Controversies of Endoscopic Surgery

Article Conference CoverageFrom ISGE - Montreal, Canada - April, 1999

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Dr. Daniell: "We're here at the ISGE and we people who do advanced endoscopy - like Dr. Duncan Turner, here - think that everybody is in the same club. That is, that we see a lot of advanced techniques and we read a lot of papers about what are really very difficult procedures, and sometimes we forget that a lot of the people in the world don't have the experience, the training, or time and effort to do endoscopy. People like Dr. Duncan Turner, for example. asked us to talk about something controversial, and I've been privy to some infighting. There's always politics in medicine and the people who don't or cannot do endoscopic surgery to a high level or degree are often very critical of those of us who do. Dr. Turner has agreed to make a few comments and maybe relate a little of his story, a little vignette, about what's happened to him recently because of all this controversy over endoscopy. Dr. Turner, I've talked too much - you take this."

Dr. Turner: "Thanks, Jim. Let's just say that the criticism usually comes from people who don't do the procedures. We certainly can be constructively critical to each other about techniques, but when we talk about the mode of access, primarily of doing surgery endoscopically, this is a different modality. We weren't trained to do it in our residencies and we've had to be trained - to take time out of our practices, and train - so that we can give to our patients what we believe is the best possible treatment. Unfortunately, and we see this talked about a lot at meetings like this, even though most hysterectomies, for instance, can be done endoscopically, they're not. Most of the time, I would say that 80% to 90% of hysterectomies could be done endoscopically, but only 10% to 20% are and there are a number of reasons for this. One of the reasons is that most surgeons, as I say, haven't been trained to do it this way and have not taken the time to do so. Another reason is that the operation often takes longer than the traditional way - or at least it does until you've done a large number of cases - and so there's little financial incentive for the physician to spend that extra time learning it. But when you see how well these patients do post-operatively, and when you see how quickly they recover, how little pain medication they need afterward, you can become a believer very quickly."

Dr. Daniell: "Let me just mention, in addition, that the history never seems to change. When I was a resident in 1967, people were severely critical of the first guy to do laparoscopy in Dallas, Texas. I remember all the talk about how they would take him off the staff. It wasn't until he was doing 15 or 20 outpatient tubal ligations every day that they started coming not to him, but to the residents, to say, 'teach us this new operation so we can learn, too.' And then 15 years ago, when the lap cholecystectomies started in Nashville, Tennessee, we were involved working with general surgeons doing laparoscopy. The chairman of our surgery department said, 'I'll retire before I'll do a gall bladder through the laparoscope, but I'll have those two young surgeons disbarred!' That guy is now doing lap cholecystectomies, and so is the rest of the world. I understand you've received a little flack in California, and all I can tell you is time will tell. If you don't have mistakes, you're not doing anything - all of us learn from our mistakes, and others can learn from our mistakes. We're not perfect, we're human, and I commend you on persisting and doing difficult procedures and talking about it and publishing in a scientific way. We're glad to have you on the board of the ISGE. Any other comments?"

Dr. Turner: "I'd like to encourage patients to be informed and be their own advocates when looking for this type of solution to their problems. I really think that with the laparoscopic cholecystectomy - the gallbladder surgery - it is patient-driven, and the surgeons could not continue to practice that type of surgery without learning the new techniques. So I've looked to the patients to help us to be able to do more, to go looking themselves for physicians who will do those surgeries in, if not the standard of care, state of the art ways."

Dr. Daniell: "Those of you who take the time to learn and to do research, that's why you're on - to get unbiased, intelligent information. Look your doctor in the eye and ask him... if it was his daughter, what type of operation would he pick for her? Sometimes it's a very interesting answer, I think. Have you ever had that experience, yourself?"

Dr. Turner: "Yes, absolutely. That's the bottom line when the patient's asking for real advice - what would you do for your wife, or your daughter, or for yourself if you're a female physician - and that has to be the most accurate answer."

Dr. Daniell: "Educated patients mean good outcomes and more intelligent selection of the pathway of hysterectomy. If you're a candidate for a hysterectomy by a minimally evasive technique, you'll have a better outcome if you're in the hands and of the care of a competent physician such as Dr. Turner, so keep working at it. Let's hope the women of the world will be able to benefit from MIS in broader ways than they have so far."

Dr. Turner: "That's my goal too."

Dr. Daniell: "Well, thank you for taking the time to let us interview you for here in Montreal."

Dr. Turner: "It's my pleasure, thank you."

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