Editor’s note: Responses have been paraphrased for brevity.

• Raymond Lanzafame, MD, MBA, FACS, Executive Director, Chairman, Scientific Chair of SLS
• William E. Kelley, MD, Former Director of General Surgery, at Henrico Doctor’s Hospital, Past president of SLS
• Mona Orady, MD, Director of Robotic Surgery Services at Saint Francis Memorial Hospital, VP of SLS
• Richard M. Satava, MD, FACS, Professor Emeritus of Surgery at the Univ. of Washington, Advisor to SLS
• Paul G. Toomey, MD, President and CEO Florida Surgical Specialists, Secretary-Treasurer of SLS

Four insights from the discussion:

1. Robotic-assisted surgery has changed the landscape and scope of minimally invasive surgery.
   The introduction of robotic-assisted surgery 20 years ago has shifted a majority of procedures from an open to a laparoscopic procedure or robotic-assisted surgery. The advent of robotic-assisted surgery has changed the landscape of minimally invasive surgery by allowing surgeons to push the limits of minimally invasive surgery to do more and more complex procedures – There’s almost no limit to the possibilities of robotic-assisted surgery. [Mona Orady, MD; Raymond Lanzafame, MD]
2. Robotic-assisted surgery has surpassed all of the barriers that challenge new technologies and will revolutionize surgery.
   Robotic-assisted surgery is now accepted as one of the standard methodologies that surgeons use in patient care. It is stable and accepted at nearly 6000 systems globally with millions of procedures having been performed. As we move into the digital age, the robot has become a global instrument; it is not limited to one’s own operating room or hospital. Everything is connected, and no other part of surgery has that capability except perhaps some components of image guided surgery. [Richard M. Satava, MD, FACS; Mona Orady, MD]
3. The current challenge for residency programs is to supply the breadth of training necessary for the current surgical landscape.
   We’re seeing different levels of robotic-assisted surgery capabilities when residents come out of training, where some can only dock the patient cart, some can operate, and some are completely safe with performing the entire robotic-assisted operation. The current challenge for residency programs is to supply the breadth of training necessary for the current surgical landscape, not just open and laparoscopic as well as endoluminal surgery, but also robotic. We have to create a balance in training so that the next generation of surgeons can do all of these procedure types with equal and exceptional insight, experience, and judgement. [Paul G. Toomey, MD; William E. Kelley, MD; Raymond Lanzafame, MD, MBA, FACS]
4. Simulation is experience
   Simulation training is utilized in many different disciplines, such as the by military or for pilots and astronauts. Simulation provides the indispensable experience and feedback. The beauty of simulation, of course, is you have permission to fail, and nobody is harmed in the simulation. Simulation not only allows you to maintain skills and learn from experience, but it allows you to measure your performance and determine the quality of your performance before you actually go out and operate on a patient. It’s time for healthcare to get on board and integrate the next generation of skill and procedure-based simulation. [Richard M. Satava, MD, FACS]

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoscopic & Robotic Surgeons. The authors of the work are solely responsible for its content.

COVID-19 has drawn many aspects of medicine into a different focus. Now, months after the pandemic made its initial impact on our hospital, we are able to reflect on all the adjustments made, how they’re working and what the future might look like. As a urologist, it’s clear that one particularly beneficial part of my armamentarium is my advanced laser. Surgeons in other fields who have upgraded their laser to the latest-generation technologies and applications have had similar realizations.

HoLEP for enlarged prostate — I perform holmium laser enucleation of the prostate (HoLEP) for treatment of benign prostatic hyperplasia (BPH). Using the second-generation 120 watt holmium laser that optimizes the “MOSES effect” I achieve enhanced hemostasis and therefore have shortened operative time. This has permitted many patients to be discharged the same day. By following an outpatient model, we reduce patients’ exposure in the hospital while lowering costs.

Patients with very large prostates who would have required open or robotic simple prostatectomy and a hospital stay can now have HoLEP, which is indicated for prostates of all sizes. What’s more, HoLEP has an excellent retreatment rate (about 1%, compared to about 17% for TURP¹). Even high-risk patients who are most concerned about going to the hospital in today’s environment can get effective treatment, go home the same day, and likely never require additional surgery for BPH.

Airway surgeries — Daniel Fink, MD, is an Assistant Professor of Otolaryngology at the University of Colorado School of Medicine and a surgeon at National Jewish Health in Denver. Dr. Fink, who specializes in voice, swallowing and airway disorders, sees the value of his CO₂ laser for improving COVID-19 safety in the OR. “For airway work, it has been very useful to have a CO₂ laser system with the ability to switch from a line-of-sight surgical approach where patients are intubated to a fiber-based approach. This dual modality in a single platform is advantageous because versatility allows me to easily pivot without the need for two laser systems on standby, saving the hospital money. Currently, I’ve found that using a flexible bronchoscope and a laser fiber through a laryngeal mask airway, creating a closed system that reduces potential aerosols, minimizes the risk of spreading coronavirus in the OR,” he explains.

Complex laparoscopic pelvic surgeries — “The advanced CO₂ laser allows me to be more precise and surgically meticulous when performing complex laparoscopic surgery, such as for severe pelvic endometriosis disease,” says Vadim V. Morozov, MD, FACOG, FACS, a gynecologic surgeon specializing in management of chronic pelvic pain, endometriosis, and minimally invasive gynecologic surgery at MedStar Health in Washington, DC and Maryland. “That high level of control allows me to work faster because I have less chance of injuring sensitive organs. This reduces operative time, which in turn ensures that OR personnel experience less overall exposure to potential pathogens, including coronavirus. The precision helps potentially eliminate intra- and postoperative complications related to the use of energy. Moreover, patients have a quicker recovery and less post-op pain, shortening the time they spend in the recovery room after the surgery.”

The very same advantages of advanced lasers that help lower patients’ potential exposure to the coronavirus also offer clinical advantages that make them wise choices for the future. Used appropriately, they are even helping us reduce aerosol exposure in the OR, a risk we were already working to mitigate before COVID-19. Going forward, we will continue to learn and evolve in ways that best serve our patients while protecting surgeons and staff.

Reference
1. Abedi A, Razzaghi MR, Rahavian A, et al. Is Holmium Laser Enucleation of the Prostate a Good Surgical Alternative in Benign Prostatic Hyperplasia Management? J Lasers Med Sci. 2020 Spring; 11(2): 197–203.

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoscopic & Robotic Surgeons. The authors of the work are solely responsible for its content.

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.

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoscopic & Robotic Surgeons. The authors of the work are solely responsible for its content.

Here in rural southwest Oregon, I am the only general surgeon in my county. It’s a challenging position that keeps me on my toes. Because there can be unexpected demands on my time, I need to work as efficiently as possible. That means keeping an eye out for new advances that can save time, make surgery go more smoothly, and reduce stress on my body. One side benefit: some technologies simplify OR staffing by elevating less-skilled assistants.

For example, I use the ClickClean, an in-abdomen laparoscope lens cleaning device (Medeon). It covers the scope in a transparent sheath, and when fluids or smoke obstruct my view, I click the trigger to advance clean, new film over the lens. The device is designed to give surgeons a clear, consistent view, while saving time and frustration, but because we don’t need to pause surgery, remove the scope, clean it, and get it repositioned, the efficiency of surgery no longer hinges on the assistant’s skill level.

Taking the camera out over and over again is annoying regardless of the assistant’s skill level, but it’s certainly easier with an assistant who is experienced in laparoscopic surgery, understands anatomy, and knows how we need to orient the scope. My assistants are usually medical students, but if none are available, my scrub tech handles the scope. If my assistant is not very experienced, I usually have to put my instruments down, clean the camera, reinsert it, and hand it back to the tech or medical student.

High-quality Microline Surgical laparoscopic instruments also reduce the skill level required of my staff, and they give me added peace of mind. For example, with a good laparoscopic grasper, it’s easy for me to firmly grasp the gallbladder and have an assistant hold the grasper and retract the liver while I continue dissection. I can proceed with confidence knowing that the grasper will not fail while the assistant is holding it.

In addition, a high-definition laparoscopic camera and 4K flat screen display (Stryker) not only help me to see better, work more safely, and reduce strain, but also help my OR staff learn the procedure and work more efficiently. Medical students can clearly see what I’m teaching them. At the same time, other staff members gain a better understanding and learn to anticipate what comes next, so the entire process go more smoothly. Inexperienced staff can learn and build their skills more quickly, so we’re raising the skill level of the pool.

All of my ergonomic choices in the OR help our staff as well. To minimize the toll that long hours of surgery take on my body, I make sure the table is at the right height, the screens are positioned just right, and cushioned handpieces make tasks less fatiguing. Staff members have less fatigue as well, and the positioning makes it easier for them to assist. For example, a technically challenging laparoscopic dissection is made easier if the ergonomics are favorable. This cuts down frustration during a difficult case.

With help from these technologies and our OR staff making surgery more efficient, I’m able to do a long day of elective cases and still be on call 24/7, responding to emergencies from the ER. I don’t always know who will be available to assist in the OR, but I’m confident that no matter who is helping, we will always provide the best care.

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoscopic & Robotic Surgeons. The authors of the work are solely responsible for its content.

By Kenny R. Sinervo, MD, FRCSC

Endometriosis is a progressive condition where endometrium-like tissue grows outside the uterus in the pelvis, abdomen and thorax. The condition causes chronic pain, inflammation, endometriomas, fibrosis, adhesions, bowel or bladder dysfunction, endocrine and immune problems and infertility. Endometriosis affects 0.7% to 8.6% of women, including 15.4% to 71.4% of women who present with pelvic pain and 9.0% to 68.0% of women experiencing infertility.¹

As a specialist in endometriosis, I see how patients are mistreated in both senses of the word. First, doctors frequently misunderstand and dismiss their complaints. The result is often repeated misdiagnosis, unnecessary treatments, and years of frustration and doubt.

When patients do get an accurate diagnosis, they are most likely to be mistreated clinically. Doctors prescribe birth control pills that just reduce the severity of symptoms. Some patients are told, “Let’s just wait until you’re ready to have kids, and then we’ll do your surgery.” In the intervening decade, endometriosis continues to progress. I see many patients who were diagnosed in their teens and placed on birth control pills, and when they come off the pill 10 or 12 years later, they are in severe pain and cannot conceive.

Endometriosis is also treated with several surgical options. For patients who do not want to conceive, hysterectomy is an aggressive approach. However, the surgery alone does not eliminate the disease or its symptoms. If the ovaries are removed, 10% of patients still have chronic pain; that number jumps to 60% if the ovaries remain.^2,3

More common today are two conservative approaches to surgery. Ablative procedures, which include cauterization, laser vaporization, or harmonic scalpel ablation of the endometria, are performed by the great majority of gynecologists. Unfortunately, these surgeries only treat the surface of the problem while leaving behind the root, so the recurrence rate for endometriosis after ablation is 60% to 80% within 2 years.^4,5 Thus, the likelihood of long-term fertility improvement is low.

The second, more effective conservative surgery for endometriosis is excision. In excision, we make an incision around the tissue and remove the full depth of the disease. This can be done with scissors and/or a CO₂ laser. I use the CO₂ laser (Lumenis UltraPulse Duo CO₂) because it causes minimal damage to adjacent tissue and simultaneously cauterizes, so I can work more efficiently and have better visualization.

In my practice, this approach limits the recurrence rate to less than 10%. The procedure is technically more difficult than ablation, but it allows us to safely excise tissue from delicate structures such as the ovaries, ureters, bowels and bladder. About 80% of my patients want to get pregnant, and a 10% recurrence rate makes that much more likely compared to ablation. As we follow these patients, their fertility rates seem to decline at normal rates based on maternal age.

If women with endometriosis were asked, “Would you rather have surgery with less than 10% chance of recurrent pain or one with a 60% to 80% chance?” they would choose excision. But not all surgeons perform excision, and they do not present that option to patients.

Instead, patients have multiple ineffective ablative surgeries, one after the other, often with complications such as retroperitoneal fibrosis. By the time patients get to me, most have had three or four unsuccessful ablative surgeries and just as many failed medical treatments. Despite those challenges, they are still good candidates for excision, and about 85% have significant improvement in pain after surgery. But they deserved better from the start. Surgeons must stop mistreating endometriosis, and they can do that by recognizing the condition early and using surgical excision for first-line treatment.

1. Ghiasi M, Kulkarni MT, Missmer SA. Is Endometriosis More Common and More Severe Than It Was 30 Years Ago? J Minim Invasive Gynecol. 2020 Feb;27(2):452-461.
2. Rizk B, Fischer AS, Lotfy HA, et al. Recurrence of endometriosis after hysterectomy. Facts Views Vis Obgyn. 2014; 6(4): 219–227.
3. Namnoum AB1, Hickman TN, Goodman SB, Gehlbach DL, Rock JA. Incidence of symptom recurrence after hysterectomy for endometriosis. Fertil Steril. 1995 Nov;64(5):898-902.
4. Yeung P Jr, Sinervo K, Winer W, Albee RB Jr. Fertil Steril. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? 2011 May;95(6):1909-12, 1912.e1.
5. Bozdag G. Recurrence of endometriosis: risk factors, mechanisms and biomarkers. Womens Health (Lond). 2015 Aug;11(5):693-9.

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoscopic & Robotic Surgeons. The authors of the work are solely responsible for its content.

In myomectomy, a procedure where uterine fibroid tumors are removed while preserving the uterus, we must cut into the compressed muscle of the uterus to excise fibroids from their pseudocapsular space. Injury to the muscle of the uterus is often unavoidable, but it must be limited to the absolute minimum necessary. Thus, we consider all options before recommending surgery, selecting only patients with symptomatic tumors that affect their quality of life, or asymptomatic tumors that are very likely to negatively affect the patient’s chances of conceiving or carrying a child.

Challenges of Improving Fertility
Cases where patients are largely asymptomatic and improving fertility is the only goal are particularly delicate. If it is deemed advantageous to remove the tumors, we still must remain cognizant that in doing so, we will injure the uterus, and we may injure the endometrium, the fallopian tubes or the vascular circulation to the ovaries. It’s an enormous task to educate patients so they can make a truly informed decision to proceed with an elective surgery given controversial opinions on this topic. Myomectomy is one of the most difficult gynecological surgeries for the aforementioned reasons (difficulty in establishing the indication for surgery, and difficulty performing uterine microsurgery that produces the least injury to the uterus and the other reproductive organs). There is no regeneration occurring in any reproductive tissue: any cell lost by surgery is lost forever. If we make any area of the uterus unnecessarily thin or fibrotic, then it could rupture or lead to abnormal placentation. The surgeon faces a double challenge with myomectomy: he/she must be both precise (microsurgical) and quick (because of the active bleeding that goes on during this repair). Blood is the sand in the hourglass of myomectomy.

A.
B.
C.
Figure Legend:
A laser knife assists in the safe excision of myomas from unusual and delicate spaces, such as anterior cervical myomas (A and B) and retroperitoneal myomas (C), due to the absence of lateral thermal spread.

Robotic CO2 Laser Myomectomy
Some major advances in surgical technology have made it easier to perform myomectomy and while preserving fertility. The first one is robotic surgery. This was a particular boon for myomectomy, because the procedure is very suture-intensive, and precise and fast suturing is very difficult to accomplish laparoscopically. Another one is self-anchoring (barbed) sutures. These further reduce uterine bleeding and surgery time.
However, if we want to operate by the tenets of microsurgery, we cannot ignore the fact that conventional robotic cutting instruments (based on electrocautery) have significant lateral thermal spread and will therefore result in the unnecessary loss of precious functional myometrium. Also in this field, technical advances have come to our aid. We have to choose the tool that will produce the least injury to the uterus, and the CO2 laser is that tool.
My current CO2 laser, the Lumenis UltraPulse Duo CO2 laser with FiberLase waveguide, also makes it easier to perform myomectomy while minimizing damage. The key is the ability to excise tissue cleanly and efficiently with a lateral thermal spread of only about 100 microns. The result is decreased loss of functional myometrium (middle layer of the uterus) compared to other technologies that have over 5mm thermal spread (50x more than the CO2 laser). Not many surgeons have adopted laser blades yet, probably because lasers with classic line-of-sight were challenging to use in the past. Laser fibers instead have a very user-friendly profile and can be safely controlled by robotic instruments inside the abdomen. These improvements reduce morbidity, complications, and need for postoperatieve analgesia, while increasing the likelihood that our patients will succeed in spontaneous or assisted reproduction.

The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoscopic & Robotic Surgeons. The authors of the work are solely responsible for its content.

By Matthew Brunson Martin, MD, FACS
Surgeon, Central Carolina Surgery, PA, Greensboro, North Carolina

Impaired visibility is a major frustration during laparoscopic surgery. Blood, smoke and steam impair our view, and we can’t safely continue with surgery until we remove the telescope, clean it and re-insert it to the same location so we can pick up where we left off. It’s time-consuming. In long procedures, we might clean the scope 5-10 times, taking 2-3 minutes for each cleaning and reinsertion, thus adding 10-30 minutes.
These challenges are most evident during difficult cases. For example, during gastric bypass on an obese patient, it is difficult to remove and reinsert the scope. Gallbladder removal produces a great deal of steam, so we frequently need to clean the lens during that procedure.
Inefficiency is a problem, but for me, the biggest frustration is the loss of focus. Often, as I’m concentrating on a challenging part of a procedure, a greasy mist or smear of blood blocks my view. I need to interrupt the procedure not only for a few minutes of cleaning, but also for me to try to get back to the same position and refocus on a difficult task. Adding to the tension, if I have a camera operator who isn’t very experienced with the equipment, it can take longer to complete the cleaning and reinsertion. The whole process is exasperating.
Industry has worked to improve the cleaning process. A povidone-iodine surgical scrub solution helps prevent fogging and repel liquids. Other cleaning options like Fog-Guard (Xodus Medical), Fred (Medtronic), and Mr. Clear (Key Surgical) do the same. We’ve used prepackaged cleaning tool kits like the Clearify Visualization System (Medtronic) and the LaparoVue Visibility System (Buffalo Filter) to help technicians work more efficiently.
Recently, I trialed ClickClean (Medeon Biodesign) a device that covers the scope’s lens with a transparent, biocompatible film. During surgery, the surgeon clicks a trigger to advance the film along the scope, thus providing clear visibility without removal and cleaning. I appreciated the system’s in situ approach, which lets me maintain focus on the task in front of me. As soon as the view became foggy or smeared, it was cleared in a few seconds with a click or two of the device.
Because I controlled the device, I didn’t need to rely on a camera operator to restore visibility, which meant the camera operator’s experience was no longer a factor in how smoothly and efficiently the surgery proceeded. It was a more relaxed experience. We also saved all the time typically spent performing multiple cleanings and reorientations.
The shorter surgery time is better for our patients, and in situ cleaning dramatically improves my experience as a surgeon. It’s a more relaxed approach for everyone in the OR. Hospitals will see the benefits as well because it saves OR time. I think that in situ cleaning will become the norm and remove a lot of time and frustration from laparoscopic surgery.
 
 
The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoendoscopic Surgeons. The authors of the work are solely responsible for its content.

By Misty Tuttle
Lead Surgical Technologist
Cone Health, Wesley Long Hospital, Greensboro

Laparoscopic surgery is a team effort. In the OR, in addition to the surgeon, we generally have one or two surgical technologists, a circulating nurse performing documentation, and a CRNA or anesthetist. A resident may observe or assist with surgery as well. In our hospital, team members usually have experience working together. Experienced teams have two clear advantages: 1) They have performed the same procedures many times. 2) Familiarity with the surgeon makes it easier to offer support, anticipate needs, and follow direction.

Although experienced teams make surgery smooth, efficient, and less stressful, it’s often not possible for all the same people to work together. Staff members rotate. People go on vacation. Some change jobs. How can we standardize a high level of teamwork in the OR, even when the same levels of experience and familiarity aren’t there? I think a combination of communication and technology work best.

When surgeons aren’t working with their usual team, it helps when they begin surgery by laying out what will happen and what they will need from team member. All the staff members need to be honest about their level of experience with the specific surgery and feel free to ask questions. Our surgeons usually do an excellent job of communicating what they’re doing during surgery and keeping us on the same page throughout the procedure. Technology contributes to that communication, with a large screen (Stryker) that allow everyone in the room to see the scope view as well as patient’s vital signs.

Together, these efforts to communicate help the group work as a team toward their shared goal of achieving the best results for our patients. When some less experienced team members are in the room, communication can elevate their performance. We also look for ways to level the field with technology.

As a surgical technologist, I have seen less experienced technologists struggle to control the scope and light cord during complex or lengthy procedures. When surgery produces significant smoke, blood, or grease that repeatedly impair visibility, necessitating repeated scope removal and cleaning, newer technicians might take more time for cleaning or find it difficult to return to the same angle and view after cleaning. To maintain visibility without interruptions, we recently tried an in-abdomen lens cleaning device (ClickClean, Medeon). A biocompatible transparent film covers the scope lens, and the surgeon or surgical technician clicks a trigger to advance the film and get a clean, clear view. The technology elevates the performance of newer technicians, whose inexperience is less taxing for the surgeon when we eliminate scope removal and cleaning.

With clear communication, good laparoscopic visibility, and technologies that help staff members work efficiently at a high level, the team is stronger. Surgeons can remain focused on surgery while other team members provide all the necessary support, smoothly working together as a whole.
 
 
The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoendoscopic Surgeons. The authors of the work are solely responsible for its content.

By Raymond J. Lanzafame, MD, MBA, FACS

Regardless of specialty, you have likely used or heard about the use of laser technology in surgery. Virtually every surgical procedure has been accomplished with laser techniques. However, adequate skills, training, and experience are required as a prerequisite in order to achieve good outcomes and operate safely. There are foreseeable problems surgeons must learn to recognize and address, and you also need to get appropriate credentialing within your facility. The process for initial and ongoing credentialing and training varies from hospital to hospital.

To help physicians get the training they need, I would like to discuss the basic requirements for laser credentialing across institutions and specialties, for both residents and well-established surgeons. Education must be ongoing, specialty specific, and wavelength specific. Refresher programs should be readily available. Residents need a wealth of safety information, a practical hands-on introduction, and a springboard for “on-the-case” training. Both residency and CME credentialing programs can benefit from these key features to meet all these needs:

• Laser basics – Every clinician using a laser should have a complete working understanding of laser physics, the individual technologies, delivery systems, principles of laser use, tissue effects, safety, and applicable standards and regulations before attempting to use a laser on patients. To be credentialed, the physician must have been trained to use lasers in a recognized and approved residency program or must have obtained training through an appropriate CME course.

• Hands-on experience – Clinicians gain a working understanding of the limits and advantages of lasers in their own hands through hands-on training. They learn to select the proper wavelength, delivery system, and laser parameters to achieve the desired outcome. It also helps if clinicians practice working with assistants experienced in laser surgery before attempting a major procedure for the first time. It’s always best practice to not try the worst of the worst patients first. Often, we clinicians jump in too quickly because we see or hear about what other surgeons can do. The specific attributes of the technology and properties of the laser-tissue interaction can help make a proficient surgeon better. The more you use a laser, the easier it is to understand its strengths and limitations in your own hands.

• Specific training – Surgeons need specialty-specific workshops or appropriate residency training to use or operate a laser safely. This training is not one size fits all. Rather, it is wavelength specific, since different wavelengths and technologies require specific techniques for safe use and optimal outcomes. In addition, surgeons may need specific training in individual procedures. For some specialties, such as otolaryngology, surgeons are usually certified for several wavelengths and techniques during residency. This is not true in other specialties. A gynecologist, for example, may be residency-trained to perform laser laparoscopic hysterectomy but may still need to seek additional CME training post-residency for credentialing in the latest CO2 fiber laser treatment for excision of endometriosis.

• Verification – It is an increasingly commonplace requirement that newly credentialed clinicians must be observed using a laser in the OR to verify their competency. In addition, residents should be supervised at all times by a laser-certified attending physician during laser surgery. These practices are similar to the requirements for surgical privileges and competency assessments in general.

• Ongoing requirements – Clinicians need to be reviewed annually for safe use of a laser in order to maintain credentialing, with special attention given during biannual renewal of clinical privileges. Clinicians should also demonstrate that they are performing the laser procedures frequently enough to be considered in good practice. For example, a clinician might be required to document performing at least five procedures over the previous two-year period to maintain privileges. Such practices help to demonstrate current competence.

Once clinicians fulfill their part of the credentialing process, it falls to administrators to guide and enforce the program through a series of checks and balances. Credentials must be verified before every surgery. A laser committee needs to provide oversight of hospital credentialing, while quality assurance monitors track outcomes. Everyone at the hospital is subject to state regulation, published standards and guidelines (ANSI, JCAHO, AORN, etc.), and peer review. In the end, surgeons’ quality education and the facility’s systematic oversight ensure that patients get safe, reliably effective laser surgery when it is the appropriate choice., It is best to reach out to a medical laser manufacturer like Lumenis to start or advance your training and to take the necessary steps toward becoming credentialed at your institution.
 
 
The content presented on this page is provided for informational and/or educational purposes. This material represents the views and opinions of its authors and should not be construed as representing or reflecting the official position, views or opinions of the Society of Laparoendoscopic Surgeons. The authors of the work are solely responsible for its content.

By Dieter Bruno, MD, FACS
Urologist, Peninsula Urology Center, Redwood City, California

A surgeon can perform a complex laparoscopic procedure exceptionally well, but if the patient develops a port-site hernia postoperatively, that will be the enduring impression of their surgery.

Port-site hernias can occur in any case, but they happen most commonly when patients are obese, elderly, or diabetic. The surgeon struggles to suture the deep fascia, and incomplete closure of that tough connective tissue results in the contents of the abdomen bulging and pushing on weaker layers. Patients see the bulge and sometimes feel pain, so we have to go back in and do a second procedure to repair the hernia, with all the added cost, hospital time, and anesthesia. In the worst cases, a piece of the intestine can bulge through the hole, causing an obstruction that requires emergency surgery.

Put simply, nothing can substitute for suturing the port right the first time.

Our Options for Port Closure
As an urologist, I need to close ports after a number of procedures, including laparoscopic adrenalectomy or hysterectomy, as well as robotic hysterectomy, partial nephrectomy, prostatectomy, pyeloplasty, and sacrocolpopexy. But port closure is the same, regardless of the procedure or the specialty.

In selecting a method for port closure, we look for options that address our toughest challenges. The most pressing problem is the difficulty of finding and accessing the fascia in large patients. Secondly, at the end of the case, we don’t want to make any errors as a result of fatigue. To my mind, that means the closure method should be very straightforward and efficient.

Some surgeons used a curved needle to close the port, but it’s difficult to get the layer we want with this method, and we need to fish for the sutures as we work. Another option that simplifies the process is the Endo Close device (Medtronic), which captures and holds the suture so the surgeon can pull it through the other side. With the Carter-Thomason CloseSure System (CooperSurgical), a reusable conical guide ensures that we angle the suture passer correctly for closure of the fascia and peritoneum. We feed the suture through the device, and then grab it and pull it from the other side. This can be difficult, so it requires some practice.

Another option called AbClose (Medeon Biodesign) standardizes how we suture and close the fascia by mechanizing the toughest aspects of port-site closure. A single surgeon or less experienced resident can safely and reliably close the fascia each time, regardless of the patient’s weight or other challenges.

Fewer Complications
The ultimate goal in working toward development of an elegantly simple port-site closure device is to reduce the risk of hernias so fewer patients face the added risks of additional surgeries. Surgery should meet its goals, not open patients to further problems. When we can close ports correctly every time, the wound closure device becomes an unsung hero in the OR that allows patients to focus on getting better, instead of on wound complications.
 
 
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