Doctor who shrunk the surgeon
About 60 per cent of surgeries in the UK are carried out through a minimal access approach. Much of the credit for keyhole surgery as we know it today goes to the surgeon-steady hands of Malta-born Sir Alfred Cuschieri, who told Cynthia Busuttil that, before being accepted, the procedure was actually frowned upon.
When a young Alfred Cuschieri started pondering the possibility of a type of surgery that drastically reduces trauma, his colleagues, and even superiors, laughed it off.
"It was actively discouraged. But when you tell a young man not to do something, he has to go out and do it," he says in a soft voice, his Maltese roots clearly distinguishable underneath his Scottish accent.
On paper his plan might sound easy: Develop technology that enables a surgeon to operate upon through a small cut. But in practice this was far from simple. Apart from the resistance from the surgical world - he was told to forget it if he wanted to be a surgeon; keyhole was something for the gynaecologists while surgeons performed big cuts and got inside the body - there was also the obvious hurdle. Cameras were way too big and getting them inside a patient's body would require more than a small cut.
"In my opinion, without the giant leap of technology to make cameras smaller, this would never have been possible."
That is not to say that before the technology was available there were no attempts at keyhole surgery. "With one hand the surgeon would hold a telescope that was put into the patient through a tube while operating with the other," he says with a chuckle, gesticulating what the process must have looked like.
Faced with these stumbling blocks, Sir Alfred started contacts with a number of people scattered across the globe, including Patrick Steptoe - part of the duo which developed in vitro fertilisation.
Trips to France and Germany - shrouded in secrecy and held during his vacation time - and contacts with a Hungarian researcher led Sir Alfred to a German instrument maker committed to develop the needed technology.
The first minimally invasive surgery was carried out in Britain in May 1987, at Ninewells Hospital in Dundee, following eight years of research by Sir Alfred and his team.
Despite the initial opposition, once the first surgeries took place, and patients started talking, the shadow of scepticism quickly lifted. "It was a different type of surgery, where the patient was not left with a scar and was out of hospital the following day. The second surgery was on a very important businessman who was off to New York on the Concorde for a meeting three days later."
And, yet, this achievement was followed by a period of great concern. "Surgeons thought they could do it without undergoing specialised training. The UK saw a number of disasters in 1988 and 1989, with some people even dying."
One of the victims was a personal friend of a noted lord who was very incensed at what was happening. But instead of trying to influence the authorities to put a stop on the procedures, Lord Wolfson offered the British government a major contribution of about £20 million provided the authorities agreed to match it.
"Those funds went towards the setting up of training centres for this kind of surgery, the first of which opened in Dundee in 1991. And from then, things started improving."
Sir Alfred explains that the surgeon's eye-to-hand coordination needs to be even more refined than when performing traditional surgery because he is operating from images rather than reality and not even looking at his hands. "Just try to eat without looking at your hands. This coordination between the eyes and the hands is not something that you are born with but something that you need to train for."
The clear enlarged images caused a new problem. Suddenly surgeons started to see bits of the anatomy they did not normally notice in ordinary open surgery, leading to misinterpretation and even damage to other organs.
"There was definitely a need for more training on laparoscopic anatomy. I think now the approach has matured and there are very few disasters."
In 2004, the Cuschieri Skills Centre, named after Sir Alfred, was opened at Ninewells Hospital, the first centre in Europe where surgeons could train through simulation programmes. Some 40 centres around the globe have been modified on the Cuschieri Skills Centre.
What originally triggered Sir Alfred's interest in minimal access surgery was his belief that patients suffered more because of the big incision rather than the surgery in itself. "Very often patients had a very big cut but very little was actually done inside. Traditional surgery was effective but it was not a kind form of treatment."
Coupled with advice from researcher David Annis, whom he describes as "his guru", that the outcome of medicine will only be improved by thinking outside the box, Sir Alfred decided to apply for a research grant. The rest is history and, nowadays, some 60 per cent of procedures carried out in the UK are done using the keyhole technique.
"I think the vast majority of surgery, with the exclusion of transplantation and trauma procedures, can be done this way."
The smaller cut also reduces the chances of post-operative infection. "It virtually abolished wound-related complications, including infections that cost a fortune to treat and delay hospital stays by an average of five days."
Keyhole surgery is not Sir Alfred's only passion and over the years the Maltese man - who was knighted in 1987 for his services to surgery - has worked on other projects, including collaboration with Sir David Lane on delivering the p53 gene into a tumour through the development of a special needle. The gene detects whether a cell has been damaged beyond repair and makes sure the cell dies. But in many tumours the protein is either absent or damaged, allowing the cancerous cell to keep on living and causing damage.
Although he admits that scientists are still a long way from curing cancer, "we are much closer".
Sir Alfred is also working on an alternative form of cancer treatment through which the tumour is not removed but destroyed in site through radio frequency heating or freezing. The idea behind this, he explains, is that a lot of tumour antigens are released over time and would generate an immune response to the tumour, in a similar way to vaccination. However, he continues, this still remains to be proven.
Looking back at his long career, what really makes him proud?
Sir Alfred thinks for a short time. "I don't know. I haven't planned my life. I think things came my way and I took the right decisions and was very lucky. I'm happy about the way things turned out."
Although he left Malta in the 1960s, soon after graduating from the University, Sir Alfred still feels Maltese. "You never forget your roots."
He left the island because he wanted to dedicate his life to the development of new surgery. And when Malta became independent in 1964, he had to choose between Maltese and British citizenship. "Since I had decided that my career lay in the UK, I chose British citizenship. But now that it is possible to hold dual citizenship, I intend to apply to get my Maltese one again."