*Looking through the keyhole*

Jerusalem’s Shaare Zedek Medical Center recently explained to the public what they always wanted to know about laparoscopy but were afraid to ask.

Doctors perform surgery (photo credit: COURTESY SZMC)
Doctors perform surgery
(photo credit: COURTESY SZMC)
When the competent surgeons of yesterday were perfecting their ability to cut patients open, repair and remove diseased or damaged organs and sew them up, children were perfecting their eye-hand coordination playing video games.
It turns out that the youngsters were investing their time well, as more than 60 percent of operations today are performed by laparoscopy – keyhole surgery – in which the surgeon doesn’t open the body.
In the coming years, even more patients will have operations via only a few tiny punctures in the skin (including one in the navel), with much less bleeding and much quicker recoveries. Tiny video cameras thread endoscopes, fiber-optic cables, graspers and cutters into the body that take the place of the surgeons’ gloved hands and direct vision.
Obviously, open surgery will continue to be practiced when large organs are involved or there are complications, but minimally invasive surgery (sometimes dubbed Band-Aid surgery because it eliminates the need for major incisions) will increasingly be used.
At a Shishi Bari (“Healthy Friday”) presentation open free to the public two weeks before Passover, senior physicians at Jerusalem’s Shaare Zedek Medical Center (SZMC) spoke almost exclusively about laparoscopy.
It was the fourth event in SZMC’s Shishi Bari lecture series following others on orthopedics, cardiology and gastroenterology, which drew standing-room-only crowds.
While surgery is usually a onetime thing and doesn’t deal with chronic problems such as cardiology or orthopedics, the event in the fifth-floor auditorium attracted an intelligent audience (judging by their questions) of more than 300 people who listened raptly for two hours and watched videos of clinical procedures without blanching.
It was emceed by Dr. Hagit Miskin, head of the hospital’s pediatric hematology unit and medical director of the lecture series, which is videotaped and appears permanently on the hospital’s website and on YouTube. The next one, in May, will deal with pediatrics.
“Nobody enjoys the prospect of surgery. I remember when I was pregnant and thought I might need a cesarean section. I understood that I might have no choice but to undergo it if the surgery was necessary. In the end, I didn’t need it. But I remember thinking to myself, ‘Who would agree to be cut up?’ But you are in good hands here.”
Medical center director-general Prof. Jonathan Halevy, who also runs the city’s Bikur Cholim Hospital as part of SZMC, noted: “We are no longer a community hospital of 400 beds as we were over 15 years ago, but a major medical center of 1,000 beds. We have the largest surgical facilities in the capital and among the biggest in Israel. To operate is not enough. One also has to prepare for it and take care of patients after it.”
“We deal with 70 patients a day, with a team of 17 senior surgeons, 13 medical residents, 41 nurses and auxiliary staffers, social workers, interns, medical and nursing students and clinical dietitians,” said surgical branch director Prof. Petachia Reissman. Last year, the branch performed 4,670 operations, had thousands of inpatients and handled 11,000 visits to its surgical outpatient clinic.
“We recently spent $30 million on building and equipping new operating rooms. Ours is the only surgical branch in Israel to be invited to participate in the ‘Innovations in Surgery International Forum’ that meets once a week by video conference.”
This is a prestigious forum of medical professionals from over 25 hospitals around the world. Last March, Reissman – who left his career at the Hadassah Medical Organization in 2002 to join SZMC – presented live from Jerusalem an innovative method for performing laparoscopy surgery on growths in the pancreas using ultrasound. The forum includes other standing members from Massachusetts General in Boston, Johns Hopkins in Maryland, the Cleveland Clinic in Ohio and Mount Sinai and Weill Cornell Medical Center in New York.
The use of laparoscopy, in which everything is recorded, is also extremely useful in teaching medical students and residents and broadcasting innovative procedures to doctors abroad. “I can sit at home and see what’s happening in the operating room and advise my colleagues if necessary. We recently did surgery and linked up with a hospital in Rome; surgeons there asked us questions.”
At first, Reissman said, “the cost of minimally invasive surgery was more expensive than open operations because of the cost of buying the equipment, but now it is cheaper to buy, and hospitalization is shorter. The high-resolution images also help the surgeon see more than he would with his own eyes.
THERE ARE a number of advantages to the patient with laparoscopic surgery versus the more common, open procedure – less pain and bleeding, minimal or no scars and a shorter recovery (although the minimally invasive procedure takes a while longer than open surgery).
The patient’s belly is inflated with carbon dioxide gas that raises the abdominal wall above the internal organs to create a working and viewing space. The gas, found naturally in the body after the blood is cleansed by the lungs, can be absorbed by tissue and eliminated by the lungs and nose. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures (when the surgical procedure is carried out in the chest cavity, it is called thoracoscopic surgery).
One-way valves in hollow tubes called trocars prevent the gas from leaking out.
Older surgeons who retrained for laparoscopy tended to have problems learning the technique because they were used to touching, feeling and palpating tissue and tying sutures. However, a new generation of surgeons took the procedure for granted, as they were used to computer console games that honed their eye-hand coordination.
Dr. Yosef Alberton, chief of the Surgery B department, spoke about laparoscopic cholecystectomy, the very common procedure to remove the gallbladder. The pear-shaped organ sits below the liver on the upper right side of the abdomen and collects and stores bile, the liquid produced in the liver that digests food. SZMC’s surgical branch performs 500 to 600 of these annually.
Between 10% to 25% of adults have gallstones – hard masses of bile salts, pigment and cholesterol that develop within the gallbladder, he said. “It is more common in women in general (especially pregnant and younger ones) and as people get older. Most people are unaware of the stones, but in less than 2%, there are symptoms.”
Stones are caused by lack of movement in the gallbladder, changes in the composition of bile and hematological diseases or infections. The yellow stones are large or small, composed mostly from cholesterol.
Small crystals turn into foci for the development of stones. The main symptoms of stones, said Alberton, are “pain in the upper right abdomen, nausea and vomiting. The stones can cause inflammation in the gallbladder and/or pancreas, disruption in liver function and jaundice. If the swelling reaches the pancreas, it could even be fatal.”
Ultrasound, said the surgeon, is very useful for diagnosing gallstones.
“As for treatment, some patients have heard of ‘dissolving’ them, but in most cases this is impossible. Some patients seek complementary medicine techniques to dissolve them, but they rarely work. One shouldn’t try them without asking an expert.”
Although kidney stones, which have a different composition than gallstones, can be smashed into little bits, gallstones should not be, because the small particles can be troublesome.
Thus the best way to deal with gallstones is to remove the whole gallbladder. “If the surgeon tries to open the gallbladder and take out the stones, it would be useless, because in a short time, it would fill up with them again,” Alberton noted.
A keyhole cholecystectomy is performed by general anesthesia and takes anywhere between 25 and 160 minutes. “If there is a lot of inflammation, there can be more complications such as adhesions.
The procedure causes only four tiny scars. How do people manage without their gallbladder,” he said.
“The vessels leading to the organ expand and take over its function. The patient remains in hospital for 12 to 24 hours, and convalescence takes a few days to a few weeks.
STOMACH-SHORTENING or – tightening surgery was discussed by Dr. Ram Shapira, head of SZMC’s bariatric surgery unit. “It’s not only an esthetic procedure, to lose weight and look better,” said Shapira. “It can also improve or even cure diabetes.”
Even if the diabetic is not obese, the surgery “fools” the body by changing the metabolic thermostat or hormones.
Obese people lose the balance between the consumption of calories and the burning of calories, he continued. As the years pass, one’s weight usually increases. People who diet often return to their original weight before the diet. “The amount of body fat is influenced by the brain, peptides, muscles and fat. Two-thirds of the population are overweight, while the obese can have a body mass index of 50. Bariatric surgery comes in three forms – bypass, sleeve and ring. But today, the third technique is used much less often.
Shapira showed a video film in which an electric stapler was used to cut out 80% of the stomach and pull it out via one of the tiny holes.
The typical bariatric surgery patient loses about a third of his weight. As a result, almost 80% of the diabetes disappears and 86% of the cases are much improved; 60% of hypertension disappears; and sleep apnea is resolved in 86% of cases. “Yet patients must change their lifestyles and exercise in addition to the surgery, or they can regain the weight,” said Shapira.
Dr. Menahem Ben-Haim, an expert in liver surgery, noted that a healthy organ can regenerate itself within a matter of weeks, but a diseased one cannot. “This was known since Ancient Greece, when an eagle daily poked holes in the abdomen of Prometheus – chained to a rock – as an eternal punishment, but he survived because it regenerated.” The liver is a large and complex organ that has many functions, such as controlling sugar balance, storing glycogen, breaking down hemoglobin and bile and absorbing fats. It also produces proteins such as clotting factor and removes toxins.
One can remove 75% to 80% of a healthy liver, but if it is sick, the reserve of cells is damaged. One can do catheterization of vessels that supply blood to one lobe that has atrophied, and the other lobe can get bigger from regeneration, he explained. Liver surgery is carried out to remove benign or malignant tissue or liquid-filled cysts. “We do not yet perform transplants of liver lobes into children from live donors here.”
Ben-Haim recalled treating a 40-year-old man who lost weight.
“We found a large tumor in his bowel. He had chemotherapy and underwent biological treatment, and then we removed the right lobe of the liver, leaving the left one. The right one grew back in two months, and we performed a second operation to remove the remaining malignancy in the liver and large intestine. Today, it is three years later, and he is free of illness. Without the surgery, he would have survived for only a few weeks.” Such a complex procedure needs a well-trained multidisciplinary team, which they have, Ben-Haim said.
Annika Schwartz, the chief nurse in the surgical branch, spoke about the psychological part of surgery and how to reduce fear in patients.
“We devote a lot of time to improving their state of mind, because this directly affects the success of recovery of our 500 patients a year. Florence Nightingale knew this centuries ago.”
The nurses sit in groups and individually with patients and family members for up to an hour to explain what will happen in the operation and how to prepare and cope afterwards here and at home. “We try to prevent every surprise. We also tell them about the patient-controlled analgesia device in which the patient presses a button himself whenever he feels he needs a painkiller,” Schwartz concluded.