Endo-Laparoscopy is the Ultimate Hope-Nayeem-Final.pptx

Endo-Laparoscopy is the Ultimate Hope

1. Endo-Laparoscopy is the Ultimate Hope: Past, Present & Future of MAS Prof. Sarder A. Nayeem, MBBS, Ph.D., FACS, FIAGES, FRCS Chairman , Bangladesh Endo-Laparoscopic Surgery Foundation (BELSF) Immediate Past President, Society of Endo-Laparoscopic Surgeons of Bangladesh (SELSB)

2. Introduction Surgery has experienced a revolution since the introduction of laparoscopic cholecystectomy in 1987 This revolution can only be compared with the invention of antibiotics, introductions of blood transfusion

3. Historical background The history of endoscope is ancient, which starts from the description of Hippocrates of Greece (460-375 B.C.)

4. Historical background cont. In about 1950 to 1960 Professor Harold H. Hopkins of England developing fiberscope and rod-lens system. W ith Karl Storz , an instrument maker of Tuttlingen , Germany in early 1960s They developed cystoscope with light source, which eventually showed the way of development of laparoscope and cold light source.

5. Historical background cont. From 1964 on, Professor Kurt Semm , a gynaecologist from Germany, played key roles in the developments of laparoscopy. Until 1985 all the procedures of laparoscopy were performed direct vision and view was restricted to only the performing surgeon and in some cases to one assistant by the help of an extension fibrescope .

6. Historical background cont. In 1985, the introduction of first computer chip TV camera made by Circon Corporation, which developed this as the by-product of technical advances in microelectronics. These CCD cameras enabled surgeons get the image of the operative field in a monitor and perform the procedures, so began the era of video-guided surgery.

7. Pioneering breakthrough 1987 became the land mark year for the first laparoscopic cholecystectomy in humans by Philippe Mouret in Lyon, France.

8. Pioneers in Europe and USA Within a year (1988) Dubois (Paris), Perissat (Bordeaux), Nathanson and Cuschieri (Scotland), Mckernan and Saye (Marietta, Georgia) and Reddick and Olsen ( Nushville , Tennessee) had poerformed Laparoscopic Cholecystectomies at their respective institutions.

9. Pioneers in Japan In Japan, Prof T. Yamakawa , Professor Y. Idezuki , Professor Daijo Hashimoto started the procedure in 1989-90.

10. Laparoscopic Surgery in Bangladesh- 1991 In Bangladesh the first Laparoscopic Cholecystectomy was performed in December 20, 1991, following the Society of Surgeons of Bangladesh ( SOSB ) Surgical Congress, in BIRDEM Hospital, Dhaka, Bangladesh.

11. Very First Patients of Laparoscopic Surgery in Bangladesh (1991) The first two demonstrative cases were performed by Dr , Hashimoto Daijo , and Dr. Sarder A. Nayeem, who also brought with them the whole set of equipment and instruments from Japan. Mr. Tsuneo Fukuyo of Shinko Optical Co., Japan played a very important key role in this venture This was a breakthrough in the history of surgery in Bangladesh

12. Development of Laparoscopic Surgery in Bangladesh (1991-1993) In 1993 the early sets of equipment and instruments for laparoscopic surgery was procured by the BIRDEM hospital and by Japan Bangladesh Friendship Hospital And in these hospitals laparoscopic cholecystectomy procedure was started on a regular basis from April, 1993, after Dr. Sarder A. Nayeem returned from Japan and joined in my department in BIRDEM.

13. Media coverages helped remarkably in the development of Laparoscopic Surgery

14. Development of Laparoscopic Surgery in Bangladesh (1993-98) Immediately after that, Professor Humayun Kabir Chowdhury, Professor Motior Rahman also started laparoscopic cholecystectomy in BIRDEM. Later, only a handful of private hospitals came forward quickly to start this procedure. In around 1998, one or two government owned medical college hospitals also started performing this surgery.

15. Laparoscopic Surgery in Other Hospitals in the Capital City (1998-2002) In late ’90s few private hospitals and clinics in the capital city of Dhaka started laparoscopic surgery S urgeons ’ personal initiatives They came to us to learn the new technique Patients ’ demand was also very high S urgeons went for a short course: in India , Singapore, Thailand etc.

16. Laparoscopic Surgery in other cities outside Dhaka Surgeons from Dhaka go outside for weekend practice Teams with full sets of equipment and instruments: Started lap surgery outside Patients ’ demand played an important role in this practice It is important to know that, all these initiatives were individual, institutional support initially was practically absent.

17. Formation of Laparoscopic Society and Relations with International Societies By the year of 1998: ‘Society of Laparoscopic Surgeons of Bangladesh (SLSB )’ with 50 Surgeons, later became SELSB in 2020 Our Surgeons also became members of: ‘ Endoscopic and Laparoscopic Surgeons of Asia (ELSA )’ Indian Associations of Gastrointestinal endosurgeons (IAGES) Asia Pacific Hernia Society (APHS) Conferences were also very important for our surgeons

18. Society of Endo-Laparoscopic Surgeons of Bangladesh (SELSB) SLSB/SELSB includes the surgeons from four categories who work with laparoscopes: Total Members: 1394 General Surgeons: 754 Gynecological Surgeon: 450 Pediatric Surgeon: 70 Urologist: 120

19. Organizing Workshop and Seminars Regular conferences, symposiums and workshops ELSA workshops and ELSA-OP Workshops Karl Storz , Olympus, Ethicon Endosurgery and others invited experts from neighboring countries training our surgeons abroad.

20. Development of Training Facilities BIRDEM and Japan Bangladesh Friendship Hospital: unofficial training from 1993 Eventually official training facilities were developed in late 90s BIRDEM and BSMMU, In recent years, training centers were also developed in Dhaka Medical College, Shaheed Suhrawardy Medical College too. UCELS is the latest and most advanced training center. From 2008 SLSB has also developed a training facility for regular training programs and also a SELSB Center in it’s own premises

21. Establishing JBFH-CELS and Development of Official Training Facilities In 2015 Japan Bangladesh Friendship Hospital developed a ‘JBFH Center for Endo- Laparoscipic Surgery (JBFH-CELS)’, an exclusive center for minimally invasive surgery treatment and training.

22. University Center for Endo-Laparoscopic Surgery (UCELS) This is the only center of excellence for endo -laparoscopic surgery in Bangladesh. All credit goes to Prof. Towhidul Alam , Dr. Abul Kalam Chowdhury and their team

23. SELSB Training Center in it’s own premises

24. Training Facilities in SLSB/SELSB Total Participant 620 Total Life Member : 1388 Training Start: Sept. 2008 41 Batches till now

25. Laparoscopic Procedures done by the General Surgeons Cholecystectomy Appendectomy All kinds of Hernia Repairs Fundoplication Enterostomy Gastric Surgeries Resection of small intestine Large Bowel Resections Splenectomy Hepatic resection Hepatic cystectomy CBD Exploration Hepaticojejunostomy Drainage pseudocyst of pancreas Pancreatic surgery Rt. or Lt. adrenalectomy Thyroidectomy, subtotal or total Bariatric Surgery

26. Laparoscopic Hernia Surgery in Bangladesh Laparoscopic inguinal hernia repair was started around 1998 at BIRDEM. Presently many surgeons in the government and private hospitals are doing different kinds of hernia surgery by laparoscopic technique countrywide with considerable success. Some special hernias like hiatus or diaphragmatic hernias can only be performed by a few surgeons.

27. Laparoscopic Hernia Surgery in Bangladesh It is also important to note that, high price of mesh for the laparoscopic repair of all kinds of hernia still seems a great obstacle for making these procedures popular among the patients. In 2016, we have formed the Hernia Society of Bangladesh (HSB), which has been designated as the country chapter of Asia Pacific Hernia Society (APHS). We are organizing regular workshops on hernia in collaboration with APHS, like Hernia Essentials, which we believe will bring huge benefits to the young surgeons of Bangladesh.

28. Laparoscopic Colorectal Surgery in Bangladesh In 1994 in BIRDEM Hospital the first laparoscopic right hemicolectomy was performed and in 1995 the same group carried out Laparoscopic APR with monopolar electrocautery . However it was not continue because of confusion regarding oncological clearance of laparoscopic colorectal cancer surgery at that time .

29. Laparoscopic Colorectal Surgery in Bangladesh At Present apart from BIRDEM and BSMMU, a considerable numbers of teams from Dhaka and outside are doing laparoscopic anterior resection, APR, sigmoid colectomy, hemicolectomy & rectopexy on a regular basis for their patients according to patients merit. However, some barriers are there for the development of this subject like patient load in government medical college hospitals, a steep learning curve and finally the cost involved in this kind of surgery.

30. Laparoscopic Bariatric and Metabolic Surgery Sleeve gastrectomy in a 58 yrs. old lady was first done at BIRDEM General Hospital, Dhaka on 20th December 2008. Since then a handful of laparoscopic surgeons are doing bariatric surgery sporadically. There is no dedicated bariatric and metabolic surgeon and team yet. Cost involvement is an important factor due to high price of staplers for Roux- en Y gastric bypass and mini gastric bypass Most of the patients are going abroad for this treatment, but BSMMU, BIRDEM and Evercare are trying for organized team for bariatric surgery.

31. Laparoscopic Gynecological Surgery In Bangladesh also, renowned gynecologist Professor T. A. Chowdhury started diagnostic laparoscopy in 1978 In 1996, Professor Laila Arzumand Banu and Dr. Sarder A. Nayeem performed the first laparoscopic assisted vaginal hysterectomy (LAVH) in Japan Bangladesh Friendship Hospital (JBFH) and they also started doing a number of gynecological procedures at the same time. Our Indian friends trained a good number of our gynecologists in India as well as in Bangladesh Now a good number of gynecologists are doing all kinds of laparoscopic surgery countrywide.

32. Laparoscopic Urology The concept of percutaneous renal stone surgery was introduced in 2001 with the help of our Indian mentors. Laparoscopic procedures- like ureterolithotomy , pyeloplasty , simple nephrectomy, radical nephrectomy, nephureterectomy were done mostly after 2008. Today the country has got 270 postgraduate qualified urologists and most of them are doing some laparoscopic procedures.

33. Laparoscopic Pediatric Surgery Though initially General surgeons were performing lap surgeries on children, pediatric surgeons started doing them from 2005. Now a good numbers of pediatric surgeons are doing laparoscopic surgeries countrywide The commonly performed procedures in children are Laparoscopic Appendectomy, Laparoscopic Inguinal Hernia Repair, Georgeson’s Procedure for Hirschsprung Disease, Laparoscopic Orchidopexy in Impalpable Testis, Pyloromyotomy , Laparoscopic Ovarian Cystectomy and Laparoscopic Diagnostic Procedures. Other procedures are also sometimes performed sporadically.

34. SLSB Training Programs

35. SLSB Office and Training Center

36. SLSB Special Lecture Programs

37. SLSB Pre-Congress Live Workshops

38. SLSB International Conference

39. ELSA-OPs in Bangladesh

40. ELSA-OPs in Bangladesh

41. Hernia Essentials of APHS

42. Robotics SILS NOTES Flexible Endoscopy Telesurgery or Remote Surgery Artificial Intelligence (AI) in Surgery Emerging Technologies

43. Robotic Surgery With the introduction of sophisticated medical robots in the 1990’s and in particular the master-slave devices( Da Vinci and Zeus), the next logical step to true remote telerobotic surgery was ready to be taken.

44. What Robotics Aimed to Improve in Laparoscopy Surgeon operates from a 2D image Straight , rigid instruments (limited range of motion ) Instrument tips controlled at a distance Reduced dexterity, precision & control Unsteady camera controlled by inexperienced assistant

45. Surgical Robots: Master-Slave Concept

46. Master-Slave Controlling

47. Master also gets assistance

48. Emulating ‘wrist movement’

49. We need to catch up with Robotics

50. Development of da Vinci for Telesurgery Defense Advanced Research Projects Agency (DARPA) for military research of remote battlefield surgery Cholecystectomy performed remotely via telesurgery from 300 miles away Intuitive surgical robots created in 1999 after acquiring patent rights from military First robotic prostatectomy performed in 2001

51. Telementoring Using teleconferencing software surgeons now have the ability to telementor other surgeons from remote locations, which involves watching, advising and directing a procedure. This technique may involve more than just observing, as mentors can indicate specific areas to the operating surgeons by digitally ‘drawing’ on the remote monitors with the resulting image seen locally.

52. Telementoring in Endolaparoscopic Surgery This telementoring is largely easy and most suitable in endolaparoscopic surgery, because here the mentor and performer share and see the same operation field. Indeed it is even possible to manipulate a laparoscopic camera and control diathermy at the distant site, thus truly making the remote operator part of the procedure.

53. SILS (Single Incision Laparoscopic Surgery) Urology Cholecystectomy Gastric band surgery Colectomy

54. N.O.T.E.S. - Natural Orifice Transluminal Endoscopic Surgery

55. Alleged benefits of NOTES No surface incision Reduced surgical site infection Reduced visible scarring Reduction in pain analgesics Quicker recovery time Reduction in hernias, adhesions Advantages in the morbidly obese

56. NOTES - Transvaginal

57. NOTES - Appendicectomy

58. NOTES – Bariatric Surgery

59. Bariatric and Metabolic Surgery 2002: Antidiabetic Effect of Bariatric Surgery: Direct or Indirect ?“ “Gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and independent effect, not secondary to the treatment of the overweight .” Potential of Surgery for Curing Type 2 Diabetes Mellitus. Rubino , Francesco - Annals of Surgery; November 2002

60. 2017 - The Role of GLP-1 in the Metabolic Success of Bariatric Surgery “ Improvements in glucose homeostasis, insulin sensitivity, and even discontinuation of type 2 diabetes mellitus (T2DM) medication can occur before substantial postoperative weight loss.” “The increase in endogenous GLP-1 signaling has been considered a primary pathway leading to postsurgical weight loss and improvements in glucose metabolism .” Hutch, Sandoval - Endocrinology . 2017 Dec 1 Bariatric and Metabolic Surgery contd.

61. Rates of Remission of Diabetes

62. Artificial Intelligence in Surgery: Promises and Perils Daniel A Hashimoto ,   Guy Rosman ,   Daniela Rus ,   Ozanan R Meireles , Annals of Surgery in 2018, July Issue Four main subfields of AI were defined: ( 1) machine learning, ( 2) artificial neural networks, ( 3) natural language processing, and ( 4) computer vision. Their current and future applications to surgical practice were introduced, including big data analytics and clinical decision support systems. The implications of AI for surgeons and the role of surgeons in advancing the technology to optimize clinical effectiveness were discussed. .  2018 Jul;268(1):70-76. .  2018 Jul;268(1):70-76.

63. Is AI going to oust Surgeons? Only time will tell, but hopefully not. Surgeons are well positioned to help integrate AI into modern practice. Surgeons should partner with data scientists to capture data across phases of care and to provide clinical context, AI has the potential to revolutionize the way surgery is taught and practiced, with the promise of a future of the highest quality patient care.

64. The Future: Endo-Laparoscopy and Beyond It has not changed the nature of disease and it’s surgical treatment. The basic principles and techniques of good surgery still apply . Appropriate case selection, excellent exposure, adequate retraction, meticulous dissection and a high level of technical expertise is necessary. If a procedure makes no sense with conventional access , it will make no sense with a minimal access approach either.

65. The Ultimate Surgery The cleaner and gentler the act of operation , the less the patient suffers , the smoother and quicker his convalescence, the more exquisite his healed wound . - Sir Berkeley George Andrew Moynihan (1865-1936) of Leeds

66. Thank You!