Minimal-invasive gastrectomy: what the west can learn from the east?

Minimal-invasive gastrectomy has been established as commonly used method for the early gastric cancer in Korea and Japan. From the first laparoscopic cancer gastrectomy in 1992 in Japan, numerous prospective randomized trials from these two countries have gained the evidence for non-inferiority or even specific benefits compared to open surgery. In Korea, the "Korean Laparoscopic Gastrointestinal Surgical Study Group" (KLASS group) founded, in 2004, successfully gained evidence not only in regards of oncological safety of laparoscopic gastrectomy, but also for the impact of different reconstruction methods and alternative extents of luminal resection on postoperative outcome and quality of life. Awaited results of latest studies from Korea, Japan, and China may suggest laparoscopic approaches as an option even in advanced gastric cancers. These studies could potentially be the starting point to find the role of laparoscopic gastrectomy in the west, where the incidence of gastric cancer is rather lower; the cancers are mostly diagnosed in advanced stages, and often, a perioperative chemotherapy is applied. Robotic (-assisted) gastrectomy was not shown to be superior to laparoscopic resection in Korea, but new technological developments should continuously be evaluated in clinical trials regarding a potentially favorable learning curve, which might play a key role in regards of the limited case load per center of gastric cancer in the west. This review summarizes the history of laparoscopic cancer gastrectomy in Asia and points out the important steps of establishing a nation-wide scientific network to support the surgical routine by the necessary evidence with a focus on Korea.

Mis comienzos en laparoscopia / My first steps in laparoscopic surgery

OBJETIVO: El autor describe algo de sus comienzos en laparoscopia, de dónde le vinieron algunas de sus ideas, el porqué y los medios con que contó al empezar. Cuenta brevemente su aportación a la Urología, que puede servir de modelo para los que están empezando. MÉTODOS: Desde que el autor era un adolescente, su padre, que era urólogo, supo transmitirle el entusiasmo por su trabajo; se sentía atraído por el instrumental desde el litotritor de Freyer hasta el resector de Iglesias. También se interesó especialmente por los libros de urología antiguos. Le causaba especial admiración ver operar en directo a don José María Gil Vernet y cuenta que fue el primer urólogo al que le vio usar un laparoscopio para el diagnóstico del testículo abdominal. En 1985, mientras estaba en la universidad de Oxford, se le ocurrió diseñar un sistema de balón para disecar el espacio retropúbico, que al cabo de los años daría lugar a la cirugía extraperitoneal. Al año siguiente tras leer el manual de laparoscopia de Semm, describió la varicocelectomía laparoscópica. Entre sus trabajos destaca el haber descrito en 1993 por primera vez la técnica de la cistectomía radical con conducto ileal laparoscópico. En 1997 ideó un sistema robótico, mediante brazo maestro esclavo, concebido inicialmente para la resección transuretral. RESULTADOS/ CONCLUSIONES: Considera que una buena idea es algo valiosísimo, que no tiene precio, porque a todo aquel que tenga ambiciones y la consiga, le permitirá salir de la mediocridad

OBJECTIVES: The author describes his first steps in laparoscopic surgery and the sources of some of his ideas. He thanks his father’s influence and the technical stimuli that catalysed his scientific curiosity. For the benefit of young urologists at the beginning of their careers he shows how the frustrations of working with the early instruments became the vital challenges that inspired creative solutions. METHODS: His urological surgeon father inspired in his young son a passion for his calling. He developed an immediate and compelling interest in the shape and function of urological instruments like, for example, Freyer’s lithotripter and the Iglesias resectoscope. Books of urological history and the works of pioneer urologists fascinated him. Watching José María Gil Vernet operate particularly impressed him and he says that Gil Vernet was the first urologist he saw using a laparoscope to diagnose an abdominal testicle. While working in an Oxford University hospital in 1985, he designed a balloon device to dissect the retropubic space. This procedure was the precursor of what several years later became extraperitoneal surgery. The following year, he read the manual of Semm’s laparoscopy and later described a laparoscopic varicocelectomy. In 1993, he published the first description of a laparoscopic radical cystectomy and ileal conduit. In 1997, he adapted a surgical robotic system with a master-slave arm to carry out firstly a transurethral resection. RESULTS/CONCLUSIONS: He says that a good idea is beyond price because it helps the inspired individual to make true a long-held ambition and achieve the signal success that lifts him out of the mud of mediocrity

[The natural orifice surgery concept. Vision and rationale for a paradigm shift]. / "Natural-Orifice-Surgery- (NOS-)Konzept". Vision und Rationale für einen Paradigmenwechsel.

BACKGROUND: During the 20th Century, laparoscopic surgery achieved high standards and significantly reduced morbidity. In order to make surgery simpler and safer, a new concept, natural orifice surgery (NOS), has recently been introduced. The approach to the abdominal cavity may be transoral-transgastric, transvaginal-transdouglas or transanal-transrectal. This article describes the logic behind this approach and the expected challenges. METHODS: In order to realize this goal, we founded the first European based working group on NOS. This group concentrates on the development of transdouglas procedures in women by using the transdouglas endoscopic device (TED). This is a wide, multi-channel instrument, which will enable surgery to be performed via a single entry. RESULTS: Simulation of various intra-abdominal operations, such as staging, cholecystectomy, appendectomy, myomectomy und ovarectomy, using TED has already been carried out. Practical studies are planned in the near future. CONCLUSION: The feasibility of NOS has been demonstrated in various experimental studies. We believe that this technique will create a spectrum of innovative and high quality operations and will improve patient safety.

[A century of developmental history of laparoscopic surgery].

Till the year 2001, the development of laparoscopic surgery will have gone through a total of one hundred years. Laparoscopic surgery has made a great progress during the last more than a decade. In retrospect its history, the development of laparoscopic surgery underwent three main eras, viz. diagnostic laparoscopy, operative laparoscopy and the modern laparoscopy era. Although the laparoscopic technology started rather late in China, it develops very quickly. Along with the development of high -- tech, laparoscopic surgery will have a promising future.