Forewords - Society of Laparoscopic & Robotic Surgeons


by Alfred Cuschieri, FRSE, MD, DSc, General Surgeon; Victor Gomel, MD, Gynecological Surgeon; and Elspeth M. McDougall, MD, MHPE, Endourological Surgeon
Prof Sir Alfred Cuschieri, FRSE, MD, DSc
Institute for Medical Science and Technology
University of Dundee, Scotland

It is with great pleasure that I readily accepted the invitation by Executive Editor, Dr. Paul Alan Wetter, to write the forward to the 3rd Edition of this Manual in view of the importance of the subject it addresses and its impact on the outcome of patients undergoing laparoscopic surgery within the various specialties. In this context, surgeons, irrespective of the surgical approach used, ‘are or constitute the treatment’ as the outcome of our patients stems directly from the care given to the patients, not just during surgery, but throughout the entire peri-operative period. We now practice in a different healthcare paradigm where ‘cure of the disease’ is not enough, as the clinical outcome of the patients we treat is also judged by the experience of patients during their hospital stay, the reduced period of short term disability following surgery and above all, the improvement in the quality of life it imparts to the patients. Indeed increasingly in some Western Countries, PROMs (Patient Reported Outcome Measures) are being used increasingly as a marker of quality of care. Additionally, we also practice, more than ever before, a transparent safety culture based on established and validated systems aimed at reduction of human error that has replaced the previous ‘shame and blame’ culture which served no benefit to doctors and patients alike. Even so, as surgeons we would do well to remember Dr Arthur Bloomfield’s (1888 – 1962) constant reminder: “There are some patients whom we cannot help….there are none whom we cannot harm.”

Section 1 of this open access on-line manual and its chapters (1 – 16) address seminal issues which apply to all irrespective of Surgical Specialty and which address most of the key topics which impact on patient safety: surgical training, surgical techniques and approaches, and surgical operative proficiency. By itself, surgical proficiency is not enough as even the utmost possible technical operative expertise and proficiency is not sufficient since good surgical care entails a broad range of competencies that ensure that the Master Surgeon is also, and above all, a good and caring doctor, with the necessary humanistic skills and clinical judgement, and who operates only when the prevailing scientific evidence indicates that the patient will benefit from the intervention. In my view, Section 1 constitutes essential reading for all residents, fellows, and attending surgeons of all surgical specialties.

The chapters in the other three sections: Laparoscopic General Surgery (17 – 39), Laparoscopic Gynecologic Surgery (40 – 64) and Endo-urological Surgery (65 – 72) are all of an impressively high standard, written by established experts in the field and outline the present state of the art in the subject matter with a text that is easy to follow and well referenced. Personally I found the chapters in my speciality (General Surgery), which I have read to be most instructive and comprehensive, to have a wealth of up to date information on both surgical techniques and patient management.

The Editors and Associate Editors are to be complemented for the 3rd Edition, which builds on the strengths of the previous two editions and will maintain the popularity and no doubt increase the readership of this invaluable on-line manual. I have nothing but praise for the quality and content of this Edition as it contains seminal, extremely useful, clinical information to all surgeons, irrespective of their experience. In this respect it has few rivals.
Victor Gomel, MD
Department of Obstetrics and Gynecology
Faculty of Medicine, University of British Columbia
Vancouver BC. Canada

The use of laparoscopic and other endoscopic access for complex surgical procedures in various disciplines is now state of the art. However, acceptance of this mode of surgical access, its use for complex surgical procedures, and its incorporation into daily practice has been slow. Yet the advantages of laparoscopic access as opposed to conventional laparotomy were already evident almost 40 years ago. Advantages that include reduced post-operative discomfort which results in less analgesia requirements; shortened post-operative hospital stay and recovery period; frequently lesser costs; and the medical and cosmetic gains associated with the avoidance of a laparotomy.

Gynecologists were the first to recognize the potential of laparoscopy for surgical access; some were performing relatively minor procedures such as ovarian biopsies and tubal sterilization by electrosurgical desiccation of a segment of the fallopian tube in the sixties. In the early seventies, pioneers in the field were already reporting on laparoscopic adhesiolysis, ablation, and excision of endometrial implants, reconstructive distal tubal surgery for infertility etc. At present, when many centers enjoy specially designed and refurbished operating theaters for endoscopic surgery, it would be useful to remind younger readers that at the time such procedures were performed with monocular vision of the operative field, the surgeon placing his/her eye directly on the laparoscope.

In the seventies, laparoscopy was frequently used to confirm the diagnosis of tubal pregnancy. In 1972, one night, having confirmed this diagnosis laparoscopically, I went on and excised the tubal segment containing the gestational sac and retrieved it through the main cannula. The next morning, the patient was feeling so well that she wanted to be discharged home. This was not the case with my department Head who told me: “I learned what you did last night. You will kill a woman in this department; if you do another case I will have to fire you.” Acceptance was slow to come.

After a long latent phase of indifference, gynecologists and even general surgeons started to become more interested in operative laparoscopy. In the eighties more complex gynecological procedures, such as ovarian cystectomy, adnexectomy, and myomectomy were being performed laparoscopically. The wider acceptance of operative laparoscopy and the undertaking of more complex procedures, by this mode of access, was the result of technical innovations: the production of endoscopes with better optics and of smaller caliber, and especially the development of lightweight mini video cameras and high resolution television monitors that permitted the surgeon and others assisting at the procedure to view the operative field in one or more monitors, and work in concert as a team. This, coupled with the report of the first laparoscopic cholecystectomy in 1985, changed the paradigm. General surgeons become rapidly interested in operative laparoscopy; and gynecologists become bolder and started to perform even more complex procedures, the most telling of these being pelvic and para-aortic lymphadenectomy and radical hysterectomy for gynecologic malignancy.

In the last two decades, endoscopic surgery moved to a phase of rapid development and progress, and wider acceptance. Many other surgical disciplines started to explore this minimal surgical access mode to perform many of their procedures. This is evident in the multidisciplinary book published by the Society of Laparoendoscopic Surgeons (SLS): Prevention and Management of Laparoscopic Surgical Complications, 3rd Edition.

This book is a treasure trove. It contains 72 chapters, each composed by recognized authorities in their field. The book is composed of four sections; the first of these, as the title implies, covers “Multidisciplinary Issues,” from ethical dilemmas in advanced surgical technology, surgical simulation and preoperative evaluation to important technical issues, including the place of the robot for the expert laparoscopists. The second section “Laparoscopic General Surgery” includes chapters on thoracic, vascular, and gastrointestinal surgery, laparoscopic surgery for abdominal trauma, emergent conditions, and other abdominal procedures. The third section “Laparoscopic Gynecological Surgery,” with its 25 chapters covers most laparoscopic and hysteroscopic gynecologic procedures. Lastly, the fourth section “Endourological Surgery” in its 8 chapters addresses major laparoscopic and robotic interventions, from radical nephrectomy to reconstructive renal surgery, and the related complications and their management.

The book will prove to be an important resource to all interested, the world over. Incredibly, it is available online, without need of a password, at no cost, and in 23 languages, through the Society of Laparoendoscopic Surgeons website, at
Elspeth M. McDougall, MD, MHPE
University of California
Irvine Medical Center
Orange, California

The rapid development of surgical technologies, particularly in minimally invasive surgery, has resulted in challenging, long learning curves for surgeons undertaking these new techniques. In addition, limited case experience as a result of restricted resident work hours and limited case volumes in surgical training programs add additional challenges to surgical education in the 21st Century. Maintenance of skills has become an increasingly important aspect of on-going surgical education and has also provided a challenge in terms of continuing surgical education. The 3rd edition of Prevention and Management of Laparoscopic Surgical Complications is a beacon of light on the horizon for laparoendoscopic surgeons as they meet the challenges of surgical education in the new millennium.

It is well accepted that the distinguishing feature of the expert or master surgeon, in addition to their unique surgical prowess, is the ability to recognize when a surgical error or complication is about to occur and implement the appropriate corrective maneuvers to counteract or eliminate the impending error. However, even in the most experienced or expert hands surgical errors can occur. Again, the expert surgeon is distinguished from the inexperienced surgeon by their judgment and technical ability to quickly and effectively institute the correct steps to control and resolve the problem thereby averting a catastrophic or morbid outcome for the patient.

The Prevention and Management of Laparoscopic Surgical Complications has been created, by recognized authorities in their surgical disciplines, on the already proven excellence of the previous two editions, which have made this reference textbook so highly regarded by laparoendoscopic surgeons worldwide. While continuing to present a multidisciplinary approach to the delineation of potential complications related to laparoendoscopic surgery, each chapter outlines the methods by which the surgeon can avoid these complications, in addition to techniques for effective management should these problems occur. This is an invaluable teaching device and as such, is already used in over 600 surgical training programs around the world.

This important laparoendoscopic teaching tool was the first of its kind to have an on-line, open access format with many advanced features including powerful search engines, hyperlinks and multiple language translations. This new 3rd edition is continuing the tradition of providing the learning material in the latest, state-of-the-art educational platforms. One of the very exciting new features of this textbook is the inclusion of embedded videos of each of the key areas of the various surgical disciplines and their commonly encountered complications. Additionally, the text of this reference will be free and will have open access in accordance with Creative Commons Copyright and in keeping with our high-tech, electronically connected generation, can be read on the computer, cell phone or iPad.

The proficient surgeon is expected to have a comprehensive knowledge base in order to understand the nuances of the technical procedure. However, of equal importance is learning and understanding what is an error, why it is an error, and what to do to avoid the error. This innovative and comprehensive Prevention and Management of Laparoscopic Surgical Complications, 3rd Edition provides all of this, and more, in an easy to use and access, highly instructive educational device. To laparoendoscopic surgeons world-wide, I invite you to read, observe, enjoy and learn well from this unique laparoendoscopic surgical learning program!