From 30-second film to micro-incision, Vietnam reaches out to the world

(Dan Tri) - Vietnam is currently one of two countries in the world reporting successful single-port laparoscopic surgery to treat choledochal cysts.

In 2011, a 30-second video clip showing part of a single-hole laparoscopic choledochal cyst surgery was shown by a Chinese doctor at a conference, surprising Associate Professor, Dr. Tran Ngoc Son, Deputy Director of the Saint Paul General Hospital (who was then working at the National Children's Hospital) as well as medical experts from many countries. For the first time, a choledochal cyst was treated through a single incision the length of a finger, while even large medical facilities in Europe still had to perform open surgery with an incision covering 2/3 of the abdomen. Just one year later, Vietnam reported to the world about the first successful single-hole laparoscopic choledochal cyst surgery. After a decade, nearly 300 children with the most common surgically treated hepatobiliary disease in children have been operated on using this advanced technique. Vietnam is also one of two countries in the world that have reported successful single-port laparoscopic surgery to treat choledochal cysts. The journey to make Vietnam's mark on the world medical map, as described by Associate Professor, Dr. Tran Ngoc Son, began on a solid foundation of laparoscopic surgery built by many generations of surgeons and advanced with the desire to help patients "have surgery as if not surgery", with the least trauma and the fastest possible recovery.

The fact that an Australian family brought their daughter to Vietnam for surgery surprised many people. It was even more surprising when people learned that an internal medicine doctor was the world's leading expert in this method. Could you share how you got involved with the surgical technique that made your name? Associate Professor, Dr. Tran Ngoc Son: First of all, we need to know that in the medical field, Vietnam may be behind in modern technology, mostly due to economic conditions, but the hands and minds of Vietnamese doctors are not inferior to those of developed countries. In general, in terms of endoscopic surgery in children, Vietnam is very famous in the world. The pioneer in developing pediatric endoscopic surgery in Vietnam is Professor, Dr. Nguyen Thanh Liem (Former Director of the National Children's Hospital). In the late 90s, Professor Liem began to apply laparoscopic surgery in pediatrics. By the early 2000s, this field had developed brilliantly and brought Vietnam to the top of the world, despite being behind. I was fortunate to grow up in such a medical field and even luckier that Professor Nguyen Thanh Liem was also my teacher. When I went with Professor Liem to attend an international medical conference in 2011, the video clip about single-hole laparoscopic surgery to treat choledochal cysts immediately impressed me and I wanted to bring it back to Vietnam. At that time, even up to now, to treat choledochal cysts in many countries, including Europe and the US, open surgery is still indicated. For a child, surgery would be a huge trauma, when making an incision 2/3 of the abdominal cavity, cutting through many muscles is very painful, making the recovery process slow and potentially posing many risks of complications. In Vietnam at that time, conventional laparoscopic surgery was successful in treating choledochal cysts in children. It was Professor Liem who made Vietnam the third country in the world to successfully apply this technique. Regarding surgical treatment of choledochal cysts, open surgery is a difficult and complicated surgery, requiring many movements. For example, the doctor must remove the gallbladder, then cut the dilated common bile duct into a cyst, cut the dilated common bile duct into a cyst, then bring the intestinal loop up to reconnect with the common hepatic duct above to collect bile. Treating choledochal cysts with conventional laparoscopic surgery is a big step forward compared to open surgery, when only 4 incisions of a few centimeters are needed. So being able to bring back a single endoscopic incision is a new development in the treatment of this disease.

It has been more than a decade since the single-port laparoscopic surgery to treat choledochal cysts was announced, why has only Vietnam mastered this technique? Associate Professor, Dr. Tran Ngoc Son: It must be affirmed that single-port laparoscopic surgery in general and single-port laparoscopic surgery to treat choledochal cysts is a much more difficult path than conventional laparoscopic surgery. We all know that when working, people must create an angle with their hands to be able to operate easily, and when performing surgery, it will help to make it easier to handle so that the instruments do not touch each other. However, when there is only one "entrance". The instruments are almost placed parallel. The hands are now tied, making the operation especially difficult. With such a narrow space, hand operations must be carefully calculated and achieve millimeter accuracy. If there is just a few millimeters off, the instruments will touch each other and get stuck. For example, with conventional laparoscopy, resection operations are often easier than reconstruction. For example, gallbladder removal is much easier than biliary reconstruction. The anastomosis technique in conventional laparoscopy requires highly skilled surgeons to perform. With single port laparoscopy, the anastomosis is much more difficult and is one of the most difficult challenges.

When suturing, the needle must be placed perpendicular to the suture position. However, as I have shared, single-hole endoscopic instruments must be placed parallel. Therefore, each stitch is exchanged for the doctor's high concentration as well as many years of experience. Since 2009, some authors have introduced single-incision endoscopy in adults. However, learning and developing this technique is not easy. Therefore, up to today, single-hole endoscopy is not popular in the world. Even at our hospital, there are many foreign medical delegations coming to study this technique, but the rate of bringing it back to practice is not high. As for single-hole endoscopy to treat choledochal cysts, no unit has yet completed the study and implemented it. Why did you decide to take this path that you knew was very difficult? Associate Professor, Dr. Tran Ngoc Son: Vietnam is the world's leading country in choledochal cyst endoscopy. There is no reason why the world can do it but we can't? This is the question I asked myself the first time I witnessed this technique and I asked myself many times when I encountered any obstacle on my journey to master single port laparoscopic surgery to treat choledochal cysts. This surgery brings great benefits to patients. If it requires expensive machinery or technology, we would be helpless, but in reality, the biggest challenge is skill and technique. This is something that can be achieved through practice, it is not impossible. So why not do it?

The journey to master this technique must not have been easy for you, especially when all the "curriculum" is just a 30-second "highlight" video? Associate Professor, Dr. Tran Ngoc Son: In fact, a doctor with a solid foundation in endoscopy only needs that short video to immediately understand the idea of ​​this method. The difficulty is the process of training the hands, as well as having a plan to deal with each specific problem that arises during the surgery. It took me a long time to research, learn and outline my own formulas to perform familiar tasks in endoscopy but with completely different postures and movements. At the end of 2011, my colleagues and I at the National Children's Hospital performed the first single-hole laparoscopic surgery to treat a choledochal cyst in a child. The difficulty came from the very beginning, when the two endoscopic instruments "squeezed" into an incision only 2cm long, so every time I controlled them, they touched and pulled each other. In a chain reaction, the rigid instruments continued to cause abdominal air leakage.

It is important to note that during laparoscopic surgery, we have to pump CO2 gas into the abdominal cavity to help the cavity expand so that it is easier to control the instruments. Only a short time after the instruments entered, the patient's abdomen was flat. This is a problem that conventional laparoscopy has never encountered. The cramped surgical field makes controlling the instruments more difficult. This surgery requires great determination and effort from not only the surgeon but also the entire team, from the support positions to the anesthetists. Wherever there is a problem, we will solve it. Each technique and operation was gradually perfected right from those first surgeries. When the instruments collided with each other or got stuck, I tried to change the angle of the instruments or even change the path to the organs. In the case of air leakage, we tried to rearrange the trocar position and combine it with suturing the hole. The surgery took about 6 hours, almost twice as long as a conventional laparoscopic surgery. Although the surgery was challenging and lengthy, the results were excellent. The patient progressed quickly, had an excellent recovery rate, and had no anastomotic leaks. The success of this surgery was both a motivation and a launching pad in the journey to master single-port laparoscopic surgery for choledochal cysts.

The surgical procedure is perfected as it is now, requiring the standardization of every small detail such as: trocar position, arrangement and movement of instruments to avoid collision, using hanging sutures to replace the third endoscopic instrument, cutting the cyst from bottom to top instead of cutting in half in the middle... Up to now, we have performed more than 300 single-hole laparoscopic surgeries to treat choledochal cysts for pediatric patients. The surgery time has been shortened from 6 hours to only about 3 hours, equivalent to normal laparoscopic surgery. Not stopping at treating choledochal cysts, single-hole laparoscopic surgery has been and is being applied by us to treat many other diseases, bringing great value to patients such as: appendectomy, cholecystectomy, ovarian cysts, treatment of congenital duodenal obstruction, partial nephrectomy, non-functional nephrectomy, abdominal cystectomy...

To perform single-hole endoscopy, does the hospital have to use additional specialized equipment and tools? Associate Professor, Dr. Tran Ngoc Son: I want to talk more broadly about single-hole endoscopy, there are many points from our equipment to our process that are different from the world. In other words, to reach the goal of mastering single-hole endoscopy, we choose a different path from our colleagues in the world. This path is optimized for 3 factors: Suitable for equipment conditions in Vietnam, minimizing treatment costs so that many patients have the opportunity to access it, and finally, easiest to transfer and replicate. In fact, to overcome the difficulties of single-hole endoscopy, many methods have been applied in the world. Many facilities will use a specialized port for single-hole endoscopy. However, this port costs about 400 USD, which will create an additional economic burden for patients. Some other authors use the technique of crossing instruments to increase flexibility. Thus, the instrument in the right hand when entering the abdomen will be on the left side and vice versa. The disadvantage of this method is that it will be completely opposite to the normal laparoscopic operation. Therefore, it is very difficult to get used to and master the operation, which means it is difficult to transfer and replicate. Some places still use instruments specifically designed for single-hole endoscopy such as articulated endoscopes or like the author of single-hole endoscopy for treating choledochal cysts using a 70cm long endoscope (usually only 50cm). However, these devices are also very expensive.

With our method, all equipment is the same as conventional endoscopy, no additional investment is required. Therefore, the cost of single-hole endoscopy is not increased compared to conventional endoscopy. In addition, the instruments used during operation still maintain the triangle principle quite similar to conventional endoscopy, making it easier for doctors to access. For a doctor with experience in endoscopic surgery, after only about 20 single-hole endoscopic surgeries, they can almost master it.

In single-hole laparoscopic surgeries, the doctor makes an incision right at the patient's navel. Why did he choose this special "gate"? Associate Professor, Dr. Tran Ngoc Son: Single-hole laparoscopy was born from the goal of minimizing invasion to the patient's body, so choosing the navel as the route to penetrate inside will help achieve this goal even better. Around the year 2000, there was a trend of laparoscopic surgery through natural holes. For example, inserting instruments through the vagina; poking a hole in the fornix to enter the abdomen and cut the gallbladder or other organs. Another entrance is the mouth; instruments go through the mouth and then create a hole in the stomach to go deeper; or enter through the rectum... This method was once popular because it helped not leave scars on the outside, ensuring aesthetics for the patient. However, having to puncture the fornix or stomach causes trauma and leaves certain complications.

The second trend, which I support and am applying, is to penetrate through the natural opening of the fetal period, typically the navel. The navel itself is a scar. When we make an incision in the navel, the surgical scar will be covered by the navel scar, helping the patient "have surgery as if they had not had surgery". For the patient, this is a great value. There are also many authors who argue that the navel is a dirty and difficult place to cut, which can easily cause pain and infection. However, the actual medical evidence shows that this is not true. The clearest evidence is that in more than 300 single-hole endoscopic treatments for choledochal cysts that we performed through an incision in the navel, the complication rate was only 1% and there were no serious complications, deaths, and no one suffered damage to other organs. This is an exceptionally low complication rate. Follow-up after 6-8 years in these patients still shows very good results. We would also like to thank the leaders of the Ministry of Health , Hanoi Department of Health, and the Hospital Board of Directors for creating favorable conditions and supporting this surgical method.

The fact that an Australian family chose Vietnam as the place for their daughter's surgery after consulting with other developed countries is a testament to the fact that Vietnamese healthcare can be on par with other countries in the region and the world. So, according to the doctor, what do we need to do to have more "Australian families" like that come to Vietnam for medical examination and treatment? Associate Professor, Dr. Tran Ngoc Son: We often worry about medical services that are difficult to meet the requirements of foreigners. However, in reality, we can see that the Australian family was very satisfied with the service and experience during nearly a week of staying at our hospital. In terms of expertise, we can be completely confident that the level of Vietnamese doctors is not inferior to those in other countries in the world. Especially in surgical fields such as endoscopic surgery and vascular intervention, we are doing very well and have a reputation. In addition, the field of traditional medicine is also a typical strength of Vietnam, especially in the treatment of chronic diseases. We provide good quality treatment comparable to developed countries in the region and the world, while the cost is very cheap. To make a simple comparison, without insurance, a hospital bed in the US costs 5,000-6,000 USD per day, and an intensive care bed costs up to 14,000-15,000 USD.

A surgery in the US costs from several thousand to tens of thousands of USD while in Vietnam it only costs a few hundred USD. In general, medical expenses in our country are usually 7-10 times cheaper than in the US. When compared to a country in the region like Singapore, our costs are also much cheaper. Many people I know who live in Western countries often like to return to Vietnam for dental services. They share that a trip back to Vietnam to have fun and have dental work done is still much cheaper than doing it abroad. However, for Vietnam to attract patients around the world or become a destination for "medical tourism ", we still lack an important link, which is marketing. Vietnamese doctors are good but only people in the industry and professionals know about it. Our services are good, the cost is very cheap but only patients who have actually experienced it, like the Australian family, know about it. And these are just isolated cases, a small number. Like in Singapore, they are very successful in providing a complete service package for foreign patients. They have a dedicated channel to market to foreign patients in need and act as a focal point for patients AZ: Round-trip transportation, connecting with doctors, completing procedures... Another example is right in Vietnam, there are many French companies specializing in finding potential customers, then connecting to bring French doctors to Vietnam for surgery. Thus, we have been and are doing good professional work, but how to let patients around the world know about that good work requires the participation of many parties, not just the medical industry. I would like to sincerely thank you, Associate Professor, for this conversation!

Content: Bao Trung - Minh Nhat

Design: Tuan Huy

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