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In the fall of 1965, Lyndon B. Johnson became the first US president to pull up his shirt and show the world a long scar from surgery to remove his gall bladder. It was so large that caricaturist David Levine shaped it to resemble a map of South Vietnam.
Today, there are very few people in the Western world who can "boast" an extensive scar after gall bladder surgery. The procedure is almost always carried out by laparoscopy - "keyhole surgery" in which a surgeon probes the patient's insides while viewing a computer screen and manipulating equipment and a tiny video camera threaded into a few small incisions.
Surgeons matter-of-factly remove appendixes, gallbladders, spleens and other organs and tissues by laparoscopy (sometimes called endoscopic surgery). The most qualified are now macerating and pulling out kidneys, pancreases, colons, adrenal glands and other more complicated organs, or repairing them without open surgery.
An international symposium on advanced laparoscopy, attended by more than 100 Israeli specialists and some of the world's leading laparoscopic surgeons, was held earlier this month at Jerusalem's Shaare Zedek Medical Center. The two-day event included not only lectures and multimedia presentations, but also live video feeds from operating theaters as participants in the auditorium observed, asked questions and made comments.
PROF. BARRY SULKY, chief of minimally invasive surgery at New York's Mount Sinai Hospital and co-chair of the symposium, said in his opening speech that even though top foreign experts had come to take part, "I don't think we'll be teaching Israeli surgeons very much, because the level of their work is very high."
The Shaare Zedek symposium was to have been held a year ago, but was postponed when the Second Lebanon War broke out, noted Prof. Leonid Lantsberg, chairman of the Israeli Society of Endoscopic Surgery and a surgeon at Soroka University Medical Center in Beersheba. A few who didn't cancel their flights nevertheless visited Israeli surgical departments. While most of the experts this time came from the US, one came from Austria and two from Mexico.
Prof. Petachia Reissman, head of Shaare Zedek's department of general surgery, chaired the conference, and said in an interview that a French surgeon, Dr. Phillippe Mouret, was the first to remove a diseased gall bladder using keyhole surgery in 1987. A few months later, his colleague Dr. Francois Dubois was the first to reproduce open-surgery techniques by holding surgical instruments with both hands; his article, published in Annals of Surgery, led to applications for other organs.
Laparoscopic surgery was uncommon in Israel until 15 years ago, when Israeli surgeons went abroad to learn the techniques. In addition, technology advanced, with miniaturiziation of the endoscopes and surgical equipment that could cauterize blood vessels to stop bleeding and suturing devices that could connect two pieces of bowel, for example. The tiny video cameras improved, producing sharper images. Today, there is no Israeli general hospital that doesn't offer laparoscopic surgery, and because Israel's hi-tech sector is so advanced, many local companies are helping develop the technology.
"At first, many senior surgeons were worried because they were used to open surgery and seeing organs and tissues with their own eyes. Even today, some older surgeons don't use it," Reissman said. Laparoscopy requires excellent hand-eye coordination - the type naturally developed by kids playing computer games. "My teenage son would be better at this surgery than me. His generation will produce excellent surgeons because of their high level of hand-eye coordination," Reissman laughed.
Most surgery can be performed laparoscopically, said Reisman, who studied at the Hebrew University-Hadassah Medical School, did advanced work at New York's Mount Sinai Hospital and at the Cleveland Clinic in Florida, and then spent years at Hadassah University Medical Center in Jerusalem's Ein Kerem before becoming head of department at Shaare Zedek.
It's easy to remove an appendix or spleen, he said, but you have to be a real expert for more advanced laparoscopy such as that discussed at the conference - treatment for colorectal cancer, inflammatory bowel disease, esophageal and gastric disorders, inguinal and abdominal wall hernias, reducing stomach size in the morbidly obese, biliary tract disease and endocrine surgery. Fully 99% of intestinal surgery, he said, can be done via laparoscopy. Even some vascular surgery is performed this way. The most complicated intestinal surgery can take as long as 11 hours, but the average for laparoscopic colorectal surgery is closer to six.
MINIMALLY INVASIVE surgery is not often performed on the heart, because large incisions are still needed for that, and it is not yet done on the brain or in orthopedic procedures, as it requires the target space to be filled with gas to enable the surgeon to maneuver inside via the keyholes (and the brain, back and arm can't be inflated). However, added Reissman, the structure of the brain, with vesicles filled with fluid, could allow optic fibers introduced through a hole in the skull. Nevertheless, laparoscopic surgery on the pancreas or liver remains very difficult.
It was not surgeons who pushed for the new technique, but patients, who preferred to have smaller scars, suffer less pain, be at less risk of infection, less likely to need blood transfusions and able to leave the hospital in 24 hours or so instead of several days. As patient demand increased, more surgeons were pressed to learn it. Today, the Israel Society of Endoscopic Surgery has 150 members.
Hospitals don't save by offering minimally invasive surgery, as the equipment - some of it disposable rather than reusable - costs more. The health funds that pay for the operations save, because patients spend less time in hospital and infections and analgesics are reduced. The Israeli economy, however, saves most, as people spend less time in hospital or recovering at home, Reissman explained.
"In our surgical departments, about 60 or 70% of operations are done endoscopically. Conversion [in which laparoscopy has to be abandoned and turned into open surgery] occurs in less than 5% of cases," he noted. Even for removing tumors, as in colon cancer, more than half of all cases can be done as minimally invasive surgery. "You can actually see better with the video camera than you can in open surgery, because the camera is very close and the resolution is very high. You can see more detail and zoom in to just one centimeter."
Asked what will happen to the field in a decade or two, the Shaare Zedek surgeon predicted that laparoscopy will become even more widespread. Computers and instruments will become even better, and there will be robots computer-guided by remote control for more delicate work, but this probably won't give much better results than human hands.
"It will all be more efficient, with less time spent on each procedure."
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