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Camran Nezhat Q&A: Minimizing Harm and Improving Recovery

Camran Nezhat, MD, FACOG, FACS
Inventor and pioneer of modern-day minimally invasive and robotic surgery; Fellowship Director of Camran Nezhat Institute, Center for Special Minimally Invasive and Robotic Surgery in Palo Alto, California.

The goals of minimally invasive surgery remain the same as laparoscopy – achieve the desired outcomes with less destruction, pain and recovery time – but the methods of achieving those goals have evolved over time. Here, the pioneer and inventor of modern day minimally invasive and robotic surgery, Camran Nezhat, MD, FACOG, FACS, weighs in on how he’s advancing these goals in 2020 and beyond.

You have spent decades helping to develop highly effective, minimally invasive surgical procedures. What current endoscopic/laparoscopic technologies do you find most beneficial to those goals?
Laparoscopes, cameras and robots have improved greatly over the years, allowing better visualization. The ability to see the surgical field and pathology better intraoperatively greatly improves the surgeon’s ability to perform safe surgery and reduce complications.

I also use a robotic system (da Vinci Surgical System, Intuitive Surgical) and the carbon dioxide laser (UltraPulse CO2, Lumenis), which can be used for precise excision of endometriosis, hemostasis, improved visualization, less tissue damage, and fewer complications compared to other alternatives. One of the greatest benefits is the limited thermal injury because we know that thermal spread can cause immediate and delayed injuries. With a carbon dioxide laser, the thermal damage on the target tissue is typically about 150 microns, compared to 3000-7500 microns with electrocautery. The more precise the energy source, the less morbidity occurs.

In addition, hydrodissection can be employed during laparoscopic surgery. This technique places fluid underneath the peritoneum and pushes vital structures like the ureter away from the operative field, thus helping preserve those tissues.

Historically, it has been particularly difficult to completely remove endometriosis cells, which can be widespread and grow on or near the ovaries, bowel and diaphragm. How can you treat every trace of endometriosis while preserving the adjacent tissues?

What the mind doesn’t know, the eyes don’t see. To effectively treat endometriosis, one must first be able to appropriately suspect the disease is present, and then be able to spot abnormalities laparoscopically, even if they are subtle. In addition to advances in laparoscopes and cameras, decades of experience treating this disease has given me the opportunity to learn about all of the variations in disease presentation as well as the ability to see every trace of endometriosis that may not be obvious to the less trained eye.

Having the right equipment and using it appropriately is also essential for thorough treatment and maximum preservation of fertility. For example, when superficial spots of endometriosis are found on the ovary, I favor using the irrigator to wash the ovary or very gently scraping the ovary instead of incising or cauterizing the ovaries. This protects the ovary from injury and avoids compromising ovarian reserve. In general, I am very cautious and use little or no energy or heat around the fallopian tubes and ovaries.

How do minimally invasive surgeries continue to improve postoperative pain, complications and recovery time?

We know minimally invasive techniques have multiple benefits for patients including smaller incisions, less blood loss, less adhesion formation, fewer wound infections, less complications, shorter hospital stays, faster recovery, and less cost. We have advocated for these techniques for decades. Postoperative pain and recovery time have continued to decrease as minimally invasive surgery has become more widespread and more efficient.

Minimally invasive surgery relies strongly on skill and precision. How do you approach complex surgeries with care, while at the same time maintaining a level of efficiency?

The more efficient the surgeon can be, the less time the patient will be under anesthesia, leading to better patient outcomes. The best solution is to proceed with surgical precision and to have a good understanding of anatomy. Minimizing extraneous movement intraoperatively can decrease surgical time, which generally leads to improved patient comfort and faster recovery as well. Another way to improve efficiency in the operating room is to use the same surgical team. Operating is a team effort, and like dancing, having the same partners each time can help us work more efficiently and improve the outcome. Finally, every surgeon should be familiar with the advantages and disadvantages of every instrument and product that he/she uses to maximize its benefit for the patient.

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