Download Advanced Laparoscopy – from development to daycare surgery

Advanced Laparoscopy
– from the Research and Development Department
to Day Care Surgery
By Bjørn Edwin
1
Contents
1. Acknowledgements
3
2. List of papers
5
3. Introduction
6
3.1 History of laparoscopic surgery
9
3.2 New Procedures
14
3.2.1. How to develop
15
3.2.2 Where to develop
16
3.2.3 How to convince
17
3.3 Day care surgery
19
4. Aims of the study
21
5. Summary of papers
22
6. Discussion
30
6.1 Development of new laparoscopic procedures
30
6.2 Complications associated with laparoscopy
31
6.3 Laparoscopy in oncologic surgery
33
6.4 Education
41
6.5 Future aspects ”The Hospital of Tomorrow”
42
7. Conclusions
44
8. Reference list
45
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1. Acknowledgement
The present work was carried out at the Interventional centre, Rikshospitalet, University of
Oslo and the Surgical Department, Ullevål University Hospital.
The thesis is a result of skills, contributions, never ending enthusiasm and a very good team
spirit of many persons.
First I will express my sincere gratitude to my supervisors, Prof.dr.med. Trond Buanes,
Prof.dr.med. Erik Fosse and dr.med. Tom Mala. Without Trond Buanes and his great
enthusiasm, great knowledge, great capacity of work and accept of my ideas this thesis had
never been a reality. Erik Fosse, as an excellent leader and with a genuine interest and great
knowledge in new techniques has given an invaluable support that has made these studies
possible .Tom Mala, with his enthusiasm, interest, knowledge and great capacity of work have
given an inestimable contribution and made this thesis possible. I also thank all of them for
encouraged me to do the doctorate study and that they have kept encouraging and given me
self-confidence throughout the work.
My sincere thank to my very good friend and colleague Prof.dr.med Arne R. Rosseland for
teaching me a lot of different types of surgery and endoscopy, always encourage me in new
ideas and studies and always to be available when I needed him, whatever the reason was.
I am very thankful to Prof.dr.med Anstein Bergan and Prof.dr.med.Odd Søreide that always
encourages me, believed in my ideas and trusted my laparoscopic skills so that I got the
opportunity to do the advanced laparoscopy.
A great thank to my colleague’s dr.med Øystein Mathisen, dr.med. Ivar Gladhaug and dr.med.
Per.F Pfeffer, for their help and support in the clinical part of the thesis and as co-authors. I
am also thankful for the support given by my other colleagues in the Surgical Deparment.
Dr.med. Airo M. Kazaryan’s co-authorship and willingness to contribute has been of great
help and is highly appreciated.
A great thank to dr.med. Erik Trondsen for his enthusiasm, invaluable support in the clinical
part of this study and as co-author.
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I also want to thank Prof.dr.med Tor Inge Tønnesen and Prof.dr.med Johan Ræder for their
inestimable cooperation, support, enthusiasm and co-authorship.
A sincere thank to all the other co-authors, dr.med. Ole Christian Lunde, Prof.dr.med. Rolf
Kåresen, dr.med. Odd Mjåland and Jorunn Skattum, for their help and support in this thesis.
Special thanks to Prof.dr.med Frode Lærum whose idea led to the establishment of the
Interventional centre.
Also a great thanks to Julia Ferkis that made it possible for me to share my ideas with Russian
colleagues, the inspiring discussions and that she never gave up telling me how important the
doctorate study was.
A special thank to Marianne Berg and her wonderful temper and for always helping me when
needed.
My sister Nusse Belton and my brother in law Peter Beaumont have been of great help
turning some of the text from bad into good English.
The great enthusiasm and cooperation of the staff at the centre have been of great help and
joy. I want to thank:
- Isabelita Fiksdal, Jennifer Alcoriza, Carina Olofson, Anne-Marie Marstein and Linda Nes
with their invaluable support and assistance during the different procedures.
- Esther Frydenlund and her staff for always supporting me when necessary.
- The staff of anaesthesiology with Steinar Halvorsen, Andreas Espinoza, Olav Hustvedt
Helga Teigland, Carmen Louwerens, Kjersti Bent, Anne Marie Halstensen for their eminent
support
- Lena Slaatsveen and her staff that took so good care of the patients
- Gunn Goksøyr and her staff in the Day Care Department, Ullevål University Hospital
- The rest of the staff at the Interventional centre for great support.
Finally, I will express my sincere appreciation to my mother, friends, my children Gorm,
Snorre , Catarina, Natasha and the rest of my family that have accepted my unpredictable
working schedule and sometimes disharmonious temper.
At last but not least a special thank to my love Anita for her tolerance in the last turbulent year
and that she always has supported my job and research and encouraging me to continue this
thesis. Without her this had not been possible.
Sætre 230605
Bjørn Edwin
4
2. List of papers
Paper I.
Edwin B, Kazaryan AM, Mala T, Pfeffer PF, Tønnessen TI, Fosse E.
Laparoscopic and open surgery for pheochromocytoma.
BMC Surg 2001;(1):2.
Paper II.
Edwin B, Mala T, Gladhaug I, Fosse E, Mathisen Ø, Bergan A, Soreide O.
Liver tumours and minimally invasive surgery: a feasibility study.
J Laparoendosc Adv Surg Tech A 2001;11(3):133-9.
Paper III.
Mala T, Edwin B, Gladhaug I, Soreide O, Fosse E, Mathisen O, Bergan A.
A comparative study of the short-term outcome following open and
laparoscopic liver resection of colorectal metastases. Surg Endosc 2002
16(7):1059-63.
Paper IV.
Edwin B, Mala T, Mathisen Ø, Gladhaug I. Buanes T, Lunde OC, Soreide O,
Bergan A, Fosse E. Laparoscopic resection of the pancreas: a feasibility study
of the short-term outcome. Surg Endosc 2004;18(3):407-11.
Paper V.
Edwin B, Raeder I, Trondsen E, Kaaresen R, Buanes T. Outpatient
laparoscopic adrenalectomy in patients with Conn’s syndrome. Surg Endosc
2001;15(6):589-91.
Paper VI.
Edwin B, Skattum J, Trondsen E, Ræder J, Buanes T. Outpatient laparoscopic
splenectomy. Surg Endosc 2004;18(9):1331-1334.
Paper VII.
Skattum J, Edwin B, Trondsen E, Mjåland O, Ræder J, Buanes T. Outpatient
laparoscopic surgery: feasibility and consequences for education and health
care costs. Surg Endosc 2004;18 (5): 796-801
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3. Introduction
Since the beginning of the 20th century physicians have promoted laparoscopy as a valuable
adjunct to the diagnosis and treatment of diseases of the abdominal cavity. Laparoscopy,
however, failed to become widely accepted among abdominal surgeons until Philippe Mouret
did his first laparoscopic cholecystectomy in 1987. This new surgical approach to the
treatment of gallbladder stones gave rise to such enthusiasm among general surgeons that a
revolutionary development of the laparoscopic technique has been the result.
Laparoscopic procedures have been promoted in ever-increasing numbers and the general
surgeon has again become the leader in the introduction of a new surgical approach1.
Laparoscopic surgery has been shown to give less pain and fatigue, fewer incisional hernias,
better cosmetics and in general a quicker return to daily life during the postoperative course
compared to open surgery2. These improved parameters have traditionally been the main
arguments for the development and incorporation of new laparoscopic procedures in clinical
practice.
Several laparoscopic procedures are now the method of choice within different fields, e.g.
laparoscopic reflux surgery3, appendectomy4, adrenalectomy5, some forms of obesity surgery6
and within the treatment of subgroups of inguinal hernia7.
The technology continues to increase at an exponential rate and some predict that almost
every abdominal operation will eventually be performed by this method.
The past decade was characterized by the question “what can be accomplished
laparoscopically” but in the near future the focus will be on “which procedures should be
performed laparoscopically”. Furthermore, with the increased use of laparoscopy, patient
logistics also needs to be assessed: Which procedures can successfully be made as day care
surgery, and what sort of hospitals should perform and educate surgeons in laparoscopic
surgery? : Ordinary or specialized hospitals reorganized towards minimal invasive therapy?
Laparoscopy has to be developed with great care, and there must be strict criteria for its use,
critical analysis of the technique and honest reporting of results, particularly serious
complications.
6
There is an increasing demand for efficiency and cost effectiveness in hospitals but safety
must always be in focus, asking the question: How can this new procedure best undergo safe
development?
A change in the strategy for development and introduction of new techniques and
technologies in clinical practice is required. Traditionally all developmental work has been
done in locations where routine procedures are being performed, in competition with the
everyday work. This mixture of routine and developmental work is inefficient. Our solution
has been to use an independent Research and Development (R&D) department i.e. the
Interventional Centre at Rikshospitalet to create a link between clinical practice and applied
and basic research. This department is designed as a testing ground for new interventional and
diagnostic procedures before they are put into clinical practice.
Advanced Laparoscopy
During the last years a huge amount of different laparoscopic procedures has been described.
Procedures concerning parenchymal organs such as adrenal glands, spleen, liver, prostate and
pancreas have gained more and more attention. Surgery on these organs requires special
surgical expertise with detailed knowledge of the anatomical structures, pathophysiology,
pathology, different surgical procedures and advanced technical equipment. Reconstructive
surgery like anastomosis of tubular structures often has to be performed and therefore these
procedures require advanced endoscopic skills. The laparoscopic surgeon must be trained in
careful dissection especially around vessels, intra corporal suturing, working from different
optical angles and over multiple quadrants. The advanced laparoscopic surgeon also has to
work equally well with the left and right hand. Furthermore the surgeon must be familiar with
new laparoscopic equipment including laparoscopic ultrasound, stapling devices and
dissecting instruments such as AutoSonix and CUSA (cavitronic ultrasound surgical
aspirator). Accordingly, our definition of advanced laparoscopy is surgical procedures
requiring the above mentioned skills.
The optimal venue for introducing new laparoscopic techniques
If we compare the introduction of new methods and workflow before and after1996 i.e. when
the Interventional centre was introduced, it is apparent that the main operation room has been
unloaded and both every day work and developmental work can be efficient. (fig.1)
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Blue arrow’s :
workflow and introduction of
new methods before1996
Workflow before
1996
Research and Development
department
Main operationroom
Surgical
Department
Outpatient
Laparoscopic
Surgery
Workflow after
1996
Red arrow’s :
workflow and introduction
of new methods after 1996
Fig.1
Day Care Surgery
With the introduction of new mini invasive surgical techniques and modern anaesthetic drugs
a shift from treatment and nursing in hospital to treatment in specially designed departments
with the postoperative period at home or in hotels has been possible. This type of surgery has
been described in literature under different names such as day surgery, day care surgery,
outpatient surgery or same day discharge (SDD) surgery.
Another reason for the increased interest in outpatient surgery is the economic pressure on
hospitals and the attempt to reduce healthcare costs, to release hospital beds and to shorten the
waiting time for the patient before treatment.
8
This type of surgery will probably expand in the future and ”The Hospital of Tomorrow” is
probably going to be reorganized towards day care, ERAS (enhanced recovery after surgery)
or “fast track” surgery and hotel stay instead of expensive in-hospital solutions.
3.1 History of Laparoscopic surgery
Endoscopic examinations have their origin in the Kos school led by Hippocrates (460-375
BC). They described a rectal speculum similar to the ones used today. In the ruins of Pompeii
were discovered speculums to be used in the vagina for inspection of the cervix, examine the
rectum and obtain a view of the ear and nose hollow8-10.
The word laparoscopy is derived from the Greek words lapara, meaning, “the soft part of the
body between ribs and hip, flank, loin”, and skopein, which means “to look at or survey”11.
The endoscope
In 1806 Philip Bozzini built an instrument called the Lichtleiter that could be introduced into
the human body to visualize the internal organs. The instrument projected light from a candle
into the cavity with the help of a concave mirror.
Bozzini has been credited as the inventor of the first endoscope although his endoscope was
never tested in humans. As usual with great inventors, he did not understand the usefulness of
this invention and it was condemned as a toy by the medical faculty of Vienna12;13.
In 1853, almost fifty years later, the French surgeon Antoine Jean Desormeaux demonstrated
an invention very similar to the Lichtleiter. The candle was replaced with a brighter burning
mixture of alcohol and turpentine. It was intended to examine the bladder and urethra but
could also be used as a rectoscope. Problems related to his intervention were thermal burns on
the inside of the patient’s thighs and on the surgeon’s forehead. In 1865 he published a
monograph, “De l’endoscopie”, on his clinical findings and it is said to have stimulated
American instrument makers to take up the production of endoscopes. This is one of the
reasons that he, for many, is considered the father of the endoscope14.
The light source was one of the main problems during the development of endoscopic
instruments. The first internal light source was invented by Julius Bruck, a dentist from
Breslau, who in 1867 examined the mouth of a patient using an overheated electrically plated
platinum wire as the light source10.
Maximillian Nitze used this light source when he together with Joseph Leiter developed the
so called “ Kystoskop”12;15. This instrument was a telescope with lenses and intended for
examinations of the bladder.
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With Thomas Alva Edison’s indispensable contrivance of 1879, the electric incandescent
lamp, Nitze and Leiter, independently of each other, manufactured in 1887 a new, more
useable cystoscope with the an electric lamp12.
The start of laparo/thoracoscopy
In 1901, an experiment called “Lufttamponde” was performed where air was insufflated into
the abdominal cavity of a dog to create a high intra abdominal pressure (100mmhg). The idea
behind this experiment was that this could decrease or stop intra abdominal bleedings. The
investigator was the German surgeon Georg Kelling who observed the intra abdominal
process through a Nitze cystoscope. He published this experiment in 1901 and mentioned
“Kolioskopie” for the first time as an endoscopy of a closed cavity. Kelling saw no future in
the technique, and he did not pursue it16-20.
As many other important inventions laparoscopy was born as a side effect of an unsuccessful
experiment.
The Swedish internist Hans Christian Jacobaeus performed his first abdominal endoscopy in
1910 and had in 1911 performed 115 cases of laparoscopy with only one serious complication
of bleeding that required exploration.
Jacobaeus admitted, in 1911, that he had overlooked Kelling’s paper from 1901. He
proclaimed: “It is doubtless that Kelling deserves credit for the idea. On the other hand I
cannot grant that he proved the practical application of the method.”
H.C Jacobaeus was the first who referred to the word laparothorakoskopie when he published
his description of the inspection of the human peritoneal and thoracic cavities16.
Due to Jacobaeus paper, reports about laparoscopy were published from many parts of the
world, providing evidence of the widespread use of the laparoscopy.
The pneumoperitoneum: type of gas, insufflation method and pressure
Richard Zollikoffer started to use carbon dioxide in 192421. Roger Korbsch, Germany, after
lot of experience with laparoscopy, suggested in 1927 the use of CO2 instead of air for the
inflation of the abdomen. The reason was that CO2 was easily and very quickly absorbed. He
also recommended that the intra abdominal pressure should not exceed 15 cm H2O22.
10
How to fill up the cavity with gas was one problem? In the beginning physicians used a
syringe to fill up the cavity but in 1921 O. Goetze developed the first insufflator23.
The great breakthrough for creating pneumoperitoneum was the invention of J. Veress, in
1938. He described a spring-loaded needle with an inner stylet that automatically converted
the cutting edge into a rounded end incorporating a side hole. Veress designed the needle to
create a safe pneumothorax24.
Raoul Palmer, H. Frangenheim and Kurt Semm later developed their own types of
insufflators over the next fifty years. In 1979 K. Semm perfected his apparatus, creating an
electronic insufflator and fully monitored pneumoperitoneum became possible22.
In spite of the knowledge about CO2 and pressure, Heinz Kalk’s textbook on laparoscopy
(1962) recommended filling the abdomen with air using a 500ml syringe without pressure
control22;25. This was a dangerous procedure and perhaps one of the reasons why laparoscopy
developed so slowly.
Other gases were also discussed during the development of laparoscopy. The first to be tried
was ordinary air and it is still used some places.22;26. Air is not suitable because of its
extremely low solubility in blood making it a risk for gas embolism. Neither will it be
absorbed from the abdominal cavity, resulting in complains from both patient and radiologist.
Plain oxygen is not as absorbable as CO2 and it is in addition very explosive especially when
used together with electro cauterization22;27.
Nitrous oxide (N2O, “laughing gas“) is suitable for diagnostic laparoscopy but can not be used
together with electrocautery. Then it will be dissociated into N and O2 and can explode22;28;29.
An inert gas such as Helium is non-toxic and not flammable but the risk of gas embolism is
high22;26.
Today carbon dioxide (CO2) is the most used gas during laparoscopy. It is easily absorbed
from the abdominal cavity and dissolves well in the blood. The risk of gas embolism is thus
very low. It can cause pain after the operation and therefore it has been a discussion regarding
heated our not heated CO222;30.
The modern era and new technical inventions
One of the most important inventions was the Hopkins rod-lens system which still remains the
basis of some of the modern laparoscope. Combined with the fibre optic light source of the
1960s an improved laparoscopic view was achieved.
11
Together with the improved view and the possibility of combining inspection and coagulation
with mono and bipolar electro cauterisation, more complicated laparoscopic procedures could
be developed31.
After some urologists and physicians, gynaecologists came to understand the importance of
the laparoscopic technique. One of the most important pioneers in modern laparoscopy is the
German gynaecologist Kurt Semm. The ideas and vision of K. Semm were controversial but
allowed a safer laparoscopy. His pioneer work was probably one of the reasons why the
gynaecologists incorporated the technique into their practice in the 1970s while the general
surgeons, despite this, stayed with traditional surgery 15-20 years longer. He was the first to
do laparoscopic appendectomy in 1980 but many prominent surgeons regarded the operation
as unethical32;33;33.
Fortunately some surgeons, despite their conservative colleagues, did see the potential
benefits of laparoscopic surgery as proclaimed by Jacobeus as early as 1911, and proceeded to
develop the technique.
Erich Muhe from Germany did the first laparoscopic cholecystectomy in 1985 using Semm’s
instruments and a laparoscope (“galloscope”) of his own design19;34.
Since the surgeon had to look into the end of the laparoscope participation by other members
of the surgical team was limited. Therefore complicated operative procedures proved to be not
particular inspiring because of the inability of the assistants to effectively interact with the
surgeon.
In 1986 this problem was solved with the development of a computer chip television camera.
The camera was attached to the laparoscope and in this way the endoscopic view was might
available to everyone participating in the procedure and this also revolutionized the possibility
of educating other surgeons and house staff.
Documentation of findings during endoscopy was a necessity and already in1874 Stein
modified existing cameras to record images of bladder pathology35. In 1893 Nitze
developed the first Photocystoscope36 and published the first atlas of pathology a few years
later37.
Wittmoser obtained the first colour slides through a laparoscope in 1952 38 and the first
laparoscopic movies, dealing with liver diseases, were created by Segal in France in 1959 37.
Today video-imaging has facilitated the documentation of operative procedures enormously39.
12
After the introduction of video-imaging laparoscopic systems, Philippe Mouret, in Lyon,
France, removed a diseased gallbladder in 1987 and he showed the video to Francis Dubois
who then performed his first clinical laparoscopic cholecystectomy in May 1988 and reported
the multipuncture technique in 198939;40. Around the same time, the procedure of
laparoscopic cholecystectomy was established in Bordeaux (Perissat), Nashville (Reddick et
al.), Dundee (Cuschieri and Nathanson), and Los Angeles (Berci et al.)38.
For the surgeon, the exceptional success of laparoscopic cholecystectomy became the
stimulus for expanding the role of minimally invasive surgery.
Shortly after the introduction of laparoscopic cholecystectomy, the major part of the surgical
repertoire was reported as being done laparoscopically: highly selective vagotomy (Dubois,
1989), truncal vagotomy and seromyotomy (Kakhouda and Mouiel, 1990), ligamentum teres
cardiopexy, ligature of bullae and pleurectomy, thoracoscopic esophageal myotomy
(Cuschieri et al.,1990), abdominal cardiomyotomy, total and partial fundoplication (Cuschieri
et al., 1991)38, partial gastrectomy (Goh et al., 1992)41, splenectomy (Delaitre
et.al.,1991,Caroll BJ et al., 1992)42;43, adrenalectomy (Gagner M. et al.1992, Higashihara E. et
al.1992)44;45, resection of liver tumors (Gagner M. et al.1992,Wayand, W. et al.1993, Huscher
C. et al 1993)46-48 , laparoscopic pancreatic surgery including Whipple’s procedure(Gagner et
al.1994 , Cuschieri A. 1996)49;50 and colon resection (Monson,J.R.T. et al. 1992, Schlinkert,
R.T. 1991, Cooperman A.M. 1991)51-53.
In Norway Bjorn Helge Nilsen did the first laparoscopic cholecystectomy in August 1990 at
the Gjøvik hospital 54. Other hospitals i.e. the Haukeland hospital, the Central hospital of
Akerhus, Bærum hospital, Ullevål hospital, Trondheim University hospital and the Central
hospital of Hedmarken (Elverum) and several others started less than one year later. During
the two-three first years procedures such as laparoscopic fundoplication, lymphadenectomies,
appendectomies, splenectomies , nefrectomies, PGV, repair of perforated ulcer, inguinal
hernias and different colon surgery were performed 55.
At the Interventional centre we started few years later with among others laparoscopic
pancreatic surgery (Edwin et al. 1997)56, laparoscopic adrenalectomy (Edwin et al. 1997)57
and laparoscopic resection of liver tumours (Edwin et al.1998)58.
Most of the developments in solid organ surgery were made in the first three years after the
introduction of laparoscopic cholecystectomy, but there was a lot of negative criticism during
13
this period and the surgeons who did this pioneering work did so at the risk of compromising
their careers 59. The surgical community was divided and this could be one of the reasons for
the slow development.
3.2 New Procedures
Several inventions have changed the way we live, e.g. the wheel, eyeglasses, the watch, the
printing press, vaccinations, the light bulb and penicillin etc. Looking back into the history we
can see that great inventions, especially in technology, lead to great and often dramatically
changes in the society i.e. that our society, thinking and in a way the system in belief comes
out of the technological development.
In medicine, new inventions typically start with the development of new technology and after
a while it will be adapted into medical use. The history of endoscopy/laparoscopy shows the
reverse: an invention for decided medical use turns out to be able to revolutionize parts of
surgery and results in a paradigm shift in the methods of performing of surgery 12;60.
The development of minimal invasive surgery has been characterized by criticism and doubt
from conservative surgeons. According to Schopenhauer all new ideas goes through three
stages. This statement was further developed by the cardiac surgeon Michael Mack’s (Dallas)
“Seven stages in the evolution of an idea” and reads as following:
“Idea Stage”: Won’t work, been tried before
Successful Experiments in Animals: Won’t work in man
After One Successful Clinical Patient: Very lucky
After 4 or 5 Clinical Successes: Highly experimental, too risky, immoral and unethical. I
understand they’re having a number of deaths they’re not reporting
After 10-15 Patients: May succeed occasionally in carefully selected cases, but most patients
with the defect don’t need the operation anyway
After a Large Series of Successes: So and so in Shangri-La has been unable to duplicate their
results, not practical, only experts can do it. I hear a number of their patients are now dying
late deaths.
Final Stage: You know, this is a very fine contribution! A straight forward solution to a very
difficult problem. I predicted this, as a matter of fact in 1929, I had the same idea. Of course,
we did not publish anything, nor did we have penicillin, cortisone or fine anesthesia in those
days….”
14
3.2.1 How to develop
From idea to a complete new procedure or product is a complicated process. This process may
be explained by use of the “innovation line” that consists of three phases:
1. Invention 2. Development 3. Innovation.
Invention
Historically, an idea from a pragmatic genius rather than properly scientific knowledge
formed the basis of an invention and the development and application were described in
almost a visionary way.
Development
The individual invention was seldom perfect and improvement had to be developed according
to “trial and error” principle.
In modern industry the invention procedures especially phase 1 and 2 will be placed with
groups of companies with large human resources and funds for basic research and
development so tasks can be shared between many people.
Innovation
The social implementation or process attached to the practical and social utilization is the
innovation. In medicine this is the process where the invention can be evaluated according to
the importance for the patient and society and also in clinical work12.
The industrial way of introducing technology by a clear separation of production and
development has little echo in the medical community. New surgical techniques and
technologies in medicine are usually introduced in to clinical practice alongside the routine
work after some initial training by the surgeons on models and animals, or sometimes
without special preparatory training.
In order to ensure the safety of patients, to provide adequate documentation and to maintain
routine efficiency it is mandatory to focus on the way by which the development and
introduction of new procedures and technologies are performed.
On this background, and in order to co-ordinate and promote the development of new clinical
applications and to structure collaboration and communication across traditional specialty
boundaries, a medical R&D department was established at Rikshospitalet University hospital
in 1996 (Laerum et al.1996)61.
15
3.2.2 Where to develop
The Interventional Centre was established as an independent R&D department at
Rikshospitalet University Hospital, Oslo in June 1996 (Lærum et.al.1998)62 to create a link
between clinical practice and applied and basic research. The department was designed as a
testing ground for new interventional and diagnostic procedures before they were put into
general clinical practice. Both the specialised equipment and the staff at the Centre were
organized to constitute a ‘common toolbox on neutral ground to be used by other
departments at the hospital as well as other research groups at other hospitals or institutions
where time-consuming and risky procedures could be developed and tested outside the
ordinary departments without any stress or competition from acute situations or elective
profitable surgery.
Building and facilities
The Centre was built with three experimental suites in immediate vicinity of the general OR
area of the hospital. One suite was a combined surgery and angiography suite (Angiostar,
Siemens, Erlangen Germany), allowing standard angiographic guided intervention as well as
surgery. In a second suite an open interventional MRI (Signa SP, General Electric Medical
systems Milwaukee, WI) was installed, along with equipment for videoscopic surgery and
thermal surgery. The third suite had no fixed imaging equipment, but the room was equipped
with laparoscopy rack (Olympus), endoscopy rack for transbronchial and transoesophageal
investigations and interventions and robots (Aesop and Zeus, Computer motion, Goleta CA,
USA). From each room 16 video channels are lead to a dedicated room for film editing and
telecommunication.Videos of interest with corresponding sound can be transmitted to lecture
rooms or out of the hospital. The department got full approval as an operating suite as well as
an animal facility, allowing training and development on animal models as well as treatment
and advanced diagnostics on informed patients and healthy volunteers.
Organisation
The Interventional Centre is organized as an independent hospital department. Since January
2002 it has been organized in a matrix fashion in order to facilitate effective execution of
projects. The head of department and five section managers constitute the management group.
A national council has an advisory function for the department. The staff consists of doctors
and nurses from several different disciplines, as well as non-medically trained scientists
within engineering, mathematics and physics.
16
The permanent staff of approximately 30 persons supports clinicians and scientists from other
departments in the projects. All activity at the centre involving patients and animals are
designed as project after regional ethical committee approval and informed consent by the
patient.
3.2.3 How to convince
One must attend in medical practice not primarily to plausible theories, but to experience
combined with reason -- Hippocrates
Minimal invasive surgery has been shown to be beneficial for the patient especially in regard
to duration of hospital stay and rapid postoperative recovery 63. Most patients today prefer to
be operated with minimal invasive surgery instead of open surgery. One example
demonstrating this, is that after the introduction of laparoscopic living donor nephrectomy,
there was a nearly twofold increase in the total number of live renal donations, and there was
a significant expansion in the unrelated-donor pool 64.
Sometimes the effectiveness of a new intervention is so substantial that no control group is
needed e.g. no one who was familiar with the inevitably lethal outcome of bacterial
endocarditis would have demanded a controlled trial of penicillin65.
This type of problem can also be a dilemma in the assessment of laparoscopic surgery, as the
new method can be so obviously better for the patient that it is unethical to use the old
method66.
Traditionally, surgical treatment is based upon Baconian empiricism: the results of operations
are evaluated upon retrospective analyzes of large patient series. This method has proven to
fail in producing definite conclusions67;68.
The use of randomized trials, however, is superior to other methods in producing reliable
conclusions in regard to clinical practice but we must still be aware of the problem with
selection bias, technical bias and patient bias65;67.
The nature of the present thesis is mainly feasibility or pilot studies with potential problems
associated with false positive or negative results due to “investigator bias”, generating biased
patient selection and the false conclusions based on small patient numbers69. However,
feasibility studies are necessary, and have to come first. Their nature is preparatory work for
later randomized controlled trials. Every new innovation and idea must be tested in order to
ensure the safety of the procedure before they are more extensively evaluated in clinical trials.
17
Adequate documentation of the technique and teaching of surgeons are mandatory before any
multi-centre, randomized study can generate valid data.
Generally, Guidelines for clinical practise should be based on scientific evidence, and
preferably a meta-analysis of randomized clinical trials offering probability estimates70;71.
A problem with guidelines based on meta analyses are that the procedures will have to be in
common use for some time before they can be used as a standard procedure.
As the science of medicine advances, decision making based on clinical experience and
opinion is bowing to a more evidence-based approach.
Evidenced-based medicine (EBM) defined by Sackett and colleagues is “the conscientious,
explicit, and judicious use of current best evidence in making decisions about the care of
individual patients”72. This is a way of formalizing the scientific approach to the practice of
medicine for identification of “evidence” to support our clinical decisions. By using this
information, clinicians can categorize evidence, assess causality, and make evidence-based
recommendations. But we must remember the practice of EBM is not restricted to conclusions
based on randomized controlled trials (RCTs) and large meta-analyses but in fact uses all
available data73.
To quote D.L Sackett: “We can learn three useful things from small clinical trials. First, we
can learn when to challenge conventional but untested therapeutic wisdom. Second, because
the patient number in any trial is the number of events, rather than the number of study
patients, some small trials are so definitively positive that they are sufficient to identify the
best therapy. And third, small trials, even when individually inconclusive, can serve as the
basis for convincingly conclusive overviews and meta-analyses that carry, and deserve,
greater credibility than a single large trial of similar size to their sum.”74
Therefore studies like those in the present thesis, may have great importance in providing
important evidence.
From earlier experience in day care surgery75 and our results from pilot studies, we found that
advanced laparoscopic surgery (adrenalectomy and splenectomy), could be done safely as day
care surgery and that it might convincingly illustrate the advantage of laparoscopy compared
with open technique. The next phase of the present study was therefore to perform “the out
patient surgery test”, i.e. combine advanced laparoscopic surgery with specially designed
18
anaesthesiology, and nurses trained in the rapid postoperative mobilization.
3.3 Day care surgery.
In Gynaecology laparoscopic outpatient treatment has been well known for many years76;77.
However, already in 1990 Reddick et al. presented their first 37 patients treated with
outpatient surgery78. Some of the main reasons for increased outpatient surgery have been the
attempt to reduce healthcare costs, to release hospital beds and to shorten the waiting time for
the patient before treatment. One of the most common day care operations today is
laparoscopic cholecystectomy.
Our own experience with day care surgery goes back to 1991. At the Elverum Central hospital
we had to decrease hospital beds during the summer to save money. Only acute disease and
cancer patients were then intended to be treated surgically. Consequently, one solution was to
treat the waiting patients with troublesome gallstone disease, was laparoscopic
cholecystectomy as outpatient surgery as long waiting time is associated with higher
morbidity 79. The results were encouraging and we presented them in 1993 at the annual
Norwegian surgical meeting75. The presentation and the suggestions were not accepted as
good treatment and it was criticized and marked as unjustifiable and dangerous surgery. Three
years later Ullevål University hospital presented their results with day care surgery and
concluded that it was safe to operate patients this way 80. Thereafter day care surgery was an
accepted treatment in Norway.
Also Reddick’s first results were discussed and questioned81.
In general surgery a broad repertoire of surgical procedures done as day care surgery has
been described e.g. laparoscopic cholecystectomies, fundoplications, adrenalectomies,
herniarepair2;80;82-85 and laparoscopic splenectomies86.
Previously, a main point of the criticism against day care surgery was delayed recognition of
serious complications. Several studies, however, have shown that day care surgery is safe if
some basic rules are followed:
- The patient should not be left alone, but have a competent adult at home
looking after her/him during the first 24 hours.
- The patient should live within 30 minutes drive from the hospital.
- The patient should not have personal inability to respond adequately to pain/discomfort (e.g.
mental retardation).
19
- ASA>II and an expected long operation time are relative contraindications.
- Uncorrectable coagulopathy is an absolute contraindication.
- Information and follow-up of the patient is of great importance 2;85;87;88.
Other mandatory factors for successful daycare surgery are:
- excellent cooperation with your anaesthesiologist
- specially designed anaesthesia
- a very experienced surgical team
- experienced nurses, trained in rapid postoperative mobilization
Anaesthesia
Total intravenous anaesthesia (TIVA) with e.g. propofol and remifentanil has become the
method of choice of anaesthesia for day care surgery. A problem in day care surgery is the
incidence of unplanned over-night admission, varying a lot between different studies87;89
To avoid unplanned admission, adequate postoperative pain and nausea relief is essential90;91.
Patient comfort postoperatively is strongly dependent on the level of anaestesiological
expertise.
Surgeon’s experience
Another important factor to succeed with day care surgery and prevent unplanned admission
is to have an experienced surgical team, preventing long operation times, postoperative
complications and maintain surgical safety2;77;92.
Outpatient surgery can be one way to defend the increased cost of expensive laparoscopic
equipment. The clinical outcome of advanced outpatient surgery, generate visions for hospital
reorganization. Instead of expensive in-hospital solutions, ”The Hospital of Tomorrow” can
become a patient friendly service institution, much more like a modern home than an old
hospital. Safety rules, however, have to be developed, enabling the clinicians to discover
serious complication as fast and precisely as if the patient was surrounded by nurses and
doctors in a well organised in-house department.
20
4. Aims of study
1. Establish safe laparoscopic procedures in the R&D department and subsequently
perform the procedures in a conventional surgical department or a designed day care
centre.
2. Study the feasibility of laparoscopic resection of pheocromocytomas.
3. Evaluate the feasibility of advanced laparoscopic procedures in the treatment of
pancreatic and liver tumours.
4. Record patient safety and satisfaction for advanced laparoscopic procedures (i.e.
adrenalectomy and splenectomy) performed in a day care setting.
5. Compare the outcome of different laparoscopic procedures, recorded as success rate
(completed surgical treatment, without admission) performed in large scale in a day
care centre.
6. Analyse the consequences of large scale day care laparoscopy for surgical education,
health care costs and hospital organisation.
21
5. Summary of papers
Paper I
Laparoscopic and open surgery for pheochromocytoma
Laparoscopic adrenalectomy is one of the most successful applications of minimal invasive
surgery. Surgery on pheochromocytomas is a challenge for the surgeon and especially for the
anesthesiologist because of the risk for cardiovascular instability during the operation.
Scepticism against laparoscopic removal of pheochromocytoma was based on the concern that
pneumoperitoneum might stimulate catecholamine release and therefore increase the risk of
serious cardiovascular complications93;94.
We assumed the opposite, that laparoscopic adrenalectomy performed with a low intra
abdominal pressure (8-9 mmHg) resulted in less manipulation of the tumor than in open
surgery and early occlusion of the main adrenal vein cardiovascular reactions may be
prevented or decreased. Pheochromocytomas are relatively rare, and a randomized trial in one
hospital was not achievable. We therefore made a historical comparison comparing seven
laparoscopic patients, treated from 1997 to 2000, with “historical control”: The nine patients,
undergoing open surgery for pheochromocytoma from 1990 to 1996.
To evaluate cardiovascular stability during operation, an increase in systolic pressure of more
than 33% within 10 minutes was considered as a hypertensive episode, and a heart rate of
more than 100 per minute was defined as a tachycardic episode. The requirement of
vasoactive drugs was recorded in all patients. Our results showed that laparoscopic removal of
pheochromocytomas was as safe as open surgery with less postoperative opiate need and short
hospital stay. Patients in the laparoscopic group experienced less hemodynamic in-stability
than patients operated by the open approach (documented as hyper and hypotensive episodes
in demand of medical treatment).
Paper II
Liver tumors and minimally invasive surgery: a feasibility study.
Liver resection is one of the most challenging procedures in abdominal surgery. The open
approach is the preferred method for resectable primary and secondary liver malignancies.
When we started this study, laparoscopic liver surgery was still controversial although some
reports showed that it could be performed safely48;95;96. The multimodal treatment, combining
tumor ablation with laparoscopic liver resection, was also a new concept. If successful, it
might represent an important new option for patients with a pessimistic prognosis and very
22
limited treatment alternatives. As in paper I, it was important to work undisturbed from
hospital routine activities and independent of the time consumed during the operations. All
these requirements were again met in The Interventional centre.
Eight patients, 3 women and 5 men median age 68, range 33-73 years, were operated between
August 1998 and April 2000. A total of 11 liver resections were performed. Two of the
patients had two resections during the same operation and in 2 patient’s cryoablation was
performed during the same anaesthesia.
The median largest diameter of resected specimen was 8 (3,5-16) cm and the largest specimen
weight was 418 g. Histopathology showed adenocarcinoma in 9 specimens (6 patients),
malignant melanoma in one and focal nodular hyperplasia in one specimen. One of the 11
resected specimens did not have free resection margin. This was a re-resection after a
recurrence close to previous resection. Preoperative bleeding was 500 (100-1000) ml. Blood
transfusion was required in two patients. Median operation time was 165 (145-245) min.
Gas embolism secondary to pneumoperitoneum has been described by others and CO2
bubbling through hepatic venous branches is the presumed cause95;97. Our strategy was to
keep central venous pressure low but not below 4 cmH2O, combined with low intra abdominal
CO2 pressure (8 mmHg) to reduce the pressure gradient between the two compartments. We
did not observe any gas embolism in this series.
The study indicated that laparoscopic liver resections could be done safely in selected
patients. Advantages of minimal invasive surgery such as less postoperative discomfort, faster
mobilization and shorter hospital stay also applies to patients after hepatic surgery. The new
multi modal treatment, combining cryoablation and laparoscopic liver resection, was found to
be feasible and safe, indicating that this could be a new treatment alternative for patients with
otherwise inoperable liver lesions.
Paper III
A comparative study of the short-term outcome following open and
laparoscopic liver resection of colorectal metastases
Few studies had compared short time outcome of laparoscopic liver resection to that of a
conventional technique95;98. In a retrospective study we focused on 60 patients that had liver
resection performed between January 1998 and July 2001. Among these 60 patients, 27 were
operated with minor resections (non anatomical wedge resections and left lobectomy
(segment II and III)) using both open and laparoscopic techniques, enabling comparison.
23
Fourteen patients had conventional open liver resections performed and 13 patients had
laparoscopic resection made. The numbers of resections were 18 in the open group and 21 in
the laparoscopic group (2 patients in the laparoscopic group underwent 2 separate resections
(re-resections)). All patients had metachron metastasis from previous colorectal cancer. Of
special interest were the success of tumour resection, safety, preoperative data, postoperative
comfort and hospital stay. The resection margin is an important determinant of long-term
survival following liver resections, and hence an essential outcome parameter in the
assessment of surgical technique 99;100. The surgical technique was similar to that described in
paper II58.
Our concern was that it could be more difficult to assess resection margins laparoscopically
than during an open operation.
Resection margin involvement was found in one (1/21) specimen in the laparoscopic group
and in 2 (2/17 eligible resections) specimens in the open group. These results are similar to
those reported from large series of open surgery99;100. The free resection margin was 1 cm or
more in 15/21 (71%) laparoscopic resections, and 10/16 (63%) eligible open resections
(p =
0, 57). Parameters recording patient comfort/recovery revealed a significant difference in
postoperative need of analgesia and hospital stay with advantage in the laparoscopic group.
Our conclusion was that laparoscopic minor liver resections are safe. Tumour-free resection
margins do not differ between laparoscopic and open groups, but laparoscopically operated
patients experience improved postoperative comfort and reduced hospital stay.
Paper IV
Laparoscopic resection of the pancreas: a feasibility study of the short
outcome.
Our interest for this procedure started in 1997 after having operated laparoscopically a patient
with Mb. Bechterw, generating an extreme thoracal kyphose. This patient had a
neuroendocrine tumor in the distal pancreas. His kyphose made it impossible to reach
pancreas via an abdominal incision as the pancreas was located above the costal margin. The
distance between the sternum/costal margin and the spine was only few centimeters. The
alternative access was a thoracotomy. Mb. Bechterw had made the thoracic wall stiff and after
a thoracotomy the risk for prolonged respiratory problems was considered highly increased.
With the laparoscopic camera and instruments we managed to pass under the costal margin
and performed the mandatory distal pancreatic resection. During this operation we noticed the
24
fantastic overview and clear anatomic conception, obtained with the laparoscope.
Accordingly, we wanted to pursue the possibility to do distal pancreatic resections
laparoscopically, to assess the safety and feasibility of this type of operation, performed in the
Interventional centre.
All patients with distal pancreatic tumors who were operated on at the Rikshospitalet were
included.
Median age was 56 years (range, 21–81). The American Society of Anaesthesiologists (ASA)
physical status score was: ASA I = 7 patients, ASA II = 17 and ASA III = 8 respectively.
The patients were placed in a supine position or in a 30–45 degree half lateral position with
the left side up, depending on the location of the tumour. A 30 degree laparoscope was
inserted through the umbilicus and a intra abdominal pressure of 8–11 mmHg was used. Two
to four additional trocars were inserted but the arrangement was standardized for distal
pancreatic resection for the last 15 patients: one trocar in the umbilicus, one in the midline in
the epigastrium, one in the left flank, and one just below the left costal margin in the
medioclavicular line.
After mobilization, the pancreas was examined using a 7.5-MHz laparoscopic ultrasound
transducer (SSD 1700; Aloka, Tokyo, Japan) applied directly on the pancreatic surface. The
dissection was done with the use of an Autosonix (Autosuture, Connecticut, USA). Three
different resections were done 1: enucleation 2: spleen preserving distal pancreatic resection
and 3: distal pancreatic resection with splenctomy. The enucleation was done with an
Autosonix (Autosuture, Connecticut, USA) and diathermy. The vessels were divided with an
Endo-GIA (Autosuture) and 2.5-mm staples and the pancreas were divided with an Endo-GIA
(Autosuture) and 4.8-mm staples.
The median operation time was 205 (60-332) min, blood loss 300 (100-1500) ml, needs for
opoids 2 (0-13) days and postoperative hospital stay 5.5 (2-22) days, respectively.
Post operative complications occurred in nine of the 24 resected patients (38%).
Two patients died postoperatively: The first, eight days postoperatively of acute myocardial
infarction, the second, due to sepsis and multiorgan failure.
Pancreatic fistulas occurred in one of the 24 patients (4.2%) in this series.
In conclusion, this paper indicates that laparoscopic distal pancreatic resection is feasible and
offers similar benefits to the patients as minimally invasive surgical procedures for other
diseases. The procedure is complex and requires experience in pancreatic surgery and
advanced skills in laparoscopic techniques.
25
Paper V
Outpatient laparoscopic adrenalectomy in patients with Conn’s syndrome
Laparoscopic adrenalectomy, performed in the Interventional Centre seemed appropriate for
day-care surgery, and since March 1999, 13 selected patients, (7 men and 6 women), were
entered into our outpatient laparoscopic adrenalectomy protocol. The patients had been
referred for inpatient care but were recruited into the outpatient program based on our
previous experience with laparoscopic day care surgery75;85;101 and all available information
about security rules for outpatient laparoscopic adrenalectomy.
The criteria for exclusion included pheochromocytoma and large tumours (>10 cm) as well as
histologically verified adrenal carcinoma, even in smaller tumours. All our patients happened
to have Conn’s syndrome.
The surgery was performed by the transabdominal lateral flank approach in all cases. A total
intravenous general anaesthesia technique with a special focus on post-operative pain
prophylaxis and nausea prophylaxis was used
102;103
. In each instance, the operating surgeon
evaluated the patient’s clinical stage 3–4 h post-operatively before deciding on discharge from
the hospital. Thus, even though all of the patients were scheduled for day care, the final
decision regarding hospital discharge was not made until well into convalescence.
Antihypertensive medication ended at discharge in 12 patients and in one case, medication
was continued for 2 weeks postoperatively.
On the 1st and 7th postoperative days, patients were asked to rate their satisfaction as:
excellent, medium, or dissatisfied.
Four weeks postoperatively, aldosterone levels were controlled in the outpatient department.
Clinical stage, focusing on blood pressure, was also controlled at this time.
We showed that average operative times exceeding 2 h could be avoided. The median
operative time was 38 min (range, 35–112) and more than half of the procedures took <40
min. We did not see any severe complications such as bleedings or reactive hyperkalemia.
All of the patients were able to go home within 3–6 h postoperatively. Patient satisfaction was
excellent on the 1st and 7th postoperative days in 12 patients and medium in one case. There
were no readmissions which is the best outcome of all the comprehensive laparoscopic
procedures performed on a day care basis in our department.
We concluded that laparoscopic adrenalectomy is a procedure well suited for outpatient
surgery, as safety requirements, can be satisfactory met.
26
Paper VI
Outpatient laparoscopic splenectomy
In most indications splenectomy is best performed via the laparoscopic approach, the only
obvious disadvantage seem to be long operative times, most often exceeding 2 hours. As
shown in paper V, we experienced successful ambulatory adrenalectomy, and saw again an
opportunity to enlarge the repertoire of day care surgery with laparoscopic splenectomy.
The purpose of the study was first to record the operative times for a laparoscopic team who
had completed most of the learning curve and second to investigate how the combination of
good surgical technique, anesthesiology, and support of nurses trained in the rapid postoperative mobilization of patients after comprehensive laparoscopic surgery influenced
patient safety and satisfaction.
Between January 1st 2000 and December 31st 2002, 12 selected patients (7 men and 5
women) were entered into the outpatient laparoscopic splenectomy protocol. Inclusion criteria
were limited to patients not hospitalized and who had haematological or neoplastic indications
for splenectomy and were classified as American Society of Anesthesiologists (ASA) I –III.
Ten of 12 included patients were discharged 3-6 hour postoperativly; the other two were
admitted primarily to hospital. One additional patient was readmitted due to fever, which was
finally explained by measles. The median operative times was 58 min (range, 45-135). All
except one patient with ITP (idiopathic thrombocytopenic purpura) had increasing
thrombocytes before discharge.
Patient satisfaction was measured as excellent in nine, intermediate in two and poor in one
case, due to postoperative pain. This study showed that laparoscopic splenectomy could be
performed successfully as day care surgery, as 75% of our patients reported excellent
satisfactions on the 1st and 7th day, and no eventful courses or complications were associated
with the day care treatment algorithm.
Further we showed that surgical security was satisfactory, and there was no bleeding per- or
postoperatively. Our data also demonstrated that average operative times exceeding 2 hours
could be avoided. Compared with our previous experience with different outpatient surgery,
splenectomy seems to be the most difficult procedure to perform successfully as day care
surgery with a primary admission and readmission on 25%.
27
Paper VII
Outpatient laparoscopic surgery: feasibility and consequences for
education and health care costs.
This is a prospective, observational study describing outcome of ambulatory laparoscopic
cholecystectomy (LC, n = 1060), antireflux surgery (n = 113), adrenalectomy (n = 22) and
splenectomy (n = 12) and possible implications for surgical education and health care costs.
The number of primary and secondary admissions, as well as postoperative complications, has
been recorded prospectively together with patient satisfaction in four categories, excellent,
good, intermediate, and bad.
Surgical security and education
All the procedures have been performed or assisted by a senior laparoscopic surgeon. The
intention was to include all the operations in our surgical education program, and the Day
Surgical (DS) center became an important part of the laparoscopic training program. Each
resident performed at least 30 procedures during her or his DS center period, and was
thereafter authorized to operate independently on in-hospital patients. The surgical technical
quality in every patient was supervised by the laparoscopic seniors.
Patient safety
The patients were discharged in the afternoon, 2 to 4 h after the end of their operation. One of
the two operating surgeons assessed every patient clinically before discharge.
The patients brought home a written information form with key telephone numbers, including
the cell phone of the surgeon in charge of the operation, in case of problems or emergencies.
All patients received a routine follow-up call from the centre the day after surgery.
Health Care Costs
Compared to treatment on an in-house basis with a one-night stay, the reduction in primary
admissions was 1086. The average cost for one postoperative day in our hospital is at present
$620. Accordingly, the calculated value of the present cost reduction amounts to $673,320.
This calculation is insufficient for a total evaluation of the health care cost but still it gives an
indication of the potential in ambulatory laparoscopic surgery.
28
The education has also a cost. Accordingly, the resident represents an ‘‘extra surgeon,’’ as the
senior surgeon can safely perform most procedures alone, assisted only by an experienced
nurse, who is always participating. The educational costs was calculated to $100 000 if a
resident takes part in all 1200 procedures. The reduced costs generated by the introduction of
ambulatory surgery for the present patient groups are six times greater, and hospital budget
has room for educational exploitation of all operations .
With a success rate of ambulatory treatment in 83.5% of 1060 LC patients, 80% of 113
antireflux procedures, 100% of 22 laparoscopic adrenalectomies and 75% of 12 laparoscopic
splenectomies and serious complications only in 1.5% this study shows that day care surgery
can be done safely and with a high patient satisfaction. The study thus gives a vision for “The
Hospital of Tomorrow”, and underlines the need for reorganization of the hospital of today.
29
6. Discussion
After 10 to 15 years of developmental laparoscopic work, a new phase of minimal invasive
surgery is now needed. This phase has to answer some key questions with evidence based
data:
-
Which conditions should be treated with minimal invasive surgery?
-
Are cancer patient’s best treated with minimal invasive or open surgery?
-
What is the best way to develop, learn and assess new procedures?
-
What sort of hospital should perform each type of surgical procedure?
-
How should surgical care be organized in hospitals in the future
-
How to expand day care surgery?
-
How to develop evidenced based surgery from our knowledge today?
6.1 Development of new laparoscopic procedures
In the present study we have addressed some of these questions well aware of the limited new
evidence generated from our data. In the first four papers we have tried a new model for
developing new surgical methods. This implies using a R&D centre where all settings are
optimized; i.e.
-
most advanced equipment
-
most skilled and dedicated staff
-
a broad collaboration with several different types of professions, working in multidisciplinary teams
-
a working place, protected from interruptions of daily activity in the hospital
-
a place were research models can be designed
To our knowledge, Frode Lærum and Arvid Stordahl were the first promoters of the this
concept104 but also others have encourage similar ideas105-107.
In our experience during the studies shown in paper I,II,III, and IV it have been a great
advantage to use the Research and Development (R&D) department (The Interventional
centre) for introducing new methods. From earlier experience, introducing new laparoscopic
procedures, we know that frustration based on different arguments always appears. In the
R&D department setting it has been no stress or interference from other parts of the hospital
where routine work is performed. Neither have our developing work resulted in any
30
adjournment of the daily activity in the main department because of e.g. time consuming
procedures. It has been easy to create multidisciplinary discussions and always a possibility to
get help from the most experienced personnel. Last, but not least it was always a good spirit
and teamwork.
The results also show that advanced laparoscopy can be done retaining the patient safety.
How can patient safety be secured and improved? Successful error avoidance in surgical
laparoscopy starts with careful patient selection goes on with accurate preoperative
investigation and then includes awareness of abilities/skills of the surgical team.
Conscientious technique, prompt recognition and attention to technical complications are
important factors for success, together with an ever present high index of suspicion for
complications occurring during the intra-operative as well as post-operative period. In the first
four papers we believe that it has been possible to fulfil most of these criterias because of the
Interventional centre. In paper V-VII security rules have been executed by the trained
personal in the unit together with experienced surgeons.
6.2 Complications associated with laparoscopy
Intestinal and Vascular injuries
In paper III we observed one bowel perforation that was associated with widening of the
umbilicus incision when a liver specimen should be retracted but not with insertion of the
trocars. The perforation was primarily sutured and no postoperative complications developed.
All the patients included in paper III had had previous surgery and therefore adhesions that
made the procedures more complicated. In the laparoscopic cholecystectomy group (LC)
(paper VII) and in the laparoscopic fundoplication group (paper VII) three respectively one
gastrointestinal injury was achieved. Two of the perforations in LC could be due to trocar
injuries and these patients have had previously abdominal surgery but the in the other two
patients the perforations were probably of another etiology. Two patients had vascular injuries
due to the laparoscopic dissection (paper IV) but not because of trocar or needle insertion.
A number of different complications associated with the laparoscopic technique have been
described in the literature. Trocar and needle injuries to the intestine or major vessels are the
most common and represents more than one third of all injures. The insertion of the first
31
trocar is often considered the most dangerous step in laparoscopic surgery, with a
complication rate as high as 1.1%108;109. With an open technique described of our team in
1994 we have tried to avoid these type of injuries, especially the vascular one’s 110. The
injuries are common in the presence of adhesions in patients with previous intra-abdominal
surgery. The complications of gastrointestinal injury has been associated with a relatively
high mortality rate of 5%108.
Vascular injury due to insertion of Veress needle or the first trocar are reported with an
incidence of 0.1% to 2%111. According to the literature, the rate of complications related to
needle and trocar insertion subsequently decreases as the surgeon’s experience performing
endoscopic surgery increases108.
Gas embolism
An apprehended but probably very rare complication of laparoscopy is the gas embolism. It is
especially discussed in connection to laparoscopic liver resection112;113. In one study minute
cardiac bubbles was showed on intra operative ultrasonography but without knowing if this
will have any implications on the patient114. We have not feared this complication as CO2 has
a rapid diffusion gradient through the bloodstream. We also know that cardiothoracic
surgeons have used CO2 to evacuate air embolism when it have been suspected during cardiac
surgery on pump115. Neither in the largest studies of laparoscopic liver resection48;115-117 or our
studies (paper II and III) have this type of complications been reported. This experience is
further supported by a recent report from our centre following 53 procedures of laparoscopic
liver resection118.
Pancreatic fistulas
In paper IV we had one patient with fistula which is relatively low compared with the results
from other centres. One reason can be that we are stapling the pancreas with big staples
(4.2mm), but the definition of pancreatic fistulas may also be different. In the literature a large
amount of different definitions exist, and it is important to obtain international
standardization, in order to compare outcome correctly119. A recent report indicated that
laparoscopic resection of the pancreas had an unfavourable high frequency of postoperatively
fistulas120, and in a review from M.Gagners group fistulas were described in 8-27% of
reported series121. However, the incidence of pancreatic fistula following laparoscopic distal
resection is comparable to the results following open surgery119;122.
32
Mortality
The postoperative mortality for the patients included in this thesis, was 0.2%, ie. three
patients. One died after a laparoscopic cholecystectomy, that was complicated by a duodenal
perforation, reoperated, but later she developed acute respiratory distress syndrome, and
finally died in sepsis. The two others died after laparoscopic pancreatectomy. One, with
previous myocardial infarction and a history of pulmonary and vascular disease, died in a
myocardial infarction eight days postoperatively. The other was converted to open surgery
due to bleeding near the portal vein. An extended resection of distal pancreas, celiac trunk and
the portal vein with reconstruction was done. The patient died 22 days after primary operation
due to general deterioration and multi organ failure. All deaths generate from complications
well known from open surgery and in frequency comparable with open series123.
The rate of postoperative deaths should be improved, however, the present frequency
underlines the safety of simple (ex cholecystectomy) as well as advanced laparoscopic
procedures, performed in-house as well as outpatient.
6.3 Laparoscopy in oncologic surgery
In the present work patients with cancer have been operated laparoscopically. This is
controversial and there is and have been a debate on whether or not laparoscopic techniques
are appropriate in oncological surgery. We assumed that cancer patients would most likely
benefit from the exploitation of minimally invasive techniques. Paper II, III and IV have
given an indication that port site metastasis can be avoided also further supported from the our
latest results in laparoscopic liver resection118. The short term outcome has been better than
previous open surgical procedures for the same malignancies, and we now follow all those
patients, recording long term survival. Distal laparoscopic resection of the pancreas seems to
give cancer patients an improved survival 124, but further follow up is mandatory.
Patophysiological mechanisms
The impact of surgical stress on the immune response is a possible predictive factor of
patient’s clinical outcome 125. Postoperative immune suppression is proportional to the extent
of the surgical trauma, which may influence the rate of septic complications and tumour
metastasis formation postoperatively126-128. Laparoscopic surgery reduces the surgical trauma,
and may thus limit the postoperative immunesuppresion after laparoscopic oncological
procedures.
33
Despite this, possible facilitation of tumour growth by laparoscopic techniques has been
shown129-136. A main event generating scepticism in regard to laparoscopy in oncological
surgery was the description of port site metastasis. Port site metastasis can be defined as
“early tumour recurrences that develop locally in the abdominal wall, within the scar tissue of
one or more trocar sites or an incision wound after laparoscopy or thoracoscopy and these
should not be associated with peritoneal carcinomatosis.” 137 They may be excised locally and
they should be considered not as an ominous but rather an unfavourable prognostic sign.138
The first report of metastasis to a laparoscopic port site was described of Döbrönte et al.139 in
1978 and in 1994 Berends et al. presented an incidence of port site metastasis, after
laparoscopic resection for colon cancer, in 21%140. Port site metastasis are described after
different types of malignancy e.g. intra-abdominal malignancies including cancers of the
pancreas, esophagus, colon, stomach, gallbladder, endometrium, fallopian tubes, ovary,
cervix, bladder, kidney, and retroperitoneum141;142 143. It is still controversial whether or not
port site metastasis after laparoscopic surgery are more common than wound recurrence after
open surgery, but the incidence is reported to be < 1% in both open and laparoscopically
treated colon cancer144-147. Comprehensive experimental research works have investigated
several possible mechanisms behind spread of cancer cells by laparoscopic techniques
including the effects of the pneumoperitoneum. But despite extensive research efforts, the
aetiology of port site metastasis is still unknown and it is probably multifactorial142.
The most relevant etiology behind port site metastasis is thoroughly described by Curet141,
and the key factors are:
1) direct wound contamination
2) aerosolization and chimney effect
3) haematogenous spreading
4) pneumoperitoneum
a) carbondioxid
b) intra abdominal pressure
c) blood flow
5) immune response
6) surgical technique
Point 1, 2 and 3will be characterized under wound implantation.
34
Wound implantation
The extraction of specimen through a narrow incision represents an obvious risk for
contamination with tumour cells. In about 0.35% of patients operated with laparoscopic
cholecystectomy, unsuspected gallbladder cancer will be diagnosed. In 17.1% of these port
site metastasis was found148, and more than 50% of port site metastasis were located in the
port where the specimen was retracted. However, in other series, 43% appeared in other port
sites (not used for specimen retraction)148;149. Removal bags have not protected against remote
or multi focal port site metastasis148, compatible with the concept that direct contamination
with tumour cells cannot explain all port site metastasis. Free malignant intraperitoneal
cells150 can theoretically contaminate instruments and ports anywhere in the abdominal wall,
and be a part of an explanation for observations described above. Exfoliation, shedding and
aerosolization give potential risks for creating free intraabdominal tumor cells but most
studies have failed to demonstrate significant aerosolization in vivo as well as in vitro
experiments151-153.
Haematogenous spread
Only 1% of cells reaching the general circulation survive, and only 0.1% of them are able to
induce metastasis. Neither animal nor human studies have revealed evidence that
hematogenous spread plays a major role in the etiology of port-site metastases 154;155.
Carbon dioxide
Pneumoperitoneum may increase the risk of tumour spread and growth. Different reasons
such as carbon dioxide, intra abdominal pressure and the blood flow must be considered.
Jones et al showed that use of CO2 pneumoperitoneum, in a hamster model, resulted in
increased implantation of free intra abdominal cancer cells at wound sites of the abdominal
wall or in the abdominal cavity156.
Bouvy et al showed that laparoscopy with CO2 pneumoperitoneum resulted in increased
tumour growth and bigger port site metastasis compared with gasless laparoscopy157.
Compared with other types of gas e.g. Helium, CO2 seemed to stimulate growth of tumour
cells 158 . Promoting effect of CO2 on intraperitoneal tumour development compared with
gasless laparoscopy have also been reported159.
35
Lower pH is known to impair local defence mechanisms160 and CO2 pneumoperitoneum may
decrease subcutaneous pH levels so this can be one explanation for the higher incidence of
port-site metastasis in laparoscopy with CO2 than with other gases161.
Hyaluronic acid has shown to increase during CO2 pneumoperitoneum. Secretion of
hyaluronic acid from mesothelial cells is thought to be a key factor that causes adhesion
between cancer cells and mesothelial cells and may be associated with port-site metastasis
after laparoscopic cancer surgery162;163.
On the other hand studies also have reported that tumour cell proliferation and growth are
independent of the insufflating gas used164. Other studies have even claimed that CO2
pneumoperitoneum does not promote cancer cell proliferation but instead has a toxic effect on
cancer cells165.
The relation of port-site metastasis to a specific type of gas requires further research.
Blood flow
Pneumoperitoneum and its effects on blood flow have mainly been studied with focus on
general haemodynamic consequences and effects on the splanchnic circulation166. If intraabdominal pressure exceed 15 mm Hg, the risk of significant changes in splanchnic
haemodynamics increase167.
Brundell et al showed that CO2-pneumoperitoneum increased the peritoneal blood flow but
this was not seen when Helium was insufflated. It is imaginable that such hyperaemia may
increase the tendency for implanted tumour cells to metastasize in these sites168. Lundberg et
al. showed that pneumoperitoneum generated by both air and CO2 increases tumour growth in
a rat model169. Accordingly, they argue that CO2 cannot be the only factor causing port site
metastasis. Later they have shown that pneumoperitoneum with air caused a reduction in
blood flow in the abdominal wall and they also got an enhanced tumour growth170.
The fact that ischemia may promote tumour development170;171 mandates further studies of the
effects of pneumoperitoneum on blood flow and tumour growth in the abdominal wall.
Immune response
A disturbance of the homeostasis, e.g. tissue injury from a surgical intervention, starts a
complex series of metabolic and immunological reactions collectively termed “the acute
36
phase response” or “stress response”. These events act to re-establish the physiologic
homeostasis. A surgical trauma produces a local reaction at the site of injury, which involves
activation of platelets and the coagulation cascade with clot formation, dilation, and leakage
from capillaries as well as the accumulation and activation of leucocytes, platelets, fibroblast
and endothelial cells. Most of these cells release inflammatory mediators or cytokines. These
cytokines mediate a variety of systemic effects by interaction with the body’s neuroendocrine
axis. The neural and endocrine response to these inflammatory mediators and to afferent
sensory input, include the release of catecholamines from sympathetic nerve endings and the
adrenal medulla, aldosterone from the adrenal cortex, antidiuretic hormone (ADH) from the
posterior pituitary, adrenocorticotropic hormone (ACTH), thyroidstimulating hormone (TSH)
and growth hormone from the posterior pituitary, and insulin and glucose from the pancreas.
This results in peripheral fat and protein breakdown, insulin resistance, water retention and
gluconeogenesis which are in proportion to the degree of surgical injury172. The most studied
cytokines in relation to laparoscopy, are interleukin-6 (IL-6), tumour necrosis factor-a
(TNFa), and interleukin-1 (IL-1). Other variables used to measure the immune response to
injury are T-cell function, T-cell subsets, and the expression of major histocompatiblity
complex on antigen-presenting cells173 .
Cytokines
Cytokines are low-molecular-weight polypeptides or glycoproteins that regulate numerous
cellular functions and allow both autocrine and paracrine signalling. They influence cell
differentiation, proliferation and activation and modulate proinflammatory and antiinflammatory responses enable the host to react appropriately to pathogens. Besides
activation, cytokines enhance proliferation and differentiation (e.g., lL-6,
growth factor for B-cells) as well as chemotaxis173;174.
CRP and IL-6 are the most investigated cytokines in studies that deals with laparoscopic and
open surgery173.
It has been shown that CRP is significantly lower after laparoscopic than open surgery in
different procedures and this can indicate a lower burden on immunity175-178.
Less increase in plasma concentration for IL-6 175;179 and IL-1180 after laparoscopic surgery is
also shown. Changes in TNF and IL-8, are less clear181.
Cellular immunity
37
Cellular immunity consists of a nonspecific defense and an antigen-specific host defense. The
first system entails natural killer cells, granulocytes, and monocytes/macrophages, all part of
the initial reaction to pathogens. The second is represented primarily by T-lymphocytes and
involved with a durable immune reaction (Fig.2)173.
Fig.2
T- cell function can be tested on basis of delayed-type hypersensitivity (DTH) response and
we know that it is significantly depressed after laparotomy182. Both in animal and human
studies it has been shown that DTH response is better preserved after laparoscopy than
laparotomy183-185.
T-cell response can be measured in different ways:
a) Measuring the ratio between CD4+ (T-helper cell) and CD8+ (cytotoxic T Lymphocyte)
b) Measuring the ratio between the two kinds of CD4+ T-cells that are known: T-helper 1
(Th1) cells and T-helper 2 (Th2) cells = Th1/Th2
After any kind of operation, the CD4/CD8 ratio changes significantly, as compared with the
response to anaesthesia alone. The reason for the changes is an increase in CD4+ cells and a
decrease in CD8+ lymphocytes186.
38
Both human and animal studies have been done178;186-188, but clinical consequences of changes
in the CD4/CD8 ratio remain unknown. After laparoscopic surgery the ratio between the Th1
and Th2 cells changes. It is assumed that preservation or elevation of the Th1/Th2 ratio is
beneficial to the patient, but the clinical relevance is not clear189.
Regarding circulating monocytes, laparotomy seems to result in greater decreases in HLA-DR
(human leucocyte antigen) expression189;190. Reduced expression of HLA-DR, is associated
with an impaired ability to eliminate pathogens effectively and therefore associated with an
increased risk of infection191. After laparoscopic surgery expression of HLA-DR is
preserved183;190. A randomized clinical trial by Hewitt et al.188 comparing laparoscopically
assisted and open surgery for colorectal cancer showed other values of HLA-DR expression
on monocytes. A significant reduction was found after both surgical procedures, with no
difference between open and laparoscopic surgery.
Surgical technique
The cleaner and gentler the act of operation, the less the patient suffers, the smoother and
quicker his convalescence (and) the more exquisite his healed wound.
Lord Moynihan
Surgical technique is probably the most significant issue, explaining why port site metastasis
develop and how they can be prevented192. Mutter et al. showed that manipulation is the main
factor acting on tumour dissemination in both laparoscopy and laparotomy but with a
beneficial effect on local tumour growth in the laparoscopic group193.
Lee et al showed in a mice model with splenic tumour that traumatic handling of the splenic
tumour before resection resulted in significantly more port site and incisional tumours. They
also showed the addition of a pneumoperitoneum after splenectomy did not significantly
influence the incidence of port site tumours in either the group with crushed or not crushed
tumour capsule. This may indicate that surgical technique plays larger role in the development
of port site tumours than the CO2 pneumoperitoneum194. In a later published study with a
similar model they showed that the incidence of port tumors decreased significantly in the
laparoscopic group with increasing experience of the surgeon195. Laparoscopic surgery can be
difficult and require a longer learning curve than open surgery. Studies have shown that e.g.
in laparoscopic colorectal surgery, with increasing experience, technically more demanding
39
operations, can be performed with reduced operating times and conversion rates, but with no
increase in morbidity or mortality196.This may be one of the reasons for frequencies of port
site metastasis as high as 21%140 in the beginning of the era of laparoscopic colon cancer
surgery compared with more recent studies where it is reported as low as 0,6%197.
A prospective randomized study in pigs, investigated the influence of the quality of surgery
on port-site recurrences when one group had received protective measures such as trocar
fixation, prevention of gas leaks, rinsing of instruments with povidine-iodine, minilaparotomy
protection, rinsing of trocars before removal, peritoneal closure and rinsing of all wounds with
povidine-iodine. The incidence of tumour recurrence was 64% in the control group but only
14% in the group that had received protective measures198.
Balli et al have suggested some rules to prevent port site metastasis during laparoscopic
resection of colorectal cancer199 but with only small modifications they may be used as
generally criteria applicable for other malignancies (see Table 1.):
Before resection:
After resection:
Minimize tissue trauma by proper placement of trocars,
Irrigate trocars with 5% Betadine before removal
perpendicularly to peritoneum
Bag the specimen
Perform trocar fixation
Protect extraction site
Prevent CO2 leakage around trocars
Drain peritoneal cavity before deflating, thus
Minimize handling of tumour
preventing the “slosh” phenomenon
Carry out colonoscopy and intraluminal irrigation with
Perform trocar site closure
Betadine
Deflate the abdomen with trocars in place
Carry out colonoscopy and intraluminal irrigation with
Avoid liquid spillage when closing the trocar sites
Betadine
Use closed suction drain
Clean instruments with Betadine after each use
Irrigate trocar and extraction site with Betadine and
water
During resection:
Do not cut through or handle the tumour
Additional factors:
Perform high vascular ligature
Adequate training
Control colon lumen especially of resected specimen
Adequate technique
Proper patient selection
Surgical team training
Adequate laparoscopic equipment for colon resection
Table 1 Means of reducing the risk for port site metastasis during laparoscopic resection of
colorectal cancer199.
40
To prevent implantation of viable intraperitoneal cells, use of tumouricidal agents has been
suggested. More than 30 years ago Morales et al proposed this for open surgery200. More
recently it has been suggested as a strategy to prevent port-site metastases 201;202 and may be
delivered by parenteral or intraperitoneal routes142;203;204 .
Irrigation of port sites with cytotoxic agents to reduce tumour growth at port site has been
studied but no difference in tumour growth was found 205. On the other hand no adverse effect
either was shown so e.g. Betadine, which is used in laparoscopic colon cancer surgery, will
most certainly still be in use until more data is available.
Probably one of the most significant issues is surgical technique, and oncologic surgical
principles used in open surgery, will help to avoid port site metastasis due to technical
surgical problems206.
In conclusion an enormous amount of experimental studies have been done concerning
laparoscopy and tumour dissemination and growth. It is still not clear if laparoscopic surgery
have a beneficial or unfavourable effect in cancer surgery compared with open surgery.
Perhaps one of the most interesting fields in laparoscopic surgery is the postoperative
immunological defences. It seems to be characterized by a short period of immune
suppression attributable to CO2 insufflation but systemic stress response is less affected after
laparoscopic surgery than conventional surgery. In clinical practice this is supposed to
represent decreased postoperative infections, more sporadic local recurrence and even less
distant metastasis.
The only true test of the safety associated with laparoscopic techniques in cancer will come
from long-term survival data generated by the large scale randomized studies. Dissemination
and recurrences of tumour seem mainly to result from suboptimal surgical technique or
instrumentation, i.e. inadequate training. Therefore it is important always to provide for
adequate laparoscopic equipment and surgical team training when new laparoscopic
procedures are used in cancer surgery.
6.4 Education
Adequate documentation of training and/or experience in laparoscopic surgery is today a
must, and lack thereof is a significant error in surgical practice. The advantage of
41
training/development of new methods in an R&D department, over conventional specialist
training in ordinary operating rooms, have been clearly illustrated by the very short operation
times, recorded for laparoscopic adrenalectomy and splenectomy, when these procedures
were introduced as routine practice in the day care centre (Paper V and VI). Even though a
limited number of surgeons could be trained in the R&D department, large scale specialist
education was feasible in the day care centre, when the number of patients was increased, and
high quality supervision was secured by the most experienced surgeons (Paper VII).
6.5 Future aspects ---”The Hospital of Tomorrow”
In paper VII, we have analyzed some of the consequences of laparoscopic day care surgery
for hospital organization and economy. Shorter hospital stay would be expected to reduce
health care costs, and we have illustrated a possible calculation of the amount of saved
money, based on the minimal reduction of days in hospital. The main question in this context
is: What happens with the “empty bed”, i.e. what is the opportunity cost, when a gall stone
patient or a reflux patient is taken out of the surgical department? If the empty bed can serve a
more “heavy” patient, cost effectiveness increases more than illustrated by the calculation in
paper VII. Oppositely, if the bed is empty, and no staff can be eliminated, a day care
procedure does not reduce costs at all. In Ullevål University Hospital the empty bed was filled
by patients, operated for pancreatic cancer or liver metastasis, generating a significant benefit
for hospital effectiveness. However, we do not assume that advanced laparoscopic surgery,
performed as day care, can solve all problems related to increasing surgical costs. But the
flexibility, generated by advanced laparoscopic day care is a new and promising option, which
can take care of surgical education, patient safety and satisfaction, and increase the value of
investments put into health care.
Looking at the clinical outcome in paper I-VII it is remarkable how little pain and need for
anaesthetics the patients required postoperatively, how fast they are mobilized and how short
time they stays in hospital. The low frequency of postoperative complications is also apparent.
This generates a vision – a possibility for different future planning of hospitals. Patients
treated with minimal invasive therapy (MIT) do not need the same postoperative observation,
intensive care and nursing compared with patients operated with open techniques. Many
patients can also be operated as “outpatients” (paper V,VI; and VII). This implies that the
42
future hospital can be build smaller with operation theatres and intermediate departments for
wakeup, examination and further decision making. After rapid recovery, the patient is
assessed for discharge after 3-5 hours, and numerous patients are not going to stay in the
hospital over night.
We also need hospital or departments where new procedures can be developed and evaluated
i.e. similar to the Interventional centre but the last word is not said in this discussion.
Surgeons must realize that radiological and flexible endoscopic techniques are or should be
part of the armamentarium of the modern surgeons and future will show that we will move
towards a closer and closer interaction between interventional radiology, interventional
flexible endoscopy, and endoscopic surgery. The future will also give us robotics, new
technology and improved surgical techniques and expanding presence of technology in the
“The Hospital of Tomorrow” pose special challenges that will have to be solved.
“Mutatis Mutandis”
43
7. Conclusions
- In our experience a R&D department shielded from routine surgical practice is a prerequisite
for safe and adequate development of new advanced laparoscopic procedures.
- Laparoscopic resection of pheocromocytomas can be performed safely.
- Laparoscopic resection of liver and pancreatic tumours is feasible and safe in selected
patients. Long-term outcome in patients with malignant disease needs further evaluation.
- The hospital stay following laparoscopic resection of the liver and the pancreas seems to
be reduced as compared to conventional surgery.
- Advanced laparoscopic procedures can be safely and adequately performed as day care
surgery for diseases in the spleen and the adrenal gland.
- Laparoscopic splenectomy and adrenalectomy can be satisfactorily performed for most
patients as day care surgery.
- With the use of a special designed day care surgery unit the need for education and
training in laparoscopic procedures can be taken care of.
- Day care surgery can make the hospital more cost effective if ”empty beds” gives room
for new patients requiring admission.
- These seven studies indicate a pathway to “The Hospital of Tomorrow“ where method
development is shielded from the clinical routine and where advanced procedures can be
performed in a streamlined day care setting.
44
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