Endoscopic Surgery



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Amar Sawhney:  “My name is Amar Sawhney, and I’m here at the FIGO 2000 meeting at the OBGYN.net booth with a very prominent endoscopic surgeon from Kiel, Germany - Professor Liselotte Mettler.  We would like to talk to her a little bit about some of the pioneering things she has done in endoscopic surgery.  Professor Mettler, can you give us a little bit of a historical context on endoscopic surgery and gynecology and how you came to enter into this field?”

Professor Liselotte Mettler:  “Endoscopic surgery was started and propagated by my teacher, Kurt Semm in Kiel, Germany.  It has had some previous successors like Raoul Palmer and Hans Frangenheim but the real going of the gynecologists was from 1970 on, and when the surgeons came into the field around 1985, then the field really exploded.  Nowadays, endoscopic surgery is the modern surgery that has replaced, I would say, about 50% of all surgical procedures and certainly in the field of gynecology.”

Amar Sawhney:  “Excellent, what are some of the procedures that endoscopic surgery is very well suited for?”

Professor Liselotte Mettler:  “It is suited for all gynecological surgery and going of course into general surgery.  We use in surgery an organ orientated catalogue of indications.  So it’s surgery on the cervix for benign and malignant indications, on the uterus, tubes, ovaries, in the whole pelvis, and also on the breasts.  Especially at this Conference, we put some emphasis that also in malignant disease endoscopic surgery can be applied as a minimally invasive technique with the same possibilities.”

Amar Sawhney:  “That’s very interesting, so from the patient’s prospective, what can the patient expect when she undergoes endoscopic surgery as opposed to open surgery?  What are some of the benefits for the patient?”

Professor Liselotte Mettler:  “Her benefits are a minor invasive procedure so she has several holes of incision in her abdomen but no long cuts.  Of course, this surgery is already producing less adhesions than a laparotomy would and the pain following it is less provocative.  Her reintegration into family and professional life is much faster, and I would say because of the better vision of the magnification at laparoscopic surgery, the treatment possibilities are better also.”

Amar Sawhney:  “So you can actually get a much better outcome as well as give the patient a chance for an early return to work so I think there are several benefits that come about from that.  What are some of the advances that you have seen happening in endoscopic surgery?  You’re at the cutting edge of endoscopic surgery, what are some of the techniques that you’re involved with right now?”

Professor Liselotte Mettler:  “The instrument development in the last twenty years has been great and we are still on an ascending branch.  Instruments with multiple degrees of liberty are coming in, and nowadays robotics are coming into the picture and tomorrow we have robotic surgery.  In Germany, we have the Karlsruhe Research Institute which has put about one-hundred engineers on this topic so we are using trainers and simulators like the pilot’s are using and this is enabling us not to learn on the patient but learn outside, and then do this keyhole surgery which in reality is a much better picture surgery directly on the video screen.”

Amar Sawhney:  “Wow, that sounds very exciting.  Do you think it will ever be a situation where endoscopic surgery becomes something that every surgeon can do or will it take some specialized training and only some people who can do the more advanced techniques?”

Professor Liselotte Mettler:  “I think it is already a surgery that has set foot in every hospital and it depends on the leadership of the hospitals how much they innovate but it is a modern surgical tool which I think in America has kept much faster ground that it does in my German country, for instance, because people are open to new things while in Germany they stick to the traditional ways a lot.”

Amar Sawhney:  “That’s excellent.  What do you see with endoscopic surgery in cancer types of surgeries?”

Professor Liselotte Mettler:  “For instance, in young patients 20-25 years of age with early cervical cancers, the possibility of preserving the uterus is given with a technique called trapolectomy.  We can get access to the lymph nodes to really see how far the disease has spread with laparoscopic surgery, so the lymph adenectomy done under laparoscopy and the actual treatment in the small cancers was just the cervical resection.  With larger cancers a hysterectomy trans-vaginally is giving the patient the possibility of not having a big cut from laparotomy but still having the lymph nodes out with the same results.”

Amar Sawhney:  “That’s excellent, that seems like a logical way to proceed.  If you were to dream for a second, what are some of the unmet needs right now, what would you like to see develop in endoscopic surgery, and what are some of the things that you wish were out there?

Professor Liselotte Mettler:  “Some of the problems that patients have are adhesions.  Now my teacher, Kurt Semm, always told me that laparoscopy takes away adhesions 100%.  I would say it takes it away 40% but we do have fewer adhesions then at laparotomy but we still have them.  If we have to go in for that second procedure, we see how these adhesions are impeding fertility, how they are producing pain, and how bowels obstruct each other.  So we are really thinking about a good product for adhesiolysis, and I recently had a chance to test the product, which I’d like to talk about.  It’s a spray gel that you send up high and in a way it’s an interesting product that you take the two components into the body.  It forms a protective gel which is effective for a moment but for the important moments till adhesions would form.”

Amar Sawhney:  “Is there a time limit for which adhesions should be prevented, and what do you think that time limit is?”

Professor Liselotte Mettler:  “I think they start to be formed in the first days if not hours after the surgery.  So if at that time we can bring an agent there to take them away, we could take a lot of morbidity of our patients away.”

Amar Sawhney:  “So you’re currently involved in a clinical trial, if I understand that right?”

Professor Liselotte Mettler:  “Yes, with a clinical trial at the present time we investigate myoma surgery and we see that the adhesion formation is minimal and we hope to get a good result of that study.”

Amar Sawhney

:  “That’s very exciting.  I thank you for your time and thank you



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