BACK in 1990, when surgeons started to perform laparoscopic cholecystectomy (the most common keyhole operation for removing a gallbladder today), the medical fraternity was completely divided about whether laparoscopic surgery was safe.
There were conflicting reports, to the extent that the first surgeon - Phillippe Mouret in France - who performed this operation was almost struck off the medical register for doing a seemingly dangerous operation.
Other pioneers, like Dr Tim Wilson in Sydney, was also in deep trouble for his use of a laparoscope to find a patient’s appendix and later remove it through a tiny incision over the organ.
Laparoscopic surgery like this had never been attempted in children, and at that time there was no equipment for surgeons to do so. But the courage and preseverance of a few paediatric surgeons to walk the untrodden path over the last decade has made it possible.
One of them is Prof Tan Hock Lim, a Malaysia-born paediatric surgeon previously based in Australia before his return to Malaysia last year.
Like many pioneers, he was faced with the resistance to change. Many thought he was crazy to venture into the realm of the untried and untested.
“When I started to do this kind of work (in laparoscopic surgery), I was in Australia. And I was condemned by many of my colleagues; paediatric surgeons who say that ‘this guy has really gone crazy’,” said Prof Tan, recalling the time when he was developing laparoscopic surgery in children.
Even after gaining consent from his patient and his hospital’s ethical committee to perform the operation, surgeons stood up and condemned him when he presented his results in Europe and the United Kingdom. “They said, ‘why is he doing (laparoscopic surgery) when we can make a simple cut to do the operation?’” Prof Tan said.
However, with a clear vision and strong belief that this was the way forward for the future, Prof Tan and two or three other pioneers in North America continued to develop laparoscopic surgical methods and equipment for children.
It was only when the Great Ormond Street Hospital for Children in London asked me to teach them laparoscopic surgery that he received recognition from a major institution that “maybe, laparoscopic surgery had something to offer children after all”, said Prof Tan.
Minimum invasion
When urologist John EA Wickham coined the term “minimally invasive surgery” and later wrote about it in the British Medical Journal in the late 90s, he noted that it is common sense for any surgical procedure - which aims to achieve a satisfactory outcome - to be carried out with minimal trauma to normal tissues and surrounding organs, although this may make the technique or operation more difficult for the surgeon to perform.
Prof Tan felt the same way about surgery. “In many instances, surgery is a simple thing. We (surgeons) go in there and we ‘chop’ something out. The ‘chopping’ off part is the easy bit; the healing part is the difficult bit,” he explained in simple, laymen terms.
Minimally invasive procedures such as laparoscopy, although associated with smaller wounds and reduced post-operative hospitalisation and discomfort, should be proven safe and efficient (comparable to that of an open surgery) before it could be offered as an option.
“Cutting through the skin, muscle and sometimes bone to get to the diseased organ in conventional surgery is generally the part which causes the most tissue damage, even though it will eventually heal in time,” said Prof Tan.
“There is also the risk of wound infections after the operation,” he added.
However, open surgery is still the mainstay of surgical interventions in many diseases.
Minimally invasive procedures such as laparoscopy, although associated with smaller wounds and reduced post-operative hospitalisation and discomfort, should be proven safe and efficient (comparable to that of an open surgery) before it could be offered as an option.
“If you can do exactly the same operation without making the cut, then you end up with much less tissue damage and trauma – psychologically, emotionally and physically to a person,” Prof Tan said.
“But you must be able to show that you can do the operation safely and competently,” he added.
Laparoscopic surgery, also called keyhole surgery, is a minimally invasive surgery done literally through keyholes, of which the surgeon inserts surgical equipment to perform complex operations.
“Laparoscopy involves a different skill set? It involves a whole new training procedure,” Prof Tan said, adding that surgeons need to be highly skilled to perform the surgery.
Is laparoscopic surgery safe or better than conventional (open) surgery? The answer to this vexing question is emerging, said Prof Tan.
Overall, in the hands of a skilled laparoscopist, there is now a lot of scientific evidence based on properly designed, carefully controlled, prospective, randomised trials comparing open surgery to laparoscopy that find laparoscopy better for most but not all surgical conditions.
However, as there have also been a few adverse findings where conventional open surgery clearly offers better results than keyhole surgery, Prof Tan reckoned that surgeons should recognise this and go back to open surgery until it can be shown that laparoscopic surgery is better than the open operation for these conditions.
According to a report by the US FDA and Center for Devices and Radiological Health, patient injuries in laparoscopic surgery can occur during the insertion of trocars (hollow cylinders with sharply pointed ends used to introduce instruments used in the surgery).
“Increased morbidity and mortality result when laparoscopists or patients do not recognise injuries early or do not address them in a timely manner,” the report stated.
In Malaysia, laparoscopic surgery is available, but not the full range of it, said Prof Tan.
Developing novel techniques: First, do no harm
“It is very strange: firstly you have got to have a vision, and you have got to believe in what you do. And by the same token, as a responsible surgeon, you have to walk a very thin tightrope to make sure what you are doing is right for your patient,” Prof Tan said.
Prof Tan’s forays into laparoscopic surgery in children can be traced back 22 years, when he started seeing a lot of children with kidney stones during his tenure as a consultant paediatric surgeon in Melbourne.
While conventional open surgery requires a surgeon to make a cut at the side of the abdomen so that the stones can be taken out from the kidney, Prof Tan refined a (laparoscopic) technique used in adults so he could “puncture the kidney with a needle, put in a tube and ‘drill’ out the stones; under the guidance of x-ray images”.
“The only scar they have is a small puncture,” Prof Tan said.
The challenge of operating on children is the limited space surgeons have to manoeuvre, said Prof Tan. Therefore, new surgical techniques or equipment need to be designed.
To develop a method that is untried and untested, Prof Tan took one step at a time to ensure no harm comes to his patients. “Some operations have to be tested out in animal models first and new instruments may have to be developed.
Describing his training in laparoscopic surgery as a little similar to flying a flight simulator, Prof Tan practised until he was most confident he could perform the operation before he did his first.
In the last two decades, Prof Tan was involved in the development of various laparoscopic surgical techniques and instruments, including the “Tan Endotome” and the “Tan Pyloric Spreader”, which were among the first instruments he developed.
Subsequently, Prof Tan went on to develop more paediatric laparoscopic procedures: those that enabled him to operate on the pylorus – which is part of the stomach (pylorectomy), kidney (pyeloplasty), bile duct and spleen. His work has been widely cited, making him one of the world’s authorities in paediatric laparoscopic surgery.
Nevertheless, Prof Tan is not resting on his laurels yet, as he is still actively involved in the research and development of the surgery. “I am still developing new instruments for use,” he said.
Bringing technology home
After 43 years living abroad, Prof Tan still remembers the sights and scenes of Kuala Lumpur when he left for Australia in his teens. However, it was not so much nostalgia, but the desire to give something back to the country that brought Prof Tan back in town.
“I have the vision to build what we call an advanced surgical skills centre where all Malaysian surgeons can learn how to do (laparoscopy) because right now, if you want to go for a serious level of learning, you have to go overseas, to a major centre (of learning),” Prof Tan said.
“This centre will be a bit like a flight simulator where pilots learn to fly before they take off in a real aircraft,” he explained.
Although the advanced surgical skills centre is still in the planning stage, Prof Tan said the centre will feature state of the art operating theatres, simulators and teaching facilities to train surgeons of various specialties in laparoscopic surgery when it is completed.
“My vision is to build that centre in Malaysia, not only to train Malaysia, but to make sure that Malaysia can become the regional training centre for advanced surgical skills,” he added.
Prof Tan believes it is no longer acceptable for surgeons to train on real patients. “If you want to do an operation, you have to prove that you have the necessary skills in a skills lab first,” he said.
Is it cost efficient for Malaysia to embrace such a technology in its healthcare system? Yes, Prof Tan said.
“Even though laparoscopic equipment may be seen to be expensive, it frees up beds and allows for greater efficiency if the patient only has to stay in for one or two days as opposed to one week. “About two months ago, I removed a kidney in a young child on a Thursday afternoon and he left the hospital the next day!” Prof Tan said.
“The only other alternative to increase capacity is to build more beds. But the cost of building one hospital bed in Malaysia is now estimated to be at least one million ringgit. This is more that what it would cost for any hospital to start laparoscopic surgery,” he added.
But what about the socioeconomic costs and emotional cost to our society?
Prof Tan says,” When you consider that many Malaysian families depend on a double income, the fact that a patient can return to work much quicker makes a lot of sense, quite apart from the fact that keyhole surgery is less debilitating.”
There are now several centres doing minimally invasive surgery in Malaysia. In the Kelang valley, Prof Tan, who is now based at Prince Court Hospital and Prof Nada, is a new consultant fully trained in the UK also does this type of surgery at University Malaya Medical centre.
There are now several centres doing minimally invasive surgery in Malaysia. In the Kelang valley, Prof Tan, who is now based at Prince Court Hospital and Prof Nada, is a new consultant fully trained in the UK also does this type of surgery at University Malaya Medical centre.