Camran Nezhat - Surgical Techniques

Surgical Techniques

Nezhat introduced several innovations that were at first considered unacceptable deviations from classical surgical techniques. The first departure from traditional surgical methods occurred in approximately the mid-1970s, when Nezhat began experimenting in the lab with “operating off the monitor”, a phrase that refers to the method of performing endoscopic surgery (referred to as a laparoscope when used for abdominal surgeries) while viewing a TV/video monitor in an upright position, operating off the video images, instead of looking directly at the patient. Prior to Nezhat’s innovation, surgeons performed laparoscopy while peering directly into the endoscope’s eyepiece, a method which limited their ability to perform operations because it left only one hand free, limited their field of vision, and required them to hunch over and move around in awkward positions (see the before and after pictures).

With these physical limitations in place, surgeons found it difficult to believe that operative laparoscopic techniques could replace classical surgery and, initially, many in the medical community considered the entire notion to be an untenable, unrealistic, and dangerous idea., The idea of using the endoscope as an operative devise also went against at least 200 years of medical tradition, which had established the endoscope, since its approximately 1806 modern debut of endoscopy by Philip Bozzini, as a predominantly diagnostic tool; operative applications in gynecology were confined to simple interventions, such as lysis of adhesions (removal of scar tissue), biopsies, draining of cysts, cautery of neoplasms, and tubal ligations. When Nezhat began using his new video-laparoscopic technique of operating off the monitor in an upright position, he was able to achieve more advanced operative procedures for the first time., Performing these advanced surgeries laparoscopically was the second unorthodox conceptual change that Nezhat introduced. Other innovations by Nezhat that were considered controversial included the introduction of new surgical procedures and new surgical instrumentation designed specifically for use in laparoscopy. Because these new surgical concepts went against established norms of classical surgery and were believed to be dangerous, Nezhat fell under intense scrutiny and criticism from those within mainstream medical establishments, and later from the national newspapers (see “Controversies” section below)., For approximately the next 25 years, Nezhat became one of the most visible and controversial figures in the minimally invasive movement because of his vocal advocacy of these new techniques and for continuing to push the envelope by performing more advanced procedures laparoscopically. Even as late as the 2000s, there were many opponents to these techniques who continued to call into question the safety and necessity of video-laparoscopy, especially when used for more advanced laparoscopic techniques. However, by approximately the mid-1990s it can be established that most of the initial misgivings about video-laparoscopy had subsided because by then the nation’s most prominent academic medical schools in the U.S., such as Stanford University School of Medicine, had adopted this change and began teaching it as part of the standard medical school curriculum. By the early 2000s, many medical societies, such as American Association of Gynecologic Laparoscopists, Society of Laparoendoscopic Surgeons, and SAGES, also began offering fellowships in advanced operative video-laparoscopy.

There are still several contraindications for advanced operative video-laparoscopy, such as in emergency room medicine. However, with these and a few other exceptions, today the debate has now been resolved in favor of advanced operative video-laparoscopy for most surgical situations. The mainstream medical community has acknowledged operating off the monitor in video-laparoscopy to be the gold standard in various disciplines, such as gynecologic, gastrointestinal, thoracic, vascular, urological, and general surgery. For this reason, Nezhat has been cited by laparoendoscopic surgeons as the father of modern operative laparoscopy, for introducing important technological and conceptual breakthroughs that helped medicine move toward minimally invasive surgery.

The reason that the medical community now considers advanced operative video-laparoscopy so important is that it provided an alternative to classical surgery – laparotomy – which required a large incision, between 12-14 inches, which exposed patients to serious, life-threatening complications (see image of large incision). These large incisions were held open by metal clamps, called retractors (see image), which created even more trauma to the tissue. Though these open methods were convenient for the surgeon, it was very debilitating and painful for the patient, causing more adhesions (scar tissue), more extensive blood loss, necessitating large volume blood transfusions, and requiring longer hospital stays, with 1–3 weeks in the hospital, including possible time in the ICU, considered as normal outcomes. Another serious complication was chronic incisional hernias, a condition in which the incision fails to heal, causing it to continually ooze and break open, even for years after the surgery. However, the most important difference was that, when compared to video-laparoscopy, a laparotomy posed more serious, permanent, and life-threatening complications, including a higher incidence of death.,,,,,

By the late 1970s, with the exception of a few surgical virtuosos, such as Raoul Palmer, Patrick Steptoe, and Kurt Semm, gynecologic surgeons were only able to use the laparoscope to perform a few simple operative procedures, such as aspiration of cysts, lysis of adhesions, cauterizing of neoplasms, biopsies, and tubal ligations., This meant that other, more complicated gynecologic surgical procedures, such as the treatment of advanced stage (stage IV) endometriosis, hysterectomies, radical hysterectomies for cancer, para aortic node dissections, tubal reaanastomosis (reconstructive surgery of the fallopian tubes), full removal of ovarian cysts, and myomectomies (full removal of fibroids), could only be done via laparotomy. Some of these conditions, such as endometriosis, fibroids, and cysts, can be chronic diseases that require multiple surgical interventions. This meant that, prior to minimally invasive surgery, many women underwent multiple laparotomies for only mild pathologies. In these cases, the surgical intervention of a laparotomy was considered to be more damaging than the disease itself., Prior to the advent of video laparoscopy, other types of surgeries (from other disciplines), such as the removal of the gallbladder (colecystectomy), bowel, bladder, and ureter resections and reaanastomoses, etc., were also only possible via laparotomy.