Guest Bio:
Sir Alfred Cuschieri – (a pioneer of minimal access surgery) Professor of Surgery at the Scuola Superiore Sant’Anna since 2003 and Chief Scientific Advisor to the Institute of Medical Science and Technology at the University of Dundee
List of question themes and full question:
- Developing an idea & persistence – Sir Cuschieri, you obviously do not need any introduction with regards to what you and a small group of people achieved for minimal access surgery, but we would particularly like to hear about the process by which you developed this idea. When the key people around you were telling you that your idea would not work, what was it that kept you going?
- How did the journey feel? – During the development of this technology, did you ever feel like you were on the verge of something? Or did it feel like you were in uncertain territory?
- Current problems – What problem do you see in medicine currently that you feel the younger generation should be working on?
- Hiring – You mentioned that you built a team of people consisting of chemists, engineers etc. What would you look for in someone joining your team?
- Books – Lastly, do you have any favorite books or resources that you’d recommend? It does not need to be restricted to medicine alone.
Podcast Transcript
Developing an idea & persistence
Q1: Sir Cuschieri, you obviously do not need any introduction with regards to what you and a small group of people achieved for minimal access surgery, but we would particularly like to hear about the process by which you developed this idea. When the key people around you were telling you that your idea would not work, what was it that kept you going?
A1: Well, you know, all of this really happened during my surgical training in London and thereafter in Liverpool, which was a very good city to train in because people presented with advanced disease requiring major surgery. As a trainee, I realized how many elderly patients above the age of 65, 70 would die postoperatively because of poor pain control and I’m talking about the 1960s, 70s you know. A great percentage of people in this age group died of postoperative pneumonia, because they had huge incisions from the xiphoid to the symphysis pubis – they would say good surgeons = big incisions – and the pain relief was dreadful, non-existent I would say. We gave the patients injections of a morphine derivative which doesn’t exist anymore and there would be at least 5 to 10% mortality from pneumonia, the mortality was incredible. I went to my boss who was a very well-known professor at the time and I said “look, there must be a better way of doing surgeries without these big incisions” and he really tore me down, saying “if you are frightened of blood and big incisions, you should have never chosen surgery as a career”, so I sort of shut up. I had done some reading, though, on the concept of operating through small incisions – not keyhole surgery, but small incisions – and it lead me to become interested in two people, a German professor and an Austrian professor, both non-surgeons. During my summer holidays, I wrote to them asking if I could visit them.
When I went to Germany I thought this guy was doing something incredible. He was operating through a telescope, nobody could see what he was doing, but he was actually operating! He had a scope, like a tube, and an instrument in the other hand and he was doing simple operations, e.g. tubal ligation. There and then, I knew this was the future of surgery. I went back, finished my surgical training, and was appointed as a lecturer in Liverpool under a very good mentor at the time, a Professor David Ellis, who did not poopoo the idea and encouraged me to develop it. So, I went on an engineering and optics course for a year because I knew I needed knowledge that the medical undergraduate education did not provide. We are too insular in medicine, in my opinion, and I think every medical student should choose a non-medical subject to study alongside, be it electronics or whatever.
Anyways, this one-year course made me realise that what I was thinking was possible. I applied for a grant initially from the Wellcome Trust, who gave me the first grant of my life, to explore this concept and travel to other places, which I did, and there I found a very nice man in Ormskirk, a little place north of Liverpool. He was a gynaecologist who was doing laparoscopy working with a Professor Edwards in Cambridge, and he showed me what he was doing. He had made an attachment to the telescope, a rigid tube using split-beam imaging so I could see what he was doing, and what he was doing for Professor Edwards was harvesting eggs for his experiments on in-vitro fertilization. For me, this was incredible, to find this guy in little old Ormskirk doing this, and that’s how I realized that this technology not only had bearings on general surgery, but it also had bearings on other disciplines. For a long time, though, despite the development of new technologies, there was no company in the UK which was interested in this.
The second thing that happened there was this guy told me to go and see a professor at Imperial College who had designs for a new telescope. You see, the telescopes at the time didn’t use fibre optic technologies because it didn’t exist, but Harold Horace Hopkins, a Professor at Imperial had developed a very novel rigid telescope based on previous designs – the Hopkins rod lens system – which was incredible. He fell out with Imperial because they did not realise the importance of his invention. At this time, I had a contract with a small company in Germany called Karl-Storz, and so I brought Harold to the company because nobody would produce this for him in the UK. Karl-Storz, who was at this time employing six or seven people in a hut, agreed to do it for us and so he produced two telescopes: one for me and one for a very good Hungarian friend of his, George Percy, which started a lifelong relationship between us – Percy eventually became my mentor as well. I started clinical use with this instrument and initially we were pumping filtered air instead of CO2, which meant we couldn’t use electro-coagulation. Eventually I realized that if we used a non-combustible gas then we could use electrocautery.
I had the good fortune to be promoted to senior lecturer and there I met a very famous haematologist who would later become a professor of medicine in Oxford, Sir David Weatherall, who was very interested in my work. You see, in those days, patients with lymphomas needed a staging laparotomy, a great big incision, just to find the stage of their disease, which wasn’t very good. When he saw that I could produce pictures for him with minimal access, he made me, he really made me in Liverpool. And so this simple technology stopped an unnecessary operation which killed a lot of patients with advanced lymphoma.
Then it went on from there really, and it became more complex. I got major funding to start a group which, until recently, consisted of 20 or so people ranging from engineers, to chemists, to material scientists. I had the best multidisciplinary team and we did the best technology development in the whole of Europe as a university in Dundee. From 1998 until now, we have accumulated a wealth of experience and we also have what is known as ISO-134 certification, which states that whatever we produce as instruments can be directly used by industry clinically and are CE-marked. And so, that’s how it started: from a young person who witnessed elderly patients dying because they were unable to breath postoperatively due to pain, to making something that is minimal access surgery today.
It is called ‘minimally invasive surgery’ by many, but that is an incorrect term. Remember, you can kill with a needle: as soon as you puncture the skin, you can introduce infection. But my surgery was designed to reduce the trauma of access and that’s why its proper name is minimal access surgery. If you want to call it keyhole surgery, that’s crap.
How did the journey feel?
Q2: During the development of this technology, did you ever feel like you were on the verge of something? Or did it feel like you were in uncertain territory?
A2: Well, a lot of hurdles were put in our way, some quite well-deserved. I was ordered by the ethics committee to do many operations in animals, pigs specifically, to show that this technology was safe, which I knew it was. We lost something like 10 years and we should have been the first by far, but the French went and did it a year before us, because we had started 10 years earlier, but had to do 200 operations on pigs to show that I could remove the gallbladder safely. Now, I admit that these restrictions were necessary. I did think at the time though, why did it have to be 200 operations? Who decides the number? If you are already in a job as I was, as senior lecturer, and you got to teach surgery, you were pretty good with surgery as part of your work. So, to do that many operations, which initially used to take an hour and a half (nowadays, you can do that in a fraction of the time) was time-consuming. The other thing was, there was great resistance from the surgical community. Secondly, which was worse, was that people saw videos of our operations and thought “Oh, I could do that without training” which led to a period in which there were many disasters. That motivated me to institute the surgical skills unit to train people on how to do this type of surgery.
Current problems
Q3: What problem do you see in medicine currently that you feel the younger generation should be working on?
A3: I personally think that doctors do not get sufficient training in the safe use of technology. I know many surgeons whom I call ‘technologically illiterate’. They don’t know how to set up the tray for the operation, they don’t know how to remedy if things go wrong and they rely on technicians. To me, nobody, least of all surgeons, should use a technology that they can’t have total control over i.e. they know how it works, they can fix issues that arise etc. In surgical training, missing that aspect leads to misuse of technology. I personally believe there should be a degree in medical technology so that somebody who wants to be a surgeon could learn the safe use of these tools.
Hiring
Q4: You mentioned that you built a team of people consisting of chemists, engineers etc. What would you look for in someone joining your team?
A4: The most important thing: Are they good in their subject? Secondly, can they think out of the box, do they have the capacity for innovation? You see, when you have a team like I have, they challenge me all the time. Some of them will come up with an idea and we’ll discuss the idea so that by the time our discussion ends, it’s really totally changed so that it is now doable. Those two things are crucial to me.
Books
Q5: Lastly, do you have any favorite books or resources that you’d recommend? It does not need to be restricted to medicine alone.
A5: There is a book called ‘Human Error’ by James reason that changed my life and I think you should read it.