Bridging gap between innovation and training
October 2007
Philippe Grange, a consultant at King’s College Hospital NHS Foundation Trust, has firm views on the barriers to widespread adoption of innovative laparoscopic approaches, the role of robot technology and the need to address conservative training. LOUISE FRAMPTON reports.
Open surgery is still considered the gold standard, according to Philippe Grange a consultant at King’s College Hospital NHS Foundation Trust. A leading expert in laparoscopic urology, he is frustrated by the slow acceptance of minimally invasive surgery. King’s College Hospital is providing a leading-edge program to ensure future generations of surgeons develop the skills they need to performthe latest keyhole techniques and an important part of the training involves the use of the EndoAssist robot, from Prosurgics.
The widespread dissemination of the laparoscopic approach has been an uphill struggle, however.
“In 1987 a French surgeon removed a gall bladder using the laparoscopic technique which caused a big shock in the surgical community,” Philippe Grange explained. “Today, no one would consider the removal of a gall bladder by open surgery as being the gold standard but it took nearly twenty years for clinicians to reach this level of agreement. Furthermore, twenty years later, training is still not adequate and remains open surgery based,” he exclaimed.
More advanced laparoscopic surgery arrived by the early nineties, allowing the removal of kidneys (nephrectomy) and by the mid-nineties, surgeons started to remove just one half of a kidney (partial nephrectomy).
“Surgeons started to question the need to remove the whole kidney in cancer patients, while other surgeons thought they were ‘mad’ claiming the cancer could reoccur,” he said. “Ten years later, these surgeons have been able to demonstrate that patient outcomes for those with half a kidney removed are as good as for those that receive a full nephrectomy.”
Philippe Grange pointed out that if a patient has had their whole kidney removed, and later develops cancer in the other kidney, they risk becoming reliant on dialysis. He was among a handful of pioneering surgeons that questioned the need for this type of procedure to be performed by open surgery. It has not been an easy journey, however. He has found it difficult to convince his peers that partial nephrectomy can be carried out using laparoscopic techniques, and that the approach is safe and can be taught.
“The majority of nephrectomies are now carried out by laparoscopy, but there is much more room for partial nephrectomy,” he commented. “Ten years ago, nephrectomy by open surgery was being taught and that was it. At some centres, one very lucky fellow would have the opportunity to watch a performing laparoscopic surgeon for a year, but there has been very little formal training in these techniques. What is being taught is still open nephrectomy, with some laparoscopy,” he commented.
SNOWBALL EFFECT
“The growing ‘snowball’ of laparoscopic nephrectomies has reached the bottom of the hill but the sun is already threatening to melt it,” he warned. “We have a situation where surgeons are training juniors open surgery, but training themselves to perform laparoscopic surgery. There is a big gap between innovation and teaching.”
Natural orifice transluminal endoscopic surgery (NOTES), which involves accessing the abdominal cavity via one of the body’s natural orifices, is also breaking new ground in the field of laparoscopic surgery. A few cases have created significant interest where the patient wanted to avoid scarring for cosmetic reasons, so surgery was performed via the vaginal wall. Philippe Grange pointed out that just a few cases such as these can have a snowball effect and become the established technique – the gold standard – but it takes a long time to gain acceptance for pioneering procedures and current medical training is a major hurdle.
He predicts it will take another twenty years for everything to become the gold standard in terms of a laparoscopic approach, but questions: “Why has there been so much resistance to this innovation?”
He believes that surgeons have been put off by the perception that the approach is expensive at the beginning in terms of investment in equipment. “They believe it is dangerous (the learning curve is long and may be harmful to the patient). Moreover, surgery is quite conservative and teaching surgery even more so,” he added.
ROBOT TECHNOLOGY
One important development in the field of laparoscopy, in his view, has been the emergence of robots which have proved to be helpful – they have dropped the level of difficulty from “very high to just average” and make training a lot easier. He pointed out that surgeons who are not experienced in keyhole surgery can transfer their open surgery skills to laparoscopy with the minimum of training.
He believes the surgical community must think more about training these techniques to the next generation, however: “Expert procedures are not being taught which means these techniques will not be passed on if anything happens to the expert surgeons performing them or if they retire,” Philippe Grange commented. “Slowly, a way of teaching has been implemented, but it has taken a long time. For pure surgical skills in laparoscopic surgery, courses have been developed but individuals do not pass or fail. There is no assessment tool as yet.”
A training program at King’s has been implemented to teach surgical teams outside the hospital so they can ensure their learning curve does not affect patient outcomes and that the technique is implemented in a safe way. The course is attended by theatre nurses, anaesthetists and surgeons to ensure they all fully understand the skills required. An advanced course helps to establish and assess the surgeon’s technique but they are also audited at their respective hospitals to ensure there are no problems with implementation.
“After the training, we stay in touch to keep a record of the number of operations performed, the operative times, blood loss and the conversion rate (ie. whether the surgeon had to convert to open surgery during the procedure). Learning curve is not an excuse. I have a zero conversion rate,” he commented.
The first live patient is performed with Philippe Grange, while the first unaccompanied case may be performed after a year, depending on the surgeon’s level of experience. He is selective about who he trains, however. The individual’s motivation for learning the technique and their level of their skills are deciding factors.
“With open surgeons that are slow, very detailed and precise in their procedures, with very little bleeding, very few patients are required in order to train them on the laparoscopic procedure.
“Surgeons that have a clock in mind, who perform open surgery where there is more bleeding and a lot of swabs are used to press, are not suited to keyhole surgery. I tell them to come back when they have refined their technique.”
TWO-STEP TRAINING
EndoAssist robot technology was first introduced around 18 months ago at King’s and is now a key feature of the training program provided by the hospital. To help first time users gain confidence with the robot, he uses a two-step training approach. When presented with their first case, Philippe Grange will wear the headset that facilitates the movements of EndoAssist while the “trainee” carries out 90% of the procedure.
When, he or she is relaxed and they know the procedure is successful, the headset is transferred to them to continue with the remaining 10% using the robotic technology. The second patient is presented on the same day and the trainee uses the headset straight from the start, but with support on hand in case they need help with any aspects of the robot’s operation. Only by the third patient are they left alone.
Philippe Grange’s assistant at King’s is also performing surgery under his watchful eye, using the EndoAssist robot. The technology enables him to closely guide and train him on each procedure. “I am not even scrubbed. I just watch him and use a touch screen to give an overriding instruction to guide various aspects of the procedure. I can draw a line on the screen in colour to indicate where to cut. I can give voice and written instructions which makes training very easy. It also avoids the tendency during training to say ‘let me show you’ then take over the procedure which is not a helpful way to learn. “This allows you to plan the training and ensure it is as safe as if you had performed the procedure yourself. The robot allows you to be hands off when training, but you can join the operation when required if the assistant is just performing one part of the procedure, for example.
“The robot is fantastic in terms of saving time and spending more time teaching the appropriate technique to the appropriate people. Afterall, we should be training the trainees and not just the trainers.”
ASSISTANT TRAINING
He believes that his assistant is the only surgeon of his generation in the country receiving such hands on training to perform kidney, prostatectomy, upper tract urology and pelvic surgery alone, using laparoscopic techniques. With the technology to view the procedure remotely, he will also have the ability to mentor from his office in the near future.
Gordon Kooiman, previously acted as Philippe Grange’s “assistant” as part of his surgical training as a Registrar. Now a fully fledged consultant surgeon, he said: “I took convincing, when I first tried out the technology but now I am sold – it’s simple and it works. Previously, I was the one holding the camera and I thought I could do a better job. I was concerned it may prove cumbersome and thought I would be able to get to the location much quicker. But, with a bit of practice, the robot gives a better visualisation because you can get a more stable picture.”
The learning curve with EndoAssist is very quick and it took just under two hours for Gordon to become comfortable with the technology. Other surgeons at King’s – performing gynaecological, vascular and thoracic procedures – are also being trained in the use of the robot. The feasibility of using robotics in developing NOTES procedures is also being examined.
INVESTMENT
“Everything that can be done in open surgery can be performed laparoscopically using this technology. It is just a question of skills,” Philippe Grange said. “With laparoscopic surgery, the patient’s stay is shorter, there is less infection, less blood transfusion. Yet the proper economical studies have not been done. There is still a perception that robotic surgery is not costeffective, so we hope that with proper research it will be possible to provide an economic basis to justify the investment to colleagues.”
“When you first go to your manager with a plan for investment, they ask how much does it cost? Will it generate any income? Will it generate any savings and will it be any good in terms of image and prestige? I am told by my peers ‘you are lucky at King’s to have robotic technology’, but they do not realise that they will save money. They can make the case to the Trust that they will need less assistant time, as well as less theatre time, while they can perform four or five cases alone in one morning. There is a one off capital outlay and then it costs nothing.”
For surgeons at King’s performing hernia repair or gall bladder operations, on a day case basis, the number of procedures carried out has been increased typically from four to five by using EndoAssist. Another benefit of EndoAssist is the fact that it allows the surgeon to be seated during the operation, which reduces fatigue and hence improves concentration during lengthy procedures.
“You wouldn’t trust a pilot to fly a long haul flight if they weren’t sitting down, so why would you expect a surgeon to be any different?” Phillip Grange commented. There are also advantages in terms of the ability to visualise the target area: “When someone else holds the camera and they are not very focused, they do not understand what you are doing or they are simply tired after a 5-hour operation, you can start to feel a bit ‘sea-sick’ as the image moves about. The robot ensures the image is completely still. It is very precise. You can perform solo surgery and do not suffer if an experienced assistant is not available. The robot is a perfectly experienced assistant because, effectively, it is an extension of you,” Philippe Grange concluded.
You need to be logged in to read the rest of this story. If you are not already a member, please Register.
|