Smith Blog

Recently, one of our faculty, Dr. Lee Richstone was honored to be involved as a faculty member at two advanced laparoscopy courses, one in India and the other in Los Angeles. Both courses were held for other physicians who wanted to learn advanced laparoscopic skills. In particular, they wanted to learn more about LESS surgery. LESS stands for Laparoendoscopic Single Site (LESS) surgery. This is a new approach to laparoscopic surgery, where the entire surgery is completed through the umbilicus (belly-button, or navel). The result is nearly scar-less surgery!

Dr. Richstone is one of the few who are leading the way in this exciting field. In fact, we have been pioneers in LESS donor nephrectomy, LESS pyeloplasty for obstructed kidneys, and LESS partial and complete nephrectomy. In particular, our experience with LESS partial nephrectomy is exciting. When patients have small kidney tumors that need to be surgically removed, a partial (not complete) kidney removal is required. This is called a partial nephrectomy. Dr. Richstone’s experience with performing this surgey ONLY through the belly-button may be the largest experience worldwide with this technique.  With time, there’s hope that this technique will offer the best possible cosmetic outcomes while sparing the majority of the remaining kidney, which is so vital.

In December Dr. Richstone was asked to travel to Nadiad, in India, to teach these techniques by giving lectures and performing live LESS surgery. It was a fascinating trip!  Surgeons came from all over the world, including Africa, India, Singapore, Japan, among other nations, to learn. It was a great “meeting of minds”! He performed 2 LESS operations over the 3 day course that helped many patients and their families. Medicine is an amazing occupation, rich with patient experiences, research opportunities, as well as incredible opportunities to work with collegues from across the globe. It is amazing how new technology “diffuses” so quickly to far corners of the world so rapidly! Dr. Manesh Desai was the organizer of the meeting, and the host. To him we are very grateful. More recently, Dr. Richstone was invited to participate in a similar course for the American Urological Association at a course held at the University of Southern California, with doctors from all over the United States, and as far as Korea, in attendance.

When it comes to new surgical approaches in surgery and urology, we need to do a better job of getting advanced techniques “out there” to the community.  For example, far too many patients get their entire kidney taken out when only part of it needs to be removed, and far too few patients are offered the advantages of a laparoscopic approach to surgery (ref 1). This is particularly for kidney surgery where the recovery is considerable shortened, with less pain. It is worthwhile to continue to strive to offer the same success rates for surgery, but strive for a “scarless” approach to improve patient sense of well-being, and cosmetic outcome (ref 2).  We at the Smith Institute for Urology have a long track record on the “cutting edge” of patient care and research, and will continue to do so with passion and vision.

Reference:
1) Richstone L, Kavoussi LR. Barriers to the diffusion of advanced surgical techniques. Cancer. 2008 Apr 15;112(8):1646-9.
2) Richstone L, Kavoussi L.”Less” is more. J Urol. 2007 Sep;178(3 Pt 1):752.

In 1953, John Hunt led a British expedition to climb Mount Everest that unfortunately had to turn around within 300 feet of the summit.  Although the group failed its task, they defined a route and introduced a technique for carrying extra oxygen that allowed the New Zealander Edmund Hillary to reach the summit a few days later. Hillary became Sir Hillary and the accomplishment was celebrated around the globe.

Several steps have been taken in the climb towards a true Natural Orifice Transluminal Endoscopic Surgery (NOTES) nephrectomy. This means removing organs through a natural orifice such as the mouth, rectum, urethra or vagina.  Previous reports demonstrate that kidney removal through the vaginal vault is feasible.

Is NOTES the summit of “Everest” or is it Base Camp? The answer is both. NOTES has fulfilled the dream of eliminating a visable incision for extirpative renal surgery. However, there are growing series of Laparoendoscopic Single-Site Surgery (LESS) nephrectomies that have shown only cosmesis as the advantage to minimizing the incision. Until a series of NOTES nephrectomies is evaluated it is uncertain whether there will be any additional benefit to the patient. The major issues of surgery still remain with postoperative ileus, fatigue and discomfort coming from the actual renal dissection which does not change based on location of trocar placement.

This kind of surgical exploration needs to be supported.  However, the real surgical “Everest” will be a quantum leap, a total replacement of our current notion of invasive extirpative surgery.  We should never take our eyes off this ultimate prize.

Louis R. Kavoussi, M.D.
Professor and Chairman
Smith Institute for Urology
Hofstra School of Medicine
North Shore-LIJ Health System
Long Island, NY

Surgery was born centuries ago out of a raw necessity to cure in the context of a limited medical armamentarium. Early surgeons were pioneers in demonstrating the now obvious reality that the extirpation of tumors, drainage of infected kidneys, and removal of stones could alleviate pain and suffering. Initial focus addressed the disease and how to perform procedures with reasonable patient survival. With the 20th century came rapid advances in anesthetic techniques, perioperative care, antibiotics and organized surgical education, resulting in reliable surgical methods.Society has charged the modern era of surgery with an additional agenda.  Patients want and expect less: less pain, less incisions, less recuperation and less expense all with a classically successful surgical outcome.  The focus upon issues such as function and lifestyle has challenged our specialty to better understand the human body, diseases and surgical processes.  These requirements have engendered several novel minimally invasive techniques, radically different than traditional open surgery.  These approaches require a different set of surgical skills, collaborative efforts with disciplines outside of traditional surgical sciences and a creative spirit.

Over the past 30 years there has been acceleration in minimally invasive surgery that has indelibly changed the landscape of urologic practice.  Endoscopic and transcutaneous surgery for stone disease has supplanted open techniques.  Laparoscopic approaches to adrenal and renal pathology have evolved into not only acceptable alternatives but indeed the preferred surgical technique at qualified centers. Society will continue to push us to reevaluate the approach to every urologic pathologic condition, both benign and malignant.  Moreover what is minimally invasive today may not be minimally invasive by morning.

As “less” is expected by patients, our duty as surgeons continues to become more complex. Even the monumental accomplishment of removing a stone through a keyhole incision, halving the hospital stay associated with a partial nephrectomy, or slashing recovery time following RPLND is not enough. We must continue to analyze and refine all aspects of surgery.  This will require an ongoing investment in scientific inquiry, a tolerance for seemingly counterintuitive approaches and a continuous postgraduate learning process.

Lee Richstone MD

Louis Kavoussi MD

The Smith Institute for Urology
North Shore-LIJ Health System
Long Island, NY

The “Miracle on the Hudson” of US Airways flight 1549, with the survival of all 155 aboard, caused us to pause and think about the events that led to the happy outcome. We must all realize that careful planning and extensive training played a large part in this miraculous outcome.  First there are safety checklists.  Every aspect of mechanical soundness and procedural steps are reviewed.  Even the passengers are involved through the educational safety instructions prior to takeoff.  In the vast majority of air flights, safety measures help avoid situations that can lead to disaster.  Moreover, the pilots are experienced and train for hours on simulators that can reproduce any imaginable equipment failure.  Finally there was the “luck factor”: weather, empty river and nearby help.

Over the past several years, surgeons have been looking to adopt some of these practices from the airline industry to minimize complications.  Indeed a recent study by the Harvard School of Public Health in conjunction with the World Health Organization demonstrated that a simple 19 point checklist could considerably decrease complications and even death*.  Some of the items are as simple as identifying the correct side of the operation, having team members identify themselves, and checking equipment prior to surgery.  Patient education prior to surgery is also important to help assure a good outcome.  Instructing patients to avoid certain medications preoperatively, to bring films to the operating room and clean out the bowels all are important safety measures.

Unfortunately many important measures are not as easy to transfer from the airline industry to the operating room.  Although surgical simulators do exist, they are limited in their ability to truly re-create the surgeon’s experience, the precision of the procedure, and of course, the varying anatomy  that is seen with a real patient.  As such, normal routine procedures, let alone the given patient pathology, cannot be practiced for a given patient.  This differs markedly from the airline industry where planes of each manufacturer all are constructed and function in a predictable manner.  Medicine realizes that surgeon experience is important, however, there are no simulators or required mechanical exercises that surgeons must pass.  Indeed most hospitals do not set a limit on the minimal number of a case a surgeon must do to be considered competent.

Surgery must be made safer for our patients, and this is a major research initiative at the Smith Institute for Urology.  In fact, we have embarked on several initiatives that reach toward this goal. Credentialing requires documentation of experience.  Minimum volumes are required to grant privileges for high risk or robotic procedures.  Moreover, we are truly at the cutting edge of simulation and skill-assessment.  We are involved in the development of novel surgical simulators that one day may allow surgeons to practice an operation prior to coming to the operating room.  In a truly groundbreaking set of experiments, we have shown for the first time ever that surgeon’s eye and pupil function can predict surgeon skill in an objective and reproducible way.  Taking this concept even further, we have demonstrated that the brain function of novice vs. expert surgeons actually function differently based on MRIs!

Reducing the risks of human errors is critically important in high-stakes enterprises such as air-flight and surgery.  At the Smith Institute we pride ourselves at being at the cutting edge of this process, in order to make surgery safer for our patients.

*”A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population,” (N Engl J Med 2009;360:491-9)