Surgical Academy Research Articles

Proof‐of‐Concept Study on the Endoscopic Minimally Invasive Thyroidectomy (eMIT) in Humans: A Realistic Assessment is Desired: Reply

The innovative idea of a three-point transoral endoscopic approach to the anterior neck region, specifically the thyroid gland, was extensively discussed in published anatomic studies [1]. On this basis, regions providing a safe access route, without the risk of collateral damage to neural or vascular structures, have been identified. In the first attempts to reach the target area, a totally sublingual access route through the floor of the mouth was evaluated and finally abandoned owing to the lack of triangulation and the imminent risk to anatomic structures in the submandibular groove [1]. The first author of this reply then had the idea of changing the incision sites from the floor of the mouth to the oral vestibulum. Through this transoral access, an approach to the thyroid on an endoscopic basis was successfully performed for the first time in an anatomic experiment [2]. Following these anatomic studies, an experimental study on the safety and feasibility took place in pigs and was successfully completed [3]. The first successful clinical application was undertaken in a 53-year-old man on March 18, 2009, and the results were published [4]. As outlined in our more recent paper, an intensive discussion regarding all the legal and ethical aspects of a possible human application took place, and the rationale for the decision taken was outlined in that report [5]. We recommend that Dr. Benhidjeb and Prof. Stark undertake a thorough re-reading of our article as it seems that they have not understood the difference between ‘‘treatment’’ and ‘‘human experiment’’ as defined under German law. Our proof-of-concept study was not a ‘‘human experiment’’ as stated by Benhidjeb and Stark. All other issues raised in their Letter to the Editor were also raised by Benhidjeb et al. in a recent Letter to the Editor in another journal [6]. The relevant issues were extensively addressed in our reply to that letter, and the interested reader may refer to that reply, specifically with reference to the role of T. Benhidjeb, M. Stark, and the New European Surgical Academy (NESA) in the development of endoscopic minimally invasive thyroidectomy [7]. The NESA is a scientific interdisciplinary society designed to bring together ideas and solutions for surgical problems from different fields of surgery. It therefore seems abstruse when Benhidjeb and Stark state that ‘‘the NESA decided at that time not to proceed to clinical application’’ [8]. Note that it remains the responsibility of the acting scientist, the institutional review board, and the ethics committee—not a scientific society—to decide on this issue. In our report of the proof-of-concept study on eMIT [5], we outlined every complication recorded, the time of onset, and the outcome as well as the conclusions drawn from those events. This was unquestionably done in line with the relevant scientific rules because our paper passed the review process of the journal immediately, without hesitation or any mandatory revisions. The interpretations of the reported complications by Benhidjeb and Stark, notably when dealing in percentages on this small number of treated patients, is abstruse and, in our opinion, unscientific. We also reiterate that clinical application of this new and innovative approach at this stage was never recommended. The conclusion we reached T. Wilhelm (&) Department of Otolaryngology, Head/Neck and Facial Plastic Surgery, HELIOS Klinikum Borna, Rudolf-Virchow-Strasse 2, 04552 Borna, Germany e-mail: thomas.wilhelm@helios-kliniken.de

Transoral thyroid and parathyroid surgery: still experimental!

It was with great interest that we read the report by Karakas et al. [1] on transoral thyroid and parathyroid surgery. By using a modified rigid rectoscope (oraloscope) hemithyroidectomies as well as resection of parathyroid glands could be performed in ten porcine cadavers, then in 10 living and orally intubated pigs, and finally in five human corpses. Because unfortunately many claims and statements in their report are misleading, we believe that rectifications are needed. Karakas et al. stated in the ‘‘Introduction’’ of their article that ‘‘For the first time, we describe an entirely transoral access, which allows for a hemithyroidectomy and parathyroidectomy without an accessorial incision of the skin in pigs and human cadavers.’’ Later, in the ‘‘Results’’ section, they affirm that ‘‘This is the first study to demonstrate that transoral resection of thyroid and parathyroid glands is feasible using an entirely transoral access to the thyroid region.’’ Both statements are wrong. Transoral thyroid surgery is an innovative project that was initiated in September 2007 by the New European Surgical Academy (NESA) and developed in cooperation with the Department of Neuroscience Anatomy at the Erasmus MC University in Rotterdam, The Netherlands. It is a part of the NESA’s Natural Orifice Surgery (NOS) project that includes investigation of transvaginal and transoral access for various surgical procedures [2–4]. Transoral thyroidectomy is based on the hybrid technique invented by our member Kai Witzel, who was the first to describe transoral access to the thyroid [5]. Our main goal was the investigation and introduction of a technique of totally endoscopic thyroid resection that is minimally invasive and safe for the patient and also cosmetically optimal (scarless). The first step of this project consisted of anatomic studies with instrument development performed on three human cadavers. Following these detailed studies, safety and reproducibility to reach and resect the thyroid gland were assessed according to a defined road map in two cadavers. On 14 May 2008 we succeeded in performing a totally transoral video-assisted thyroidectomy that we named TOVAT. On 31 August 2008 this method was successfully used in five living pigs. On 13 September 2008 we submitted a video paper to Surgical Endoscopy that was accepted on 8 January 2009 and published online on 5 March 2009 [6]. Karakas et al. submitted their manuscript to Surgical Endoscopy on 12 June 2009, 3 months after the online publication of our video paper in the same journal, long after our paper was available on PubMed and other search engines. Moreover, we presented TOVAT as early as 30 August 2008 at the 20th International Conference of the Society for Medical Innovation and Technology (SMIT) in Vienna [7]. The abstract of this oral presentation was also published at that time in Minimally Invasive Therapy and Allied Technologies [8]. All this makes it legitimate to raise serious concerns over Karakas’ literature search before starting their T. Benhidjeb (&) O. Mann Department of General-, Visceraland Thoracic-Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany e-mail: t.benhidjeb@uke.de

Morten A. Skydsgaard, Ole Bang og en Brydningstid i Dansk Medicin (Århus: Aarhus Universitetsforlag, 2006), pp. 333, Kr348.00, paperback, ISBN: 87-7934-228-0.

Morten Skydsgaard’s biography of the Danish physician Ole Bang (1788–1877) is an informative and important book about a period of transition in nineteenth-century Danish medicine. Bang held several of the most significant posts available to physicians in Denmark. He was a professor at the university of Copenhagen, and he was the chief physician at the largest hospital in the capital, Frederik’s Hospital. Among the prominent patients in Bang’s lucrative private practice were the Danish and Russian royal families. Throughout his career he advocated a medicine grounded on careful observation at the bedside. He reformed medical education, putting clinical teaching into practice at the medical faculty. His methods of treatment became influential among Danish medical practitioners, and he was famous for his clinical skills. Bang was also engaged in health politics, and played an important role in the formation of a common curriculum for surgeons and physicians, thus putting an end to a long rivalry between the medical faculty and the surgical academy. During his long and active professional life (he retired in 1874, aged eighty-six), Bang was respected and recognised as one of Denmark’s leading medical figures. However, soon after his death he was branded a reactionary and accused of opposing new ideas, thereby hampering progress in Danish medicine—a view which has been generally accepted in Danish historiography until now. In this carefully researched book a more complicated picture is painted. Skydsgaard confirms that Bang remained faithful throughout his life to the Hippocratic doctrine of vis medicatrix nature, or the healing powers of nature. He believed that the organism did not accept disease passively but counteracted it by trying to rectify the disturbed equilibrium. Nature was, therefore, the best physician, but the human physician could help nature to fulfil its goal by removing obstacles to its action, thus assisting in the organism’s own attempt to recover. Bang employed traditional remedies like purgatives, emetics, diapnoic drugs, sialagogues and bloodletting. However, as Skydsgaard shows, he also participated fully in the new medical debates, and, early in his career particularly, he was a proponent of change in many areas. He introduced the stethoscope to Denmark, and studied in the French style pathological changes of the bowels during typhoid fever. He also engaged in medical meteorology, trying to generate new knowledge about epidemics based on an analysis of meteorological data. Furthermore, he advocated the use of statistics in medicine, and regularly published data on morbidity and mortality from Frederik’s Hospital. Later in life, however, he became sceptical of the increasing technicality of medicine, which, he held, distanced the physician from the patient. Consequently Bang found himself in opposition to younger colleagues, who emphasised the importance of autopsies, microscopy and animal experiments. For him, medicine was centred on the individual, carefully tailored to each patient, whereas for younger doctors objectivity and regularity took precedence over the individual. The most interesting chapter is that in which Skydsgaard analyses this period of change in Danish medicine by looking at how various physicians worked with one single disease—typhoid. He demonstrates well that new and, in retrospect, ‘correct’ ideas do not spread without friction. Also, it allows him to compare treatment methods. Bang’s younger colleagues, more favourably received in Danish historiography due to their introduction of ‘modern’ methods such as microscopy and laboratory tests, basically treated typhoid fever no differently than did Bang himself. Nevertheless, while overall this is a well-constructed and interesting piece of research work, it is not without its flaws. Perhaps most importantly, Skydsgaard’s selection of sources is too limited. He has studied published articles and books, as well as newspapers and letters from the period, but omitted hospital records. It is difficult to understand why this vital primary source of therapeutic data is ignored, and second- and third-hand descriptions of such treatment used instead. Additionally, Skydsgaard is not very comfortable or convincing when it comes to medical philosophy. His discussions of nosology and diagnostics are confusing, perhaps owing to insufficient knowledge of the important change from medical semiotics to medical diagnostics in the early nineteenth century. Finally, this is very much a book about Denmark, and, if more of Bang’s professional life had been placed in an international context, the work would have gained from a wider view. But, despite these flaws, there is no doubt that Skydsgaard has written a well-researched book about this interesting period in Danish medicine.

EUROPEAN MEDICAL EDUCATION TO BLOOD SPARING: AN URGENT NEED TO IMPROVE QUALITY OF PATIENTS' CARE

Scientific aspects of Transfusion Medicine are often reported. Professional “transfer” of scientific knowledge, however, isn’t reaching all concerned specialists yet. In most European countries, little undergraduate education in Transfusion Medicine is given, few training curricula exist for specialisation in Transfusion Medicine, and in other medical specialities. The prevalent attitude of most clinicians is still an “expecting” one. It is however becoming accepted that clinical medicine, in order to provide patients with the safest possible blood, has more to give than to receive. ESTM activities are largely oriented towards the contribution of clinical medicine to blood safety. Out of 80 ESTM courses performed so far, 40 were dedicated to clinical transfusion practice! A “Cooperation Agreement” as “partner organisation” was signed in 2006 with New European Surgical Academy (NESA). The need for better understanding between clinical and transfusion specialists became evident after the analysis performed in 2002 at the ESTM meeting in Lecce and the conclusions of the 2003 course in Belgrade on “The contribution of clinical medicine to blood safety”. A previous course in 2002 in Lviv on “Blood-sparing medicine and surgery: the absolute need of safe autologous and homologous blood donation” focused on blood-sparing procedures, also discussed in Riga in 2004. Similar problems of reciprocal support had been dealt with in 2002 in Sofia at the course on “Basic clinical and organisational requirements for implementing an effective haemovigilance”, and increasingly debated during other ESTM courses (2002 Portoroz, 2003 Piacenza and Napoli, 2004 Barcelona). Adequate knowledge on clinical transfusion practice by all medical specialists is an absolute target. Education in quality management is a proper common way to overcome national differences in transfusion safety. Time has come to stimulate proper attention for all what concerns the clinical side of Transfusion Medicine, and particularly blood sparing. Pressure by Scientific Societies of relevant clinical disciplines could be of considerable help. A passionate appeal from any clinical Scientific Society to all other Societies, to collect specific information on postgraduate specialisations, could allow acquisition of knowledge on already existing situations, for further discussion on how to attain a better quality of patients’ care.

Introduction to Volume I of "Memoirs of Royal Surgical Academy" (1743)

The classical text, written by the founder of physiocracy in 1743, which is published in Russian for the first time, explicates his general scientific method in a wide perspective. Quesnay fruitfully applied his method that consisted of two interconnected elements (observation and physical experience) in metaphysics and political economy. Using this method in the "Introduction", Quesnay attempted to reveal the general scientific basis of surgery, or "art to cure", and therefore severely criticized many medical and philosophical techniques widely accepted among his contemporaries.

Zum 100. Todestag Ernst von Bergmanns

"dear aunt lina. i do not know any big letters yet, but i want to thank you in small letters for the beautiful pens. say hello to grandpa and to everybody. yours truly, ernst." These are the first surviving written words of Ernst von Bergmann. Between them and his last words about his suspected colon cancer on 25 March 1907 ("I diagnosed this 5 years ago, and now it has come to pass.") lie many years in a vigorous life characterised by untiring activity and creativity, self-discipline, and care for patients and his family. They were years of enormous success in surgery and private happiness but also of professional setbacks and tragic family loss. Ernst von Bergmann became a leading German surgeon not only because of his surgical and scientific achievements, particularly in the fields of asepsis and war surgery, but also due to his exemplary character, reliability, engaging personality, and commitment to medical training in various medical societies. Of these, the German Society of Surgery is most indebted to him. After assuming a chair in surgery in 1882, he continued to play a leading role in this society, not least as its five-time president from 1888 to 1890 and in 1896 and 1900. A worthy successor to Bernhard von Langenbeck, he was a full professor at the Berlin University Hospital for 25 years. He also taught at the Medical and Surgical Academy for the Military after being appointed there by Emperor Wilhelm I on 16 November 1882. This position was important to him and corresponded to his patriotic views.

Waterford surgical October club and surgical section royal academy of medicine joint surgical symposium

Waterford surgical October club and surgical section royal academy of medicine joint surgical symposium

Kazan State Medical University - 185 years

May 14, 1999 marks 185 years since the opening of the Medical Faculty of the Imperial Kazan University, a significant event in the history of higher medical education in our country. After the medical faculty of Moscow University (opened in 1758) and the St. Petersburg Medical and Surgical Academy (1798), this faculty became the third forge of domestic medical personnel in the 19th century in Russia.

The first chairs and professors of dermatology, particularly of 'German' dermatology.

A short outline is given of the establishment of the first chairs in dermatology/venerology in Central Europe, starting with the award of the Fothergillian Gold Medal to Robert Willan in 1790 and ending past mid-century with the establishment of the professorial chairs in Munich in 1863 and of Military Dermatology at the Vienna Surgical Academy in 1870.

I.P. Pavlov.

IVAN Petrovich Pavlov (Fig 1) was born on Sept 27, 1849, in the old Russian town of Ryazan. His early education was in preparation for a career as a priest. In 1864 he finished the theological school and entered a seminary. However, his refusal to accept religious dogmas and his keen interest in materialistic ideas prompted him to leave the seminary. In 1870 Pavlov enrolled at the natural sciences division of the Physics and Mathematics Department of the St. Petersburg University, where he specialized in animal physiology under the guidance of the well-known Russian scientist I. Tzion. In 1874, Pavlov finished the St. Petersburg University with honors—he was awarded a gold medal. However, he did not regard his education as complete and continued his studies at the Medical Surgical Academy, which he finished in 1879. Shortly afterwards, Pavlov headed the Physiology Laboratory at the clinic of the outstanding Russian internist

Attending physician of the Ulyanov family A. A. Kadyan (To the 120th anniversary of his birth)

Alexander Alexandrovich Kadyan was born on April 1 (14), 1849 in St. Petersburg. His father Alexander Zakharovich Kadyan, with the rank of captain, was "a teacher of the third kind of the Second Cadet Corps." After graduating from the First St. Petersburg Men's Gymnasium, A. A. Kadyan was "recognized worthy of a commendable certificate... with the award of a silver medal", and on September 15, 1866, he was enrolled as a student of the Medical and surgical Academy.

Phrenicoexeresis operation, as a preparatory measure before hernia repair

Delageniere reported at the fPr Surgical Academy. Med No. 17, 1936) on the operation of phrenicoexeresis performed by him as a preparatory measure before the operation of hernia repair