Single-incision Laparoscopic Surgery: Less is More

PRESENTATION of appreciation to Dr Stephen after his conference at Imperial Hotel, Kuching.

DR Stephen Chang is a general surgeon practising at Mount Elizabeth Hospital,

A happy man: The patient operated by Dr Stephen was happy
to only see one hole!

AN simple explanation of single incision laparoscopic surgery (SILS).

MEETING up with Dr Stephen Chang Kin Yong for an interview was a great honour as the Singaporean general surgeon practitioner pioneered the single incision laparoscopic surgery (SILS) in 2008. He was one of the first few in the world to publish his experience in single incision laparoscopic gallbladder surgery, liver resection and pancreas resection. Apart from that, he is also the key developer of the laparoscopic approach to hepatobiliary and pancreatic surgery and has been active in developing the living donor liver transplant (LDLT) programme at Mount Elizabeth Hospital, Singapore. Sharing his perspective of liver cancer, Dr Stephen shared his experience, and insights pertaining to using the SILS technique in curing liver cancer patients.

“The liver is a very important organ,” said Dr Stephen at the beginning of the interview, “There are very few organs in the body that can match the number of functions of the liver and we know that all the blood in our body must go through the liver to remove toxins in the blood hence making it not just a filter, but also a detoxification organ.”

Dr Stephen shared that the liver also produces protein for the body thus our liver is an essential organ in our human body, “Without it, a human cannot live.”

So, what happens if the liver develops cancers? “Well, the success of treatment depends a lot on the stage of the cancer. In the earliest stage, where there is only one small nodule, I can easily cut it out with a small incision at the belly button, and the patient is discharged the next day but,” he expressed with a cautioning tone and continued, “With liver cancer, there is usually no symptom and no pain at the early stages so health screening regularly is important.”

The cheerful doctor then shared his experience on a pair of brothers whom he managed to treat successfully among his patients. After performing the surgery to remove liver cancer from the younger brother, he was asked why did the cancer develop in his liver, Dr Stephen answered, “Because you have hepatitis B.”

And this younger brother then told Dr Stephen that his elder brother also has hepatitis B. “So I told him, ‘go and ask your brother to see me.’ After screening his brother, I found out that his brother also had cancer in his liver. I performed exactly the same surgery to remove it and so I ended up saving the brothers’ lives in a span of a few months.”

Hepatitis B – a silent liver killer Dr Stephen’s experience with the brothers did not stop there. Years after, the brothers brought an older brother to see him. This older brother did not know he had Hepatitis B and only came to see him when he developed symptoms. Unfortunately the liver tumour was at its last stage, “It was incurable, and within one month, he passed away,” the doctor said sorrowfully. He then disclosed that if a person is found to have hepatitis B, the individual must undergo liver screening every six months. His or her immediate family must also screen for hepatitis B.

The same goes for those who have done liver tumour surgery, “Even after liver surgery, the patient must be followed up closely too because there is still Hepatitis B virus living inside the rest of the liver and can therefore cause new tumors to form.” The Hepatitis B virus lurks within the liver and according to Dr Stephen, it is common amongst Asian, ergo we being part of the Asian continent that have the highest number of liver cancer patients in the world.

“The virus would hide inside the liver, and use the liver cells to multiply before circulating in the blood. While in the liver, it can cause two problems – firstly, it will harden the liver ; like an engine if you overwork it, it breaks down. Secondly, it can go into the liver cell’s gene and promote liver cancer production.”

Apart from Hepatitis B, as shared by Dr Stephen, the next liver killer in the world is fatty liver caused by fat accumulation on the liver and partly due to lack of exercise. “The fat will swell the liver up and cause inflammation.

This increases the risk of liver cancer and the problem is getting more common,” the concerned doctor mentioned. Single-incision laparoscopic surgery The friendly Dr Stephen shared a piece of liver surgery history stating that few liver surgeries were performed back in the 1960s, “Before that nobody dares to operate on the vascular organ, and even today, there is not enough liver surgeons in the world.” With the advances in technology, along with blessings of innovative ideas, Dr Stephen’s SILS technique is able not only to perform liver surgeries safely, but also to decrease post-operation pain whilst offering better cosmetic results.

“Minimally invasive surgery basically involves multiple small incisions instead of the traditional big cut. Thus there is less trauma to the patients’ skin and muscles. And thanks to technological improvements, we can now squeeze all the instruments into one small incision that is only 10 to 15 millimetres long,” Dr Stephen disclosed.

Currently, Dr Stephen can finish a simple SILS technique surgery in less than an hour but he revealed that when he first used the technique back in 2008 he was extremely anxious and the first surgery took him more than three hours to complete. He is grateful to God that he could develop the technique that can benefit mankind. He is also grateful to his first patient who was his own staff nurse.

“I was not confident so I operated on her very carefully and slowly. Before the surgery I promised her that at any point in time during the surgery, if I could not confidently finish the surgery with one hole technique, I will revert to the multiple keyholes technique that I have already performed thousands of times.”

He mentioned also that his nurse had seen him performing various operations in the past and had trusted herself to be under his care, “When she woke up and saw one hole only, she was so happy!” Dr Stephen exclaimed. In his early experience he would record his surgeries, and he would watch the video playback many times to improve the technique so as to minimise the patient’s time on the operating table. The doctor’s background Dr Stephen Chang is a general surgeon practising at Mount Elizabeth Hospital, Singapore. He is also the medical director of the liver programme at Mount Elizabeth Hospital. He sub-specialises in laparoscopic surgery, management of gallbladder, liver and pancreatic disease, and liver transplantations.