Q: Why the need for an endoscopy center? Why not just make endoscopy training part of surgical training?

ZARINS: Endoscopy training is a part of surgical training. However, there are new and rapidly developing technologies that have appeared since practicing surgeons have finished formal residency training. Therefore, continuing education for the new technology is necessary.

NEZHAT: In addition, the center provides a central place to bring several disciplines together to collaborate in endoscopic techniques. Progress happens when there is a collaboration among different disciplines. Many of the surgical principles such as knowledge of anatomy, surgical skill and proper use of instrumentation can be shared among different fields of surgery. Each discipline shouldn't have to reinvent the wheel.

Q: What does Stanford really have to offer in terms of being a center for these technologies?

ZARINS: Stanford is a place that nurtures new ideas and new technologies. Just look at how
Silicon Valley virtually spun off from the School of Engineering to see what a critical mass of young minds can do to synthesize new concepts and innovations.

NEZHAT: The Stanford University campus really puts together highly advanced basic science, engineering and clinical medicine departments.

Q: Is there ever going to be a time when video-assisted surgery replaces traditional surgery?

CANNON: I think in many respects it already has. I think one of the problems that we're going to face - and now I'm speaking as chair of the medical staff credentials committee - is that in the not-too-distant future we're going to be giving people privileges for laparoscopic surgery, who won't have had much experience doing open procedures. How do we deal with this? What if we find there is a general surgeon who does nothing but laparoscopy? What happens if he or she has to complete the operation as an open procedure?

ZARINS: I agree that some people might limit the scope of their expertise, but I don't think it will replace open surgery. Certainly, residents will continue to be thoroughly trained in traditional surgery. I think it augments the surgical capabilities. Ninety percent of gall bladders may be done better laparoscopically, but I think Walter will agree that a certain percentage of gall bladders are better done open.

CANNON: I do agree.

ZARINS: The new technology provides tools, and you need to know how to use many different tools for different purposes. As a surgeon you need to have wisdom, judgment and the ability to decide which tool is best to use in which circumstance and for which patient.

NEZHAT: Video-assisted surgery has and will continue to become an alternative and at times complementary technique to open surgery.

Q: That's for now and the near future. Are you saying that video-assisted surgery won't ever replace the scalpel?

ZARINS: I don't think it will. Trauma certainly won't go away, and there is no way you can do a major trauma case laparoscopically because of the urgency of hemorrhage and blood loss. Therefore, the concept of eliminating open surgery is unrealistic and possibly dangerous. There will always be a need to take care of an acute emergency very quickly and surgeons need to be trained appropriately. On the battlefield or in other acute major trauma or blood-loss situations, you are not going to do laparoscopic treatments.

CANNON: I agree with Chris. I think we need to be prepared for open surgical procedures, but individual surgeons may choose to limit their practices.

NEZHAT: There are multiple ways to play the piano. Different circumstances and different patients dictate different surgical options. Video-assisted surgery will continue to advance and evolve. As part of this evolution, video-assisted surgery will probably become a more accepted alternative for many occasions. In our practice, for the past five to six years we have rarely have had to resort to laparotomy for any pelvic surgery.

ZARINS: .... Yes, but keep in mind, Camran, that you are doing elective procedures ....

NEZHAT: .... Yes, that's true. But as endoscopic surgeons become more and more experienced and better instruments become available, the limiting factor will be the surgeon's skill and availability of proper instrumentation. Another evolution and improvement will be further use of natural orifices of the body. Now we have minimal access surgery. Gradually, we will have incisionless surgery. The nose, mouth, urethra, rectum, vagina, veins or artery will be further used to gain access to the pathology so that it can be corrected.

Q: The center is supported financially by educational grants. Ryan, can you speak about these relationships?

RHODES: I think it's fair to look at this not from the perspective of companies' roles but in terms of the center's role in promulgating useful courses for community-based physicians, in many cases using Stanford faculty to teach. Obviously, corporations would like to see this technology flourish in a safe, efficacious manner. But the need to promulgate the technology goes far beyond corporate agendas.

Q: Medical equipment companies are involved in supporting the center. Are other industries involved?

RHODES: Yes. Energy sources, laser companies, optical companies and other companies have all participated. Any new evolving technologies are evaluated and, as appropriate, integrated. For example, we are looking closely at ultrasonic
energy - the harmonic scalpel -which has found a home in certain procedures.
Other modalities are coming around the corner that might even supersede that.

NEZHAT: We collaborate with several outside organizations, including Ethicon Endo-Surgery, Stanford Research Institute, Olympus America, Stortz instrumentation, laser maker Coherent Inc., Heartport Inc., Circon Technology, C.R. Bard Inc., etc.

Q: This may be sensitive, but what if the product is a competitor of a company supporting the center?

NEZHAT: We would evaluate it. In the center we are neutral.

Q: Chris Zarins, how do you feel from the academic side about this kind of collaboration?

ZARINS: I think university/industry interactions are extremely important for developing new ideas and, more importantly, for applying them to patient care. This is the crux of what Stanford is calling bench-to-bedside innovation, and this can't be done without both advanced university research and the corporate community working together. Specifically, a training center is an ideal place to refine new equipment.

Doctors are going to tell you pretty quickly if the equipment doesn't work. It's reality testing for the company - and ultimately for the patient.

Q: Speaking of house staff, is it possible to complete a surgical residency in 1997 without endoscopy?

ZARINS: Laparoscopic techniques are part and parcel of every residency training program. But there is a lag time. By the time it gets down to the residency level, it's probably pretty well established. A training center represents the cutting edge.

Q: If you were a busy, well-established surgeon in a rural area, would it be worthwhile to take time out to learn these new techniques?

ZARINS: Sure, it's worth it for that surgeon to come because the patient demands it. That's what the training center is all about.

Q: What's in store for surgeons when they come to the center?

NEZHAT: They could benefit in several different ways. They can participate in advanced endoscopy courses, or they may attend live surgery demonstrations, laboratory practices, fellowships or preceptorships.

ZARINS: Of course, they do have to have a California license to participate "hands on" in the operating room. But in any case, they can certainly go to the animal lab, or with approval from the attending surgeon, they can observe in the operating room.

RHODES: Watching live surgery has been a key component of the educational process, whether it's just one or two doctors in the surgery suite watching, or dozens of doctors watching a surgery broadcast into a medical school classroom, as we do often for Camran's courses. It's like a few people watching a great film together. The proximity stimulates discussion. We've had physicians drive down here from as far as Bend, Ore., or Reno, Nev., to go into the lab after they've already taken a formal course but don't feel that their dexterity skills are at a level they'd like them to be. Others go home and take the proctoring route.

ZARINS: It's important to bear in mind that confidentiality is carefully protected when patients agree to be teaching patients and have their operations videotaped.

NEZHAT: Participating California licensed physicians will receive temporary privileges.

Q: What about telemedicine?

NEZHAT: There are several aspects to telemedicine. First, surgery with robotics, which is still some years in the future. Second, surgical broadcast via satellite or telephone lines, which is now here and already at the endoscopy center.

Q: Would it be feasible simply to make videotapes of the procedures to hand out to interested physicians?

ZARINS: Videotapes are good, but live interaction is much, much different from viewing an edited videotape. You need to be able to ask questions, and ideally, you need more than one video image.

CANNON: Ultimately, to get the most out of the experience you need to be in the room. The surgeon who is learning needs to see everything possible. There are issues of anesthesia, positioning the patient, positioning the surgeon, positioning the assistants. There are the techniques of safely putting in the trocars. You need to see the instrument placements.

NEZHAT: Nothing is like the real thing. Endoscopic surgery is more of a team effort than conventional surgery and there is more to see. So it is very important for the new endoscopic surgeon to observe the whole team at work, including the operating room setup.

Q: That brings up an interesting point. When you run these classes for surgeons, how do the other personnel learn what they need to know?

RHODES: We encourage people to bring the entire OR team. People in training can play the role they will be playing in the OR back home. We have anecdotal evidence that efficiency increases if the OR team works together before doing their first case in a patient. It builds everyone's confidence and helps everyone understand his or her role in any specific operation. This year we will be doing a large training program on new technologies, including laparoscopic surgery, for nurses.

NEZHAT: Our nonsurgeon colleagues proctor and teach their counterparts. For example, several Stanford anesthesiologists, including Ed Riley and Terri Homer, play an active teaching role.

Q: At the risk of sounding like a sports reporter, I need to ask: What makes somebody like Camran great? What enables him to do that additional 10 or 15 percent of difficult cases that no one else can?

ZARINS: I think it's visualization. Camran can visualize in his mind. He can take that two dimensional TV camera and make it three dimensional. He does that by integrating all of the images sequentially in his mind. You really have to be able to do that in order to be a wizard at this. Camran can keep track of where he is; he knows the anatomy extremely well. He can dissect things out and stay away from big vessels and stay away from nerves that you need to stay away from.

CANNON: Perseverance is also a factor. I think people who are doing the most endoscopic surgery in this institution - Camran Nezhat and his brothers plus [faculty surgeon] Mark Vierra - have huge amounts of perseverance. They'll just keep going. But it's worth it, because you see the patients 12 hours after their major operation and they look as if nothing had been done.

ZARINS: Stanford is fortunate to have many leaders and innovators in this area. In addition to Camran and his brothers, Walter, and Mark Vierra in general surgery, Baird Smith in pediatric surgery has applied laparoscopic techniques to the pediatric age group, which I think is a very important. Also, John Stevens has developed minimally invasive techniques for cardiac surgery and Tom Fogarty in cardiothoracic surgery has been a leader in developing new devices and technology. There is definitely a critical mass of people interested in minimally invasive surgery.

NEZHAT: And don't forget in urology we have Chris Payne and Harcharan Gill, and in neurosurgery, Stephen L. Huhn.

Q: One of the major hazards of mimal-access surgery, I've been told, is that errors or emergencies aren't readily fixable. For example, in traditional surgery, if you accidentally cut a blood vessel, you can reach in and literally grab the vessel to stop the bleeding. With video-assisted surgery, you would then have to make an incision. Comments?

ZARINS: You can't get away with the old philosophy of some surgeons who might say, "Just go in and cut it. Hope it doesn't bleed, but if it does, fix it." Now we have to take the view, "Don't cut it until you know what it is, and do make sure it's not going to bleed before you cut it.

NEZHAT: Presently some of the emergent situations, including hemorrhagic complications, are manageable endoscopically. Gradually even more and more circumstances will be dealt with laparoscopically as well. This is when surgeons' experience increases and better instrumentation become available.

RHODES:And industry is particularly interested in developing devices that can reduce complications.

Q: Speaking of devices, is there any cross-fertilization with traditional surgical tools?

CANNON: One thing I found is that some of the endoscopic devices actually work better in many open procedures than the standard devices do. For example, the endoscopic stapling devices, because they are small, can get around little corners. In response, we are able to make incisions that are smaller. Sooner or later our open procedures will be small-incision procedures. That's happening in thoracic surgery. Endoscopic pulmonary resections are being done through a small counter-incision that is just big enough to get the instruments in and out, but not big enough to require that we cut lots of muscle and spread the ribs wide apart.

Q: I'm told that some gynecologic procedures were done using scopes as early as 1895. Was video technology the factor that sparked the explosion in the use of this procedure?

ZARINS:Yes. Visualization is the key. If you can see it, you can do it.

NEZHAT: Yes, I believe video technology was the benchmark.

CANNON: The key thing is you can see better. It's magnified; the exposure is wonderful. By the way, it's been educational as well. We used to read about anatomy of the gall bladder, but we would never see those little anatomic differences.

Q: Radiation is already being used....

NEZHAT: ...Yes, of course that will be widely used.

ZARINS: One thing we haven't mentioned is the combination of approaches. There have been tremendous advances using a whole spectrum of new technology with various types of endovascular approaches. Within the lumen of the vessel you can control the bleeding, and you can do a combination of new technologies - endoscopic with endovascular, for example.

CANNON: Camran, do you think the youth of America who are being brought up on video games are going to be better at what we're doing than we are?

NEZHAT: Yes. Hand/eye coordination combined with appropriate technology, will help future surgeons and interventionists care for their patients in new and exciting ways.

Q: Are surgeons sometimes driven by a passion for gadgetry?

CANNON: The gadget certainly makes things easier on the patient, on the surgeon, and I think surgeons are driven to obtain good results. But it's also true that surgeons like to use their hands. I don't see that changing.