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Is it time to stop making large incisions?

Where we can do surgery less traumatically and equally effectively, we should

14 February 2020, at 9:00am

When Kurt Semm was appointed to the chair of the Department of Obstetrics and Gynaecology at the University of Kiel in 1970, he introduced laparoscopic surgery into the department. At the request of co-workers, Kurt Semm had to undergo a brain scan because colleagues suspected that only a person with brain damage would perform laparoscopic surgery. It was considered dangerous, unethical and unacceptable. In 1981, Semm performed the first laparoscopic appendectomy and the president of the German Surgical Society demanded the suspension from medical practice of this “impertinent colleague” (Bhattacharya, 2007). In 1987, Philip Mouret performed the first laparoscopic cholecystectomy on a human patient (Polychronidis et al., 2008). He was also soundly chastised by the medical community and there were calls for him to be struck off for performing dangerous and experimental procedures when perfectly good and safe open techniques were available for this routine procedure. Just a few years later in 1992, the National Institutes of Health consensus conference declared laparoscopic cholecystectomy “the procedure of choice for uncomplicated cholelithiasis” (NIH Consensus Statement, 1993).

Laparoscopic surgery image
FIGURE (1) Laparoscopic surgery is safer and provides much better visualisation for the surgeon

So, what had changed?

Fast forward to today and the vast majority of abdominal procedures carried out in hospitals are done laparoscopically or laparoscopically assisted. Minimally invasive procedures have become the norm, from appendectomy to arthroscopy, cardiac bypass and even brain surgery. There was a massive paradigm shift in human surgery when they realised that laparoscopic surgery was actually safer, provided much better visualisation for the surgeon (Figure 1), minimal tissue handling, better haemostasis, access to otherwise difficult sites, considerably less pain for the patient and much shorter hospital stays – often day surgery rather than tying up a bed for a week or more. Frankly you could do a better job laparoscopically.

So why is it so slow to catch on in veterinary surgery? Initially the cost of equipment was considerable and since the procedures were not taught at vet schools and no training courses were available, the practical and financial obstacles were too great. However, equipment costs have come down enormously and a full set of suitable equipment is now less than the cost of a mid-range ultrasound machine. The range and quality of equipment has also increased, with bespoke veterinary equipment increasingly available on the market. With minimal additions to the basic equipment necessary to perform laparoscopic spays a wide range of other procedures become possible that increases the versatility and profitability of the equipment, such as rhinoscopy, urethrocystoscopy and otoscopy – even fistuloscopy, arthroscopy, thoracoscopy and coelioscopy in exotics. In general, around three lap spays a month pays for the equipment and everything on top of that is a bonus. Training is now readily available and more and more surgeons are seeing the benefits and retraining in these procedures. But there is still an inbuilt reluctance among many surgeons to change or to retrain – scepticism and conservatism persist, despite the fact that most people would expect to have a minimally invasive procedure performed on themselves if surgery was required.

The benefits of laparoscopy and minimally invasive surgery have been demonstrated time and time again over many years in published papers both in the veterinary and human press (Davidson et al., 2004; Devitt et al., 2005; Culp et al., 2009; Gautier et al., 2015), so why the reluctance?

The difficulties of retraining are another often cited barrier to performing minimally invasive procedures and it is not hard to see why competent surgeons who have been doing an open procedure effectively for years would baulk at starting from scratch once again. There is definitely a steep learning curve, but it is not as onerous as some may think. Recent papers have shown that the learning curve for inexperienced surgeons to learn laparoscopic spays is almost identical to learning traditional open spays (Pope and Knowles, 2014) and post-operative complications of all kinds are halved in laparoscopy compared to open laparotomy (Charlesworth and Sanchez, 2019). One of the great advantages of learning laparoscopic spays, apart from the benefits for our patients, is that performing routine surgery laparoscopically helps train the surgeon in laparoscopic techniques and maintain that skill. These skills can then be transferred to other, less commonly performed, procedures.

As surgeons we inevitably create tissue trauma by making incisions in healthy tissue. We rely on the patient to heal those wounds and we create the trauma with the best of intent – to improve the patient’s quality of life in the long term. But surely if we can do an equal, if not better, job minimally invasively and create less trauma in the process it behoves us as surgeons to do so. As Hippocrates famously said, “First, do no harm.” Surgeons are often urged to make a large incision as this is seen as best practice to enable adequate exposure of the operative site, minimise tension on tissues and facilitate adequate haemostasis. But if you can get much better exposure in an exploratory laparoscopy with no tension on tissues and excellent haemostasis through a couple of 5mm incisions, surely that is better than making a large incision from xiphoid to pelvic brim (Figure 2)? It is certainly better for the patient!

So, apart from lap spays, what can be done laparoscopically? Many things – but should they? Nothing should be done minimally invasively unless it can be done at least as safely and effectively as with an open technique. With practice most procedures that we traditionally do by open laparotomy can be done either entirely laparoscopically or lap assisted (Lhermette and Sobel, 2008). Everything from organ biopsies to extrahepatic shunt attenuation, tumour removal and staging, lap assisted cystoscopy, cryptorchid castration, adrenalectomy, cholecystectomy, gastrointestinal foreign body removal, full thickness bowel biopsy, even splenectomy and nephrectomy. Of course, there will always be instances where conversion to open surgery may be required or indeed where open surgery is the preferred option and open surgical skills will always be required for this reason, but where we can do surgery less traumatically and equally effectively, surely, we should.

Thoracoscopy
FIGURE (3) Post-surgical correction of persistent right aortic arch can be performed thoracoscopically

Of course, minimally invasive procedures are not confined to the abdomen. Thoracoscopy is massively less traumatic and painful than open thoracotomy, and usually affords a much better view. Biopsies of thoracic masses or lungs, pericardectomy, thoracic duct occlusion, persistent right aortic arch and even lung lobectomies can be carried out thoracoscopically (Figure 3). Faced with an uncertain abdominal diagnosis, exploratory laparotomy is commonly performed. How many of us perform exploratory thoracotomy under similar circumstances? Thoracoscopy is quick, relatively pain-free and provides excellent visualisation of most of the thoracic cavity from a tiny 5mm incision. Arthroscopy has been more readily adopted by many orthopaedic surgeons and is commonly used for intra-articular problems. Most of us regularly see patients with urinary or bladder problems but urethrocystoscopy is rarely performed in first opinion practice, yet many conditions such as ectopic ureters, urethral sphincter mechanism incompetence (USMI), transitional cell carcinoma or paramesonephric remnants can be diagnosed and treated endoscopically. The nose is an inaccessible site but can be readily examined rhinoscopically and foreign bodies removed or nasopharyngeal stenosis, tumours and fungal infections diagnosed and treated in situ. Video otoscopy permits a vastly superior examination of the ear canal, tympanic membrane and tympanic bulla, enabling efficient cleaning and treatment of otitis externa and otitis media. If you can find a hole you can put an endoscope in it. If you can’t find one you can make one!

It is so easy to continue performing procedures the way we were taught many years ago because “that is the way we have always done it” but that is probably the worst reason for using any procedure. We should continually re-examine the way we do things and modify our technique where better procedures are available and there is good evidence that it benefits our patients.

I cannot help but think that the veterinary profession is missing a trick by ignoring a trend in surgery that has transformed the human surgical paradigm since the early 1990’s. This is emphatically summed up by Marelyn Medina MD, of the Rio Grande Regional Hospital (McAllen, TX) and Society of Laparoscopic Endosurgeons who said: “The second millennium has brought with it a new era of modern surgery. The creation of video surgery is as revolutionary to this century as the development of anesthesia and sterile technique was to the last one.” This is an extraordinarily profound statement. When human surgeons equate minimally invasive surgery to the development of anaesthesia and sterile technique, I think it time for the veterinary industry to sit up and take notice. We owe it to our patients.

References
Author Year Title
Bhattacharya, K. 2007 Kurt Semm: A laparoscopic crusader. Journal of Minimal Access Surgery, 3, p. 35
Charlesworth, T. and Sanchez, F. 2019 A comparison of the rates of postoperative complications between dogs undergoing laparoscopic and open ovariectomy. Journal of Small Animal Practice, 60, pp. 218-222
Culp, W., Mayhew, P. and Brown, D. 2009 The Effect of Laparoscopic Versus Open Ovariectomy on Postsurgical Activity in Small Dogs. Veterinary Surgery, 38, pp. 811-817
Davidson, E., Moll, H. and Payton, M. 2004 Comparison of Laparoscopic Ovariohysterectomy and Ovariohysterectomy in Dogs. Veterinary Surgery, 33, pp. 62-69
Devitt, C., Cox, R. and Hailey, J. 2005 Duration, complications, stress, and pain of open ovariohysterectomy versus a simple method of laparoscopic-assisted ovariohysterectomy in dogs. Journal of the American Veterinary Medical Association, 227, pp. 921-927
Gauthier, O., Holopherne-Doran, D., Gendarme, T., Chebroux, A., Thorin, C., Tainturier, D. and Bencharif, D. 2014 Assessment of Postoperative Pain in Cats After Ovariectomy by Laparoscopy, Median Celiotomy, or Flank Laparotomy. Veterinary Surgery, 44, pp. 23-30
Lhermette, P. and Sobel, D. 2008 BSAVA manual of canine and feline endoscopy and endosurgery. British Small Animal Veterinary Association
NIH Consensus Statement 1993 Gallstones and laparoscopic cholecystectomy. The Journal of the American Medical Association, 269, pp. 1018-1024
Polychronidis, A., Laftsidis, P., Bounovas, A., and Simopoulos, C. 2008 Twenty years of laparoscopic cholecystectomy: Philippe Mouret - March 17, 1987. Journal of the Society of Laparoendoscopic Surgeons, 12, 109–111
Pope, J. and Knowles, T. 2014 Retrospective analysis of the learning curve associated with laparoscopic ovariectomy in dogs and associated perioperative complication rates. Veterinary Surgery, 43, pp. 668-677

Philip Lhermette, BSc (Hons), CBiol, FRSB, BVetMed, FRCVS, is the principal and founder of Elands Veterinary Clinic in Kent. Philip has a particular interest in minimally invasive surgery and pioneered laparoscopic bitch spays and laser endosurgery in the UK. He has contributed to numerous publications and lectures extensively in minimally invasive techniques.

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