History of Endoscopic Surgery

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Prof. Liselotte Mettler:  “I’m Professor Liselotte Mettler from the Department of Obstetrics and Gynecology at the University of Kiel in northern Germany.  It’s my pleasure to be here at the AAGL meeting in Orlando, Florida with Professor Camran Nezhat, a very esteemed colleague whom I have known for over twenty-five years.  Camran, can you tell me where you work and how long you’ve been performing gynecological laparoscopy?”

Dr. Camran Nezhat:  “Presently, I am working at the Stanford University Hospital where I am Deputy Chief of Gynecology and Obstetrics, Clinical Professor of Gynecology and Obstetrics and of Surgery, and Director of the Stanford Endoscopy Center for Training and Technology. I have been doing endoscopic surgery since my residency in 1974.”

Prof. Liselotte Mettler:  “And where was your residency?”

Dr. Camran Nezhat:  “My residency was at the State University of New York in Buffalo.”

Prof. Liselotte Mettler:  “Tell me what made you decide laparoscopy was the surgical method that you’d like to proceed with?”

Dr. Camran Nezhat:  “I was always interested in endoscopic surgery.  The problem with it, as I saw, was the so-called "one man band" production. But one we did a lot of video laparoscopy in our institution, and I did a lot of work with video at the beginning in the lab and then on humans, I thought this method could have a role for the surgeon, for the patient and for the entire operating room. Then there were the advantages of operative laparoscopy, a smaller incision, faster recovery, and of course, the magnification that you get through the endoscope, allowing you to perform microsurgery by laparoscope.  All of that intrigued me and  I decided that perhaps we should look into this further."

Prof. Liselotte Mettler:  “So that was in the late 1970, early 1980s. Before using videolaparoscopy, how was operative laparoscopy done? Who was doing it, and where?"

Dr. Camran Nezhat:  “We have to give a lot of credit to the Europeans, including yourself, Professor Semm, and Palmer and Bruhat in France.  The Europeans were ahead of the U.S. in a lot of this work.  The only reason I saw for endoscopic surgery not progressing, was, as I stated earlier, that it was simply for one surgeon.  The addition of video changed the picture and became an orchestra instead of the surgeon being able to see and operate, the whole operating room became involved.  Also, I believe there was significant progress due to collaboration between different disciplines.  The only way to progress faster and better is to collaborate with different disciplines, and we were lucky to have the advantage of working with general surgeons, colorectal surgeons, urologists, cardiothoracic surgeons, orthopedic surgeons and even neurosurgeons, sharing our experiences with each other.  This collaboration made the progress in endoscopic surgery significant.”  

Prof. Liselotte Mettler:  “You are one of the most well known and gifted laparoscopic surgeons that I have ever seen, and I have seen you work many times.  You also put your work into writing, how much have you published?”

Dr. Camran Nezhat:  “You are very kind. We are just trying to follow the good example set by others and to share our experience for the benefit of our patients. But, we have only been co-authors on two books. Of course, the second edition of our book is out and we have published some book chapters and papers, in excess of 200.”

Prof. Liselotte Mettler:  “Your red book is one that my students are using. It is a very deductive and well-written book for someone starting to do laparoscopic surgery. I think many people are going after that.”

Dr. Camran Nezhat:  “Thank you.”

Prof. Liselotte Mettler:  “What about the procedures you practice nowadays, can you go into the details a little as a gynecologist in collaboration with other medical fields? What are the procedures you are doing?”

Dr. Camran Nezhat: "Originally we, being myself and my brothers Dr. Farr Nezhat and Dr. Ceana Nezhat, did infertility work and a lot of infertility surgery in the early 1980s to early 1990s. We had a very busy infertility practice, and we had a lot of endometriosis patients, so our interests, by serendipity, ended up being endometriosis and myomas of the uterus. We have done a lot of work on endometriosis, and because of the nature of the disease, sometimes being extragenital involving the ureter, bowel, and the diaphragm, we ended up working with surgeons from other disciplines. That is how we have had the fortune of collaborating with other surgeons. Then when they saw what we were doing with endometriosis, they all thought we could help them in their discipline, thus we began working with surgeons in other specialties. That is how we have been fortunate with regards to collaboration, which has expanded our knowledge and also helped others."

Prof. Liselotte Mettler:  "From the 1980s on you went through a period of doing major infertility surgery, and nowadays also pelvic floor surgery. Do you go in peritoneally?"

Dr. Camran Nezhat:  "During our work, because of the collaboration, at first we did endometriosis. After that we did a lot of bladder neck suspensions, vaginal wall suspensions in collaboration with oncologists, radical hysterectomies, paraortic and pelvic node dissections. Then we did colon resections, ureter resections and reanastomosis, bladder resections and then anastomosis. We have done fistulas, rectal-vaginal and vesico-vaginal. We have done some work on the diaphragm, which is more related to the chest surgeon. We did some work for coronary reanastomosis and then neurosurgery, solid organ removal, etc."

Prof. Liselotte Mettler:  “You mentioned very complicated areas like the psoas hitch. To me, that is still an area where the urologist would have to perform a laparotomy and implant the ureter. Would you do that by laparoscopy?”

Dr. Camran Nezhat:  “Yes, we have worked with our urologic colleagues and we have done several, perhaps five or six psoas hitch for very bad cases of endometriosis laparoscopically. Of course our colleagues in urology are now interested in expanding more and doing other procedures laparoscopically. We have collaborated with them on extensive work on the ureters and sometimes the kidneys.”

Prof. Liselotte Mettler:  “Looking now at the technical power we are applying, we are here at a meeting where there is a lot of industry. I know you like the laser, but from a judging point of view, what other energy sources do you really like to use?”

Dr. Camran Nezhat:  “In general, everybody plays the piano differently, and every surgeon can use different instrumentation. In my opinion, a good surgeon can operate with any instrument. They get used to it and gradually with practice they make the instruments beneficial for themselves. In the past we have used a lot of CO2 laser for cutting and we still like it. We use electrocautery, bipolar and unipolar electrocautery, harmonic scalpel, and we use stapling devices when we are at a teaching center. You have to be familiar with all sources of energy or methods of surgery to be able to teach your students or to collaborate with you colleagues. So we are multi-disciplinary in general. ”

Prof. Liselotte Mettler:  “Today there was a lecture about robotic medicine that I am sure you attended. What do you think about robots in our field? Are they useful, and are we forced in teaching centers to put more emphasis on this?”

Dr. Camran Nezhat:  “I believe robotic surgery also has its place in our armamentarium. At the present time it is in its infancy. But, as it keeps growing and progresses more, we will be able to add them and use them in our work.”

Prof. Liselotte Mettler:  “Now from the industry that we are seeing here, have you had a big impression of anything new?”

Dr. Camran Nezhat:  “I am impressed with all of the companies that are constantly trying to compete and provide the cheapest, safest, and fastest instrument. Hopefully we will be able to come up with that.”

Prof. Liselotte Mettler:  “How about our daily work, do you foresee that everything we do in surgery can be done by laparoscopy or do we have a spot for open surgery still?”

Dr. Camran Nezhat:  “In my opinion, surgery can be done in many ways, but every surgeon should make the number one priority to do no harm to the patient. We must do what is safest for the patient and do it the best way. Laparoscopic surgery in gynecology could be used practically in 99% of the procedures. The only limiting factor I see is skill and experience of the surgeon and the availability of proper instrumentation. In some cases, like advanced ovarian cancer where they require advanced debulking, then I think at this time that should be done by laparotomy. But, in general, you can use laparoscopy practically for everything that needs microsurgical expertise and attention. When you are dealing with removal of a very large volume, since right now we do not have instrumentation that is good for getting rid of those volumes very fast, perhaps laparotomy, mini-laparotomy, or laparoscopically assisted might be the answer. We can still use the benefits of the laparoscope, and then do the procedure laparoscopically assisted by a mini-laparotomy.”

Prof. Liselotte Mettler:  “So you would agree that we are still climbing a mountain, but to reach our final goal with laparoscopic skills and do maybe 90% of our cases with this type of surgery, the skill still has to be developed?"

Dr. Camran Nezhat:  “I definitely agree with you. I think it is technical work and it takes a lot of time to get past the learning curve. As more and more surgeons become familiar and get through this learning curve, the situation will get better. More surgeons will learn, the instrumentation will become more user friendly, and we will have more products to choose from, making the procedure easier and safer. So, when endoscopic surgery becomes safer and easier, more and more surgeons will be doing it. We will also have new drugs, drugs that may eliminate the need for surgery, the intervention of radiology, robotics, etc. All of these developments would add to and assist with treatment of the patient. There are many exciting new developments, and if we could collaborate with each other it would make surgery in the traditional way, with large incisions, become more a thing of the past. We would do less surgery and even less minimally invasive surgery because you will have more advanced medicine, genetics, and other techniques, and the older, larger, more advanced surgery would evolve towards minimally invasive surgery."

Prof. Liselotte Mettler:  “Thank you for sharing your knowledge with the people listening to OBGYN.net.”

Dr. Camran Nezhat:  “Thank you for giving me the opportunity.”