Antia-Finseth Award Presentation at Karad 2015: Single Incision Gasless Laparoscopic Surgeries

BACKGROUND

The Association of Rural Surgeons of India [ARSI] presents this award for innovations in rural surgery. The objective is to encourage innovations in rural surgical care. Earlier the Antia–Finseth awards were given to innovations like; the use of mosquito net instead of the Prolene mesh as these materials were shown to be similar and for low cost ventilators. Such innovations have made surgeries in rural areas much less expensive and hence affordable at the same time providing high quality care.

The award was started jointly by the contributions of Dr. Antia and Dr. Finseth. Dr. Antia is a renowned Plastic surgeon who despite his very high academic achievements was interested in rural health care.

antiaDr. N. H. Antia

  • Plastic surgeon of international repute
  • Established API in 1957
  • Hunterian Professor or Royal College
  • 182 publications and foundation for medical research and community research
  • Padmashri (1990), G.D. Birla award (1995) and karma Yogi award (2006)

Dr. Finseth again is an eminent professor at Harvard University who worked all over the World to improve surgical care in rural areas.

FinsethDr. Fred Finseth

  • Eminent plastic surgeon from Yale and Harvard
  • Great teacher and mission doctor all over the World from Haiti to Ethiopia, Ecuador, Brazil, Peru, Nepal and India
  • His significant contribution to ARSI is mentioned in American Association of Plastic Surgeons

 

THE BEGINNING OF GASLESS LAPAROSCOPIC SURGERIES

Professor Hashimoto of Japan is considered the father of gasless laparoscopic surgeries. The small but definite complications of Laparoscopic surgeries and the physiological changes that are associated with laparoscopic surgeries made him look for alternatives to the use of carbon dioxide for insufflation during laparoscopic surgeries.
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gasless-laparoscopy-9-img-01

THE ANIMAL EXPERIMENTS

Once the concept of gasless laparoscopic surgery was accepted, further research with animal experiments were carried out to prove it’s superiority over the conventional laparoscopic surgery.

  • Pressure increased 8-iso PGF (2alpha)
  • Influenced the frequency and severity of adhesion
  • Increases peritoneal plasminogen activator inhibitor type 1 (PAI-1)
  • An increased PAI-1 mRNA expression at 5 h.

These studies showed that formation of post-operative adhesions were much less after gasless surgeries and they also described the reasons for the increased adhesions with use of gas.

  • Mesothelial hypoxaemia increases adhesion formation
  • Direct correlation with flow rate and abdominal pressure
  • Increased fibrinolytic changes with LS
  • Firbrinolysis leads to adhesion formation
  • Increased PAI and decreased tPA

Several reasons were identified for formation of adhesions like hypoxaemia, increased fibrinolysis, etc. Warm wet environment helps in prevention of adhesions unlike the cold dry condition provided by the carbon dioxide insufflation.

There are several physiological changes with carbon dioxide which the anesthesiologists do not like and all these are prevented by use of gasless technique.

  • Fall in pO2 and significant increase in pCO2
  • Hypercapnia and hyper dynamic circulation

As tested by intravascular carbon clearance test gasless laparoscopy has favorable effect on phagocytosis.

Hemodynamic stress response and changes in acid base balance are few things that the anesthesiologists do not like.

  • Increased intra-abdominal pressure induces hemodynamic stress response, less urine and compromised splanchnic circulation
  • Lift-laparoscopy provided normal acid base balance, less stress response, maintains urine output and avoids derangement of pulmonary mechanics

These animal experiments did prove that gasless laparoscopic surgery is far superior to the one using carbon dioxide for insufflation especially if the surgeries were of long duration. The anesthesiologist were happy as they could take up high risk patients especially those with cardiovascular risks.

THE EARLY EQUIPMENT

With the publication of the advantages of the gasless surgeries a variety of equipment came into existence. The major problem with the abdominal wall lifting equipment was the tenting or triangulation formed by the equipment. The exposure was poor.

early equipment

The fixing mechanisms were complicated. Hence it took much longer time to perform the surgeries. The mechanized devises had similar problems in addition to being much more expensive. Hence most of the publications were from single centers.

The Earlier Equipment

earlier equipment

Of all the devices the one designed by Dr. Daniel Kruschinski in Germany offered the best exposure. He also had a training program and other centers started using the Abdo–Lift. However the equipment still remained expensive and took time to set up. Slowly the enthusiasm about gasless surgeries waned.

Problems with earlier equipment:

  • Takes time to set up and fix
  • Poor exposure due to tenting of the anterior abdominal wall
  • Cost (7200 Euros)
  • The importance was given to advantage of gasless surgeries only and the possibility of single incision surgeries & cost reduction were not considered

THE RENEWED ENTHUSIASM

In recent times the concept of single incision laparoscopic surgery became popular. This however, is much more expensive because of the cost of the equipment and also the difficulty because of the new skills that are necessary to use this equipment. The gasless laparoscopic method makes equipment less expensive and the skills relatively easier to learn.

The gasless surgeries could be comfortably carried out under spinal anesthesia which is easily available in many rural areas and is less expensive compared to the general anesthesia. The implication is that the gasless laparoscopic surgeries are possible in rural areas where regular laparoscopic surgeries are not possible.

Several changes were made to the equipment that makes it much simpler and quicker to use.

The Newer Equipment is easy to start using and easy to fix if needed. It’s less expensive (Rs. 90000) and having traditional hand instruments that make learning much easier for the surgeon.

THE UNIQUE OR NOVEL FEATURES

  • The intra–abdominal portion is designed for best exposure extending up to the lateral border of the rectii muscles. While fixing a finger could be used to check that there is no intestine or omentum between the lift and the abdominal wall. The design is such that it locks into position easily and also allows the necessary movement to fix in place.
  • The lifting mechanism is simple to fix with just two click locks once held in position. The placement of the lifting mechanism is easy for the assistant or floor nurse to use.
  • The fixation to the table has a special design that allows it to fit to any type of operating table.
  • The unique design with angulations allows for best visualization during single incision surgeries.
  • The handles have the familiar locking mechanism of the open hand instruments.

SURGERIES UP-TO-DATE

Over 500 surgeries have been carried out using the equipment so far. Most of them are single incision surgeries and almost all of them benefited the rural patients. About 80% were carried out under spinal anesthesia which is less expensive and easily available in rural areas.

the common surgeries
the rare surgeries

RECOGNITIONS

  • The presentation was selected for the final round of the BMJ surgical team of the year award.
  • It has reached the final rounds of the Millennium Alliance project. If it clears this round funding is available for subsidizing the purchase of the lift for rural surgeons who register for the online course on Gasless laparoscopic surgery and for further research.
  • The Lancet Commission on global health recognizes it as one of the means of taking advanced surgeries to the remote rural patients.

ONLINE COURSE

The mdCurrent-India (http://mdcurrent.in/courses/lift-laparoscopy/) has kindly hosted the online course on gasless laparoscopic surgeries and those who register and do the course can get certification by the Karunya University and also would be eligible for the subsidy for purchase of lift and for patients if the Millennium project comes through.

mdc-course-gasless

Gnanaraj-64 Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

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