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Keyhole surgery is constantly evolving to improve outcomes and efficiency

Experienced laparoscopic surgeon Dr Bjorn Edwin explains the benefits of keyhole techniques, now becoming more common than ‘open’ methods. Not only are survival and recovery rates increased, but so is throughput

Dr Bjorn Edwin
Specialist in
Interventional Centre
University Hospital
Oslo, Norway
Interviewed by Mark

The advent of minimally-invasive surgery has been one of the milestones in medical breakthroughs in recent years. It has
not only transformed the way surgeons operate, but has impacted significantly on the patient experience and clinical outcomes. This evolution is continuing with robotic equipment, new techniques and fresh approaches. Minimally-invasive surgery is applicable to many types of operations, including heart, colon and rectal surgery, gastroenterology, gynaecology,
neurosurgery, orthopaedics, vascular and thoracic surgery, and urology. It has made a dramatic difference in treatment for patients suffering cardiovascular disease, cancer and traumatic injury. For many years, a patient undergoing a liver resection, for example, would wake up from surgery with a large scar and then spend at least a week recovering in hospital before
undergoing a rehabilitation process to get back to his or her normal pattern of life. The ongoing development of minimally-invasive surgery has changed that significantly.
With the liver resection performed laparoscopically, the patient is often able to be out of bed on the first day and able to go home within three days with a scar that is cosmetically small.
Dr Bjorn Edwin is a specialist in minimallyinvasive surgery, primarily focusing on upper gastrointestinal surgery (liver pancreas, stomach and oesophagus) and based at the  Interventional Centre, Rikshospitalet University Hospital, Oslo, which over the last decade or more has pioneered new techniques and minimally-invasive procedures. Surgeons from the Interventional Centre – which was established specifically to develop new techniques – began performing laparoscopic liver and pancreas surgery in 1997 and, over the years since, have developed studies, protocols, analysed results from such operations and also assessed costs. He says: “With the Interventional Centre, we have different specialties that can meet to discuss a problem, help each other and start the
procedure and then move it into the ordinary operating theatre setting.
“We also have time to study procedure without the stresses associated with acute centres and we can use our operating theatres for the whole of the day if needed.” However, Dr Edwin – who is now performing mainly liver, pancreas and endocrine surgery – stresses that what has changed with minimally-invasive surgery is not the operation but the technique and the instruments. “If you look at laparoscopic surgery and open surgery you are in a way doing the same operation,” he says. “You are using another technique: a minimally invasive technique. “For the patient, there is a shorter stay in hospital, less wound infection, patients are going back to work faster and they have less pain. “A lot of the discussion with laparoscopy, has been over whether we are changing methods, but if I do a distal pancreatic resection, for example, I take out the same as you do in open surgery but just through a small hole.”

Advances in equipment
The equipment has changed, too. Dr Edwin uses ultrasound scissors, and one instrument that has made a significant difference to the benefit of laparoscopic surgeons is LigaSure. The multifunctional 5mm laparoscopic instrument from Covidien offers surgeons fingertip control of both tissue fusion and bipolar dissection. Dr Edwin says: “With this, we can cut through tissue, clip it with a grasper, activate, and when we cut, we know that it is a tight seal. That is a very nice instrument that I am using now, especially in liver surgery.” LigaSure enables surgeons to create fusion cycles in two to four seconds to deliver dissection and haemostasis. Laparoscopic surgery may initially take longer while the techniques are being learned and developed, but, once mastered, the process becomes shorter, especially when aided by such innovative surgical instruments.
He says: “When adrenal glands were operated on openly, there was a very big scar to take out a small organ. Now, we are doing adrenal glands, it takes less time, especially if you have this type of instrument, but you are still also doing the same surgery as open surgery.” Minimally-invasive surgery can be combined with other techniques and instruments. Dr Edwin adds: “In minimally-invasive surgery we are using laparoscopy, but you can combine this with other techniques such as laparoscopic ultrasound, endoscopy or data from other medical image modalities to optimise and check the quality of the surgical performance.”

Refining techniques
Through the work at the Interventional Centre, techniques have been developed and refined. Dr Edwin says: “What we have shown is that almost every type of operation can be done and we will now get a balance between open and laparoscopic
surgery. “In liver surgery, I am sure 50–60% will be done laparoscopically and in adrenal glands and endocrine surgery 80–90% will be done laparoscopically.” More colon surgery will also be performed in this minimally-invasive way, he says.
However, in the remaining cases, open surgery will often be the preferred route or may be the safest option for the patient and surgeon. “With the liver, if you have a big dissection or big tumours it is not very easy to do laparoscopically,” he says.
“If you have different procedures that are complicated and where you must do a lot of anastomosis in Whipple’s procedure, it is timeconsuming to do that laparoscopically. I think that this type of operation must be further studied before it can be routinely [done] laparoscopically. But we will find the balance and 50-70% of all gastrointestinal surgery will be done laparoscopically in the future.”
Because of this need for balance, Dr Edwin believes it is important for surgeons to be properly trained in both techniques and acquire the experience of knowing when to perform open surgery or use a minimally-invasive approach. “If you learn open surgery, it is easy to stay with open surgery,” he says.  “But it is very important that surgical leaders will be trained in laparoscopy. We are in a new era now. “Patients also know this and they demand laparoscopic surgery. They know that they can go into hospital, have a liver resection and be out after three days rather than wake up with a big scar and stay in for one week.”

Improved patient outcome

Laparoscopic surgery is offering an improved clinical outcome for patients, says Dr Edwin who has performed more than 200 laparoscopic liver resections. He says: “The most important hing for treatment of malignant disease is the oncological result and that must be as good as you have in open surgery or better. That was the discussion when we started to resect colorectal metastasis of the liver. “What we see is the short-term outcome; patients have shorter stay in hospital, they have less pain, they are getting out of the bed on the first day, start to eat on the first day and you can have the patient helping themselves much faster than after an open surgery. That is to do with the technique of the operation and small incisions and modern anaesthesia. “We now have ten years’ experience with our colorectal metastasis in liver and we have compared it with the open technique and have the same, or higher, five-year survival with minimally- invasive surgery of over 50%. I would say we have shown that the oncological outcome is as good or even better.” He says there could be a number of reasons why this is the case. “One of them may be that the operation is less traumatic and the patient’s immune system is not disturbed in the same way when doing laparoscopy compared with open surgery,” says Dr Edwin.

Minimally-invasive surgery can also have costefficiency benefits for a hospital and a health system which points toward investing in such equipment and techniques. With a shorter recovery time, patients can go home quicker and free up hospital bed space sooner than if they had undergone open surgery. “With this type of technique you can get patients through the system faster and you can also increase the production,” he says.
He says this can be particularly important for private hospitals which need to show that they are efficient and have the latest techniques in order to attract patients. As for the future of minimally-invasive surgery, there are constant developments and robotic surgery has a key role to play in this, says Dr Edwin.

Robotic surgery
The Interventional Centre started performing robotic surgery before 2000, moving from external robots to those that are small enough to work within the abdomen. That offers an extra degree of movement beyond the straight standard laparoscopic
instruments. Dr Edwin says: “It is a shorter learning curve to go from open surgery to using a robot to perform minimally  invasive surgery, than from open to laparoscopic surgery.” One of the more common robotic procedures is prostatectomy, while in gastrointestinal surgery laparoscopy is still mainly used, but there is a potential to use the robot for advanced steps such as the more difficult and time-consuming element of suturing, he suggests.

Other innovations
Another technique now starting to be used is NOTES (Natural Orifice Transluminal Endoscopic Surgery). It is under way in some hospitals where, instead of going through the abdominal
wall, surgeons are using natural orifices such as the stomach or vagina to carry out procedures. Also being developed is HIFU (high-intensity focused ultrasound), a highly precise and
non-invasive procedure using a high-intensity focused  ultrasound medical device to heat and destroy pathogenic tissue rapidly. Minimally-invasive techniques continue to evolve, but they have shown major benefits across a range of disciplines in terms of cost, efficiency and clinical outcome to the surgeon, hospital and the patient undergoing a range of procedures.