Duncan Turner, MD, MBBS

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Alternatives to Hysterectomy

Coverage of 36th AAGL Congress November 2007, Washington, DC

Lack of Endometriosis Surgery Reimbursement in the US

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Will all hysterectomies be done laproscopically in the future?

: "Again, from the       World Congress of Endoscopy in Israel, I’d like to interview Dr. Duncan       Turner from Santa Barbara. He’s been one of the leading surgeons in the       United States, and the topic I’d like to talk about with him today is       safety in laparoscopy. What has always been an issue that the general       public has had concerns about is if laparoscopy is safe. Can you give us a       little update on exactly where laparoscopy stands today and what measures       there are for safety for the patients?"

:       "Thanks, Larry, it’s nice to be able to talk to you and this is a       subject that’s close to my heart, I think that it’s a really       underestimated problem. Complications of laparoscopy are often not       reported, and I think we have a false impression of the safety of       laparoscopy but if we use good surgical techniques and some new technology       that’s available to us, we can really serve our patients better and make       the whole procedure safer for them. Laparoscopy is certainly advantageous       as a way of operating, and we have to be sure that by giving the patients       particular advantages, we’re not causing them more complications. I       think the vast majority of complications with laparoscopy are on entry,       and most of the malpractice cases are concerning bowel and major vascular       injuries, and about 80% of these happen on entry techniques. Another       particular area of concern is the use of electrosurgery, which most       laparoscopists utilize to coagulate, cut, and dissect. The third thing is       one that is really a little more subtle because we don’t see the       complications of it but that is the gentle treating of tissue. When we do       microsurgery techniques in open surgery, we handle such tissue very, very       gently and make sure that the blood supply is not compromised, and one way       of doing that with laparoscopy is to remove one of the insults. And one of       the insults of laparoscopic surgery is the distension of the abdominal       wall with carbon dioxide. That is moderately harsh on the tissue but if we       can warm that gas as it comes in and humidify it, it’s being clearly       shown that this is advantageous. So going back to the laparoscopic entry       techniques, I think that there are a few really basic principles. There’s       always the question of whether they should be open or closed techniques. I       think we’ve shown that there is no great advantage from an open       technique. There aren’t fewer complications that way so let’s try to       refine the closed technique using the Veress needle. The placement of the       needle is important, I think having the initial pressure up to 20 mm or 25       mm of mercury and creating a much greater safety margin between the       abdominal wall and the major vessels in the bowel is very advantageous. I’ve       had a lot of favorable experience with the radiated expanding axis system       made by a company called Innerdyne which has made some very significant       claims of improved safety which interestingly have been accepted by the       FDA as being the safest way to use. I just can’t conceive of using other       types of equipment than that which is available to us and with shown       safety. With regard to electrosurgery, there’s a new device that’s       referred to as active electrode monitoring which adds dimension of safety       to electrocautery by giving more insulation and overcoming some of the       problems of capacitance of generation of electrical current. We have these       things available to us and we can almost exclude electrosurgical       complications except those due to surgeon error, and we’re not able to       take the human error out of things but we can try to diminish the       technical errors as much as possible. Going back to the carbon dioxide,       one of the problems that we run into with patients is that they get cold       during surgery, and the dryness of the gas has been shown to be damaging       to the peritoneum. There are new methods now of very simply and very       economically warming and humidifying the CO2 as it goes into the abdominal       cavity. And as you know in your experience with an awake patient, when we’re       doing pain mapping under local anesthesia or minimal anesthesia, these       patients can tolerate a much greater distension of the abdomen if the       carbon dioxide is warmed and moistened. It’s really been pretty       remarkable in your experience and I think that this is a very good example       of the decreased damage and trauma to the tissue. So that’s three new       technologies that I think are tremendously helpful to our patients       now."

: "One of       the things that we learned this morning, Duncan, and Dr. Nezhat spoke on       was ovarian cancer and its spread. How do you view this new heated and       humidified gas in this respect? There have been some reports that the       damage of the gas may exemplify or cause further spread of cancer tissue       within the peritoneal cavity. Can you give us your views on that?"

: "I       think one of the concerns about the spread of cancer cells is the       diminished immune response of the body immediately after surgery. I think       if there is less damage to the tissue, the body is going to be able to       withstand further insults. So if we have warmed humidified air and less       peritoneal damage, I think theoretically, we should have fewer incidence       of port metastases and spread of the tumor. This is purely theoretical and       it will be hard to prove I suppose, but we’ve got to sometimes make some       assumptions based on good scientific theory even though we don’t have       the data to support it. You know we’re not able to experiment on humans       and so we have to make some of those decisions just based on theory and on       science."

:       "Regarding the complications that we’re now experiencing in       laparoscopic surgery - the initial entry and then there’s the second       group of complications which are the intraoperative trauma or       complication, would you like to talk about the intraoperative rather than       the entry technique, just comment on that?"

: "I       think that’s really largely surgeon dependent if we exclude the entry       techniques and we exclude the unknown electrosurgical problems and the       unknown or under-appreciated problems with carbon dioxide gas. So we’re       really talking about things that are damaging to organs by surgical       technique, and there are so many. Operative laparoscopy is such a new       field that we’re still trying to find the best way to do things. One of       the really good examples of a change of technique of focusing on patient       safety is doing a subtotal or a supracervical hysterectomy instead of a       total laparoscopic hysterectomy when it’s practically possible because       you don’t have to get as close to the ureters, there’s much less       likely to be damage to the bladder, and much less disruption of pelvic       floor support if you do a supracervical hysterectomy as opposed to a total       laparoscopic hysterectomy. So I think there’s an example there of a       change of technique that has really been focused or determined not just by       patient desire to keep the cervix but by our desire to try to cut down on       the risks of complications."

: "I think       this is what these meetings come to and appreciate that we have to start       looking at what we’re doing from many aspects to not only the way we’re       doing it, but how to eliminate complications, and to get the world leaders       together like yourself to express the ideas that you’ve had here today.       I’d really like to thank you very much."

OBGYN.net Conference CoverageFrom World Congress on Gynecologic Endoscopy and The 1st Annual Meeting of the Israel Society of Gynecological Endoscopy, 2000

Duncan Turner, MD, MBBS

Articles

Alternatives to Hysterectomy

Lack of Endometriosis Surgery Reimbursement in the US

Will all hysterectomies be done laproscopically in the future?

Safety in Laparoscopy