJENDRA PATEL
MARK WHITTAKER
JENNIFER BLACK
TOM DEHN
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about laparoscopic surgery, otherwise known as minimally invasive or keyhole surgery. Basic medical telescopes or laparoscopes that allow doctors to peek inside the body have been around for more than a century and were first used to examine the abdomen in 1901. It wasn't really until the sixties that instruments were developed to be used with the laparoscope - instruments that would change it from a simple look and see diagnostic tool to one that would allow a wide range of procedures to be done without the need to open the patient up. The era of keyhole surgery had arrived and there was no looking back.
In the last 40 years the laparoscope has transformed many of the most common types of surgical operation, from hernias to sterilisations, and reduced hospital stays from days to hours. But you need certain aptitudes to be good at it, as I'll be finding out when I put my skills to the test on a new simulator being used to train the next generation of surgeons.
CLIP
Now if I get you to practise for 10 minutes on this I'll show you your score and round 1 and round 10 and you'll know the difference.
This is why I'm a GP I guess. There you go I knocked it off anyway, I don't think that counts though does it.
PORTER
More of my ham-fisted attempts at surgery later. Along with a look at how laparoscopes are being used in gynaecology and how they've transformed the treatment of gallstones. My guess today is Michael Bailey, he's professor of surgery at the Royal Surrey County Hospital and the University of Surrey and director of MATTU - the Minimal Access Therapy Training Unit in Guildford.
Michael, perhaps we should start - what's the basic difference between a keyhole technique and a conventional approach to an operation?
BAILEY
Well the word keyhole is appropriate, the difference is that where normally you would put something in the keyhole to open the door, what we're doing is operating through the keyhole. We avoid opening the door, which is the equivalent of what is now conventional and old fashioned surgery where it was necessary for the surgeon to literally put two hands through a cut in the abdominal wall. So one of the fundamental differences is that we're making a very small incision and conventional surgery makes a very large one.
PORTER
Okay, so if our listeners were to come into an operating theatre were a keyhole operation was being done, now obviously it depends on what part of the body's being looked at, but generally what would they see?
BAILEY
Well what they would see is in the modern operating theatre, such as OR1, which we're fortunate to have, the surgeon would first of all be controlling the whole thing. We have a touch panel where we can control the images from the camera, which is attached to a telescope going through the keyhole, so everyone in the operating theatre gets a very good view of what's going on.
PORTER
And that's a relatively new development isn't it, because presumably when we first started using laparoscopes you had - one hand was being used for the telescopes, you were actually looking directly down a tube.
BAILEY
Yes that is going back quite a long way I have to say but the surgeon in those days, I have to say, was the gynaecologists who initiated much of this sort of surgery in the early days. It was with the advent of the video camera systems attached to the end of the telescope that freed up the surgeon to use both his hands instead of one.
PORTER
So what's happening now is that an assistant will operate the camera will they?
BAILEY
The assistant will hold the camera, the surgeon will have two other small keyholes, with instruments - one for his right hand and one for his left hand - to do the operation looking at the television screen. There are usually in fact two or three screens for the assistant to look at and for the surgeon to look at and the nursing staff.
PORTER
Presumably, I mean one of the main advantages of laparoscopic surgery is that the patient has - doesn't have much trauma then if they've not been opened up?
BAILEY
Well often the patient is blissfully unaware of what's gone on inside because all they have to look at are these small holes which are a maximum usually of 10 millimetres in diameter and often much smaller. They recover from their operation much more quickly because they have minimal pain and very importantly the normal functioning of the inside of the abdomen is only disturbed minimally. If you have an open operation everything sort of stops working for a while and the patient has to wait maybe for two or three days to drink and eat again.
PORTER
So if you've had a laparoscopic technique you can often eat and drink straightaway?
BAILEY
You can often eat and drink straightaway. You can take out a cancer of the bowel for example and the patient can be going home on the third day, this is a complete transformation.
PORTER
My experience of laparoscopic surgery has taught me that it's quite a complex task, it's not an easy skill to pick up. How do surgeons learn?
BAILEY
Well most surgeons learn it very quickly, they start with the basic surgical skills of hand/eye coordination and moving articles from one point to another and learning depth perception - because it's a 2D system. They will then move from that to more complicated skills such as suturing, this can be very easily done in a skills laboratory.
PORTER
But are they learning on real patients or can you simulate many of these things in your unit?
BAILEY
It's important they don't learn on real patients. Safe surgery is the most important thing. So what they can do is to learn within the skills laboratory, many operations can be simulated by virtual reality or augmented reality and they can also practise operations on tissue, which we obtain from the abattoirs.
PORTER
So you can literally get in a cow's or a pig's liver with a gallbladder on it and they can practise - put that in a box and can practise with a real instrument?
BAILEY
They can practise with a real instrument and they can take their time, if they make a mistake it doesn't matter - they can do another one. And it simulates very well to the human situation.
PORTER
Well I decided to put myself through the paces. Consultant surgeon Bijendra Patel runs the MSc course in surgical skills and sciences at Barts and Royal London Hospitals, where they have one of those computerised simulators that Michael mentioned. The simulator can be used to teach surgeons everything from how to handle the instruments and camera to a full operation, complete with complications like bleeding, should they get it wrong. Despite my obvious enthusiasm for jumping in the deep end by trying to remove the simulator's gallbladder Bijendra felt I'd be better off working on some more basic skills.
PATEL
What we can offer is a training, as you can see, in a stress free environment without a drop of single blood, repeating the task as and when you want, at your convenience, developing your basic surgical and even advanced surgical skills in a simulated environment.
PORTER
Without hurting anybody. We're standing next to the simulator now which is basically - I mean looks - I would imagine the closest thing looks like an arcade game, doesn't it, we've got a computer screen here and some rather complex looking hand controls. People have got to start somewhere - what sort of tests do you do and what sort of skills do people have to acquire?
PATEL
This is a laparoscopy simulator and before you learn to do any laparoscopic procedure you need to first learn to hold the camera, develop your hand/eye coordination, depth perception because it's all two dimensional.
PORTER
By two dimensional of course people normally we're seeing - our eyes see in three dimensions, so it's very easy for us to know how far away things are. What you're saying is that with laparoscope that's not the case.
PATEL
That's not the case. Even though there are three dimensional cameras but extremely expensive and it's more of an experimental and research tool ...
PORTER
And do you envisage that people will actually be using this before they ever get to handle a laparoscope for real?
PATEL
That's the plan not only in the UK but worldwide, to train more and more people by simulation rather than on real patients.
PORTER
And at what sort of level - are we talking medical students or at least people who want to be surgeons?
PATEL
No we're talking about people who want to be surgeons. I mean there are similarly training models for medical students as well, suitable for their level of training, but this is for surgeons.
PORTER
Okay, so the object of this - this is to test eye/hand coordination - and I've got some blue balloons and red balloons basically on sticks and I've got to pop them using the controls. Now the controls are like a pair of scissors - or the handles are like scissors - and they've got two long probes and these are exactly the same sort of thing I'd be using if I was doing it for real.
PATEL
That's right.
PORTER
But instead of going into the patient they go into the bowels of what looks like this arcade machine. So we press start, it's now calibrating the instruments. Here we go. Now the first thing I've got to do is find the end of my instruments inside the patient. At the moment I've got this screen - ah right, there we go. Now the red one is my left hand and the blue one - I can't even find the blue one, where am I? There we are. The first problem - all right these balloons flash and then I've got to touch them with the electrode here and pop them - and the first problem I've got immediately is it's in two dimensions and I've got no - I don't know whether I'm half an inch or five inches in front or behind these balloons. So if I push it in - there's a blue one there - I'm behind that one - oh gawd this is [laughing]...
PATEL
Well I'm afraid it's not going very well.
PORTER
There we go - ah I've got one, I got one.
PATEL
Keep the instruments in your field of vision. If you take it out in a real patient you might damage some of the organs, so keep it in the field of your vision and go and take the shortest possible distance.
PORTER
Okay, I've got another just got another red one there. And I'm going to get this one too, feeling confident.
PATEL
That's it, you're doing well.
PORTER
Three. Okay now I've ignored what you told me and I've not got my instruments in the field of vision, I've lost - here we go. Now I'm going to have a go at the blue one. Yeah.
PATEL
Good, you've ...
PORTER
Where are we? This is like trying to paint your front hall through the letterbox or if you've ever locked yourself out of a car and had a go with a coat hanger.
PATEL
You can see the difference - first half of the test and the second half of the test.
PORTER
Yeah I'm getting the hang of it.
PATEL
In the first half you got one out of five balloons, in the second half you got five out of five balloons. So it's the time and repeating the task which will skill you. And not just one weekend course.
PORTER
Yeah I think I probably need a year or so don't I.
A very patient Bijendra Patel. You're listening to Case Notes, I'm Dr Mark Porter and I'm discussing keyhole surgery with my guest Professor Michael Bailey. Michael, you were nodding there when I mentioned medical students.
BAILEY
Well medical students are very good at this sort of surgery, they have a natural aptitude - they've been practising with their Playstations and their computers since they were knee high to a grasshopper and they take to it very naturally.
PORTER
What sort of gizmos do you have for using inside the patient - what sort of tools are available?
BAILEY
Well there's been a great advance over the last 10 or 15 years in terms of the instrumentation and technology has moved ahead dramatically. For example, instead of using clips and scissors to divide tissues and to secure the blood vessels, we now have instruments such as the harmonic scalpel which seals the blood vessels and divides the tissue automatically.
PORTER
So cut and seal as you go.
BAILEY
Cut and seal as you go. This allows the operation to be done more quickly and more safely.
PORTER
What about things like if you have to put stitches in inside a patient's abdomen, how do you do that, or do you just use clips to secure tissues?
BAILEY
No we do use sutures. It's important to teach surgeons how to suture in this environment and it's one of the skills which is very important before they ever get near to the patient.
PORTER
Because I mean - people haven't been taught how to tie a surgical knot, it's not an easy thing to learn and it's not always an easy thing to do with your hands inside a patient but to tie a knot with two - effectively two sticks on the end of your fingers?
BAILEY
Well it is a matter of practise, simple matter of practise and most surgeons can learn to do this relatively easily.
PORTER
What about the time involved in a laparoscopic procedure compared to a conventional operation - does it take longer to do the operation if you're doing it through a keyhole technique?
BAILEY
Well it takes longer initially because surgeons who are beginning to do this type of surgery. But for established surgeons in many ways it's quicker. At the beginning of the operation we go straight in through the keyhole, we don't have to make big cuts, we don't have to sew big cuts up afterwards, you get magnificent magnification - the image we see on our - on the screens are very clear.
PORTER
What happens if something goes wrong during the procedure - you nick a blood vessel or the anatomy's not normal, there's something that you weren't expecting there, that happens to all surgeons however you approach the patient - and you need to resort to a conventional type operation, is it a problem that today's new surgeons are very good at laparoscopic surgery but they're perhaps de-skilled and not getting the experience at the old fashioned conventional approach?
BAILEY
Well the need to convert to open surgery is minimal in surgeons with experience. The argument does go that what do young surgeons do if they need to convert? The fact of the matter is you would never be able to persuade a patient to undergo an open cholecystectomy for example, simply to allow the young surgeon to practise.
PORTER
Okay let's look at some examples of keyhole surgery in practice. Gynaecologists, as we said, were among the first surgeons to make the most of laparoscopes, initially as diagnostic tools, for examining the pelvis, then for applying clips to the fallopian tubes to sterilise women and now for a wide range of other routine and emergency operations such as ectopic pregnancy, where the fertilised egg implants outside the womb, normally in one of the fallopian tubes. If left the expanding pregnancy can rupture the tube and cause potentially fatal bleeding. Ultrasound scans can help doctors rule out an ectopic but the definitive test is to use a laparoscope to see what's going on. I was with consultant gynaecologist Mark Whittaker in the theatres at Gloucester Royal Hospital when just such an emergency case was added to his morning operating list.
WHITTAKER
This lady's 40 and she's had two children before, a month ago she found that she was pregnant with a positive pregnancy test and has had some pain, she's had some bleeding and so she came along to our early pregnancy clinic last week and we've done some investigations which suggest that she's either got an ectopic pregnancy or she's got an early miscarriage.
Head down please.
First we're looking for blood in the pelvis, on the first inspection there's no blood to be seen at the moment but I just need to put another instrument inside so that I can move things around. So we put a small instrument in, just above the pubic bone, and this measures about half a centimetre across and that then allows us to move things around so that we can see things clearly. So what we can now do is manipulate - I'm now looking at the right ovary and the right tube and that right tube is normal and the right ovary has a very small cyst in. And looking at the left tube and ovary that also looks normal. And we can clearly see the tube is normal, as is the ovary. But what we can see is that the uterus is soft and slightly swollen and that does suggest that she's got an early miscarriage inside her uterus.
PORTER
So not an ectopic pregnancy.
WHITTAKER
So this is not an ectopic pregnancy.
PORTER
So this part of the operation we'd have been able - this is a fairly standard procedure, if you'd found an ectopic would you have been able to operate on that laparoscopically as well?
WHITTAKER
Yeah, what's changed over the last few years in the UK is that we're now managing nearly all our ectopics laparoscopically and it's very unusual these days that a patient should require a laparotomy or a large incision on the abdomen to deal with an ectopic. There are certain circumstances, if a patient is collapsed due to blood loss, but that is unusual these days, most ectopics can be managed as a laparoscopic or keyhole procedure. And what we would do is generally identify the ectopic and then remove the fallopian tube with some small laparoscopic instruments and then the patient would tend to go home the same day, rather than stay in hospital for two, two to four days.
PORTER
So historically the patient would have been - you had to open the patient up at the laparoscopy to remove the tube. What's the advantage of having it done through the keyhole technique - the whole procedure?
WHITTAKER
Well the advantage is that you haven't got the larger incision which causes more pain and takes longer for the patient to recover from. And the fact that you're not doing an open operation also means there's less chance of getting pelvic adhesions and that may obviously be relevant for future fertility because if you get pelvic adhesions from surgery it can affect the chance of the patient conceiving in the future.
PORTER
And by adhesions you mean scar tissue - bits sticking to each other?
WHITTAKER
Yeah scar tissue where the bowel or the so-called omentum, which is the fatty layer round the bowel, can get stuck on to the remaining tube or ovary and affect how the tube or ovary functions and works.
PORTER
And does that result from handling the bowel during a conventional operation?
WHITTAKER
People don't fully understand why adhesions occur but it's something to do with handling, it's something to do with putting packs in to push things out of the way, there's a gauze pack so we can see what we're doing, and just exposure to the air of the bowel may increase the risk of things sticking together and causing problems.
So this lady now, we've now made a diagnosis - we now know that she does not have an ectopic pregnancy, so she does not have a life threatening condition, this is an early miscarriage that she's got and that will now be treated surgically with a D and C operation. So we'll be able to remove the camera from her abdomen and then do the operation vaginally.
PORTER
Mr Mark Whittaker.
Gynaecologists may have been quick off the mark when it came to embracing keyhole surgery but one of the biggest changes I've seen in 20 years of practice is in the treatment of gallstones. When I qualified removing the gallbladder or cholecystectomy meant a six inch incision and a week or so in hospital. Today it's all done through three or four tiny cuts and most people go home the same day. Thirty nine year old Jennifer Black had a laparoscopic cholecystectomy to remove her gallstones last Friday at the Royal Berkshire Hospital in Reading. We caught up with her just before the op.
BLACK
The pain is just under your ribcage on your right hand side and sometimes it's uncomfortable to move, which I take paracetamol. Because the pain's not there all the time, sometimes the pain will go and like I say if you take paracetamol or strong painkillers that usually helps. I find that if I roll over in bed and I roll onto my stomach that's when - you know you've got pressure on it and it hurts more.
PORTER
Mr Tom Dehn was Jennifer's surgeon and he talked us through the procedure.
DEHN
Right can we turn the top light off please.
Inside now you can see the liver which is that big red structure. And just have a quick look around. She's got a few adhesions between her right colon, over there, that shouldn't cause any problem. A few in the lower abdomen which is well away from us. And her gallbladder will be tucked under here. So we now have to put in three more access ports for working instruments.
Scalpel thank you.
Now you can use either disposable ones, which are throwaway, which cost 拢70 a crack or these ones which are reusable that last almost indefinitely, providing the sharp bit is sharpened fairly regularly. When we started doing this surgery in 1991 it was almost impossible to get hold of them, there were fisticuffs between surgeons to try to get the right kit. So you can see the gallbladder there with this little mottling from some cholesterol crystals that have been deposited in its wall. This bit here is the duodenum, which is the exit from the stomach, and then we have to identify the ducts that drain bile from the gallbladder and the artery that takes blood into the gallbladder.
Just in Richard, thanks, with the camera. Thank you very much.
So we're just dividing now the peritoneal attachments to the base of the gallbladder. Here you can see the artery, this is a cystic artery, that runs from the right hepatic artery. And this is the free dissection of callows [phon.] triangle which means we're then safe to apply clips to these structures and these clips seal the structures, we hope, from leaking.
Okay thanks.
So we put three clips on each structure and they're titanium so they don't set off the alarm as you go through airport security.
Alright, foot please.
And obviously by making four small incisions the biggest of which is about 12 millimetres, this is an enormous improvement on traditional surgery for gallbladder where the decision used to be anything from six inches upwards. And a number of patients with gallbladder disease are a bit overweight and with traditional open surgery there were risks with getting ...
Some scissors please.
... a clot in the legs, called a deep venous thrombosis and having respiratory infections afterwards because the pain of the incision caused the diaphragm not to move well with respiration so secretions were retained and then they got infected. But with keyhole surgery the pain post-operatively is minimal and it has great advantages in patients who are overweight because they're up and about from day - well on the first day with minimal discomfort. And our last manoeuvre is to take the gallbladder away from the liver bed.
Do you want to send for the next patient Kathy? Thank you.
So we stretch the gallbladder over and using this little hook instrument effect, so we just look under the gallbladder bed, that's nice and dry there. We then grasp the gallbladder with this instrument with claws on it and we pull the gallbladder out through the port and up through the abdominal wall.
Okay clip please.
And then we just look at the port sights as we take those out, to make sure there's no bleeding. And then if there isn't and that's the end of the operation.
Okay, gas off thanks.
PORTER
Tom Dehn removing Jennifer Black's stone filled gallbladder. And I'm pleased to report that Jennifer went home later that day and that she's making a speedy recovery.
Michael, 20 years ago Jennifer would have spent up to a week in hospital, potentially, by having that laparoscopic technique it saved a hospital bed for five, six, seven days possibly, that must have transformed the way that hospitals are managing their beds because it's going on in all the different specialities now.
BAILEY
It's transformed it completely. Much better for the patient to be at home, many more patients can be treated. The slight disadvantage of course the nurses really never get to know the patients because the day units open at 7 in the morning and they close at 7 at night.
PORTER
So the patients actually go in, in the morning, they're said hello to and then as soon as they recover they're up and gone in the evening?
BAILEY
Well even more than that. They come in at 7 for the morning's list and go home just after lunchtime usually and they come in at lunchtime for the afternoon list and go home early evening.
PORTER
And what about new developments - we've talked about advances that we've had since the first days where the surgeon would clutch the laparoscope in one hand and have some sort - another simple instrument in the other?
BAILEY
What excites me is the increasing number of procedures we can do through the keyhole way. Cholecystectomy, which there are about 50,000 a year done in the United Kingdom, is now common place. Many surgeons have not progressed beyond doing that procedure. It's possible to do virtually all the operations that we did by open surgery by keyhole surgery now, there are one or two exceptions, such as pancreatic cancer and some of the liver work but we can take out stomach, we can take out the bowel, we can repair hiatus hernias, we can deal with peritonitis and many, many of the things that we see day-by-day.
PORTER
And units like yours presumably who are leading the way in this field are you actually removing bowel cancers and things like that now?
BAILEY
Yes 90% of bowel cancers and inflammatory bowel disease is performed laparoscopically, keyhole, in our unit. In the country it is 1%. So there are big differences between different units.
PORTER
And the advantages when you're treating cancer or much the same as any other procedure - it's minimal trauma to the patient, and you get them out of hospital quickly.
BAILEY
Well it's been approved by NICE recently - the National Institute for Health and Clinical Excellence - as has hernia surgery and many of the things which initially we had to prove that it was equal or better than open surgery. But in terms of cancer procedures, radical removal, the survival rates are all just as good and in some cases better indeed, from a recent paper in Spain, than open surgery.
PORTER
Michael what about the use of robots - people will have heard or read in the press that there's this distance, where a surgeon can be away from the actual robot that's doing the operation, it's possible to have a surgeon in the States operate on you in a London hospital - is that a way forward?
BAILEY
Well it's only been done once by my friend Jacques Marescaux in Strasbourg who operated in New York on a patient in Strasbourg. It cost many millions of pounds and virtually rendered French Telecom bankrupt. But it's possible, it's the art of the possible. In reality, in day-to-day terms, we don't really need a robot. What a robot conveys to the surgeon is the opportunity to have much more movement inside the abdomen than we would normally have with conventional keyhole surgery.
PORTER
So it's not this concept of being distant from the patient and being able to call in experts from all over the world, it's actually the fact that it facilitates your laparoscopic surgery, it can do things with its hands that you can't?
BAILEY
Yes, you have six degrees of movement with a robotic arm, which itself is only a few millimetres in diameter, so complex procedures are easier. And you talked about tying knots - it's much easier to do it with a robot. But you have to remember that if the surgeon is a distance from the patient, which they are within the console, you still have to have an operating team at the operating table just in case anything goes wrong with the robot. So it's not just as straightforward as perhaps sometimes is depicted.
PORTER
Surgeons are safe for the moment.
Michael, we must leave it there. Professor Michael Bailey thank you very much. Don't forget that if you have access to the net you can listen to the programme again on our website bbc.co.uk/radio4. Next week's programme is all about the jaw, from teeth grinding and jaw ache to reconstructive plastic surgery.
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