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Laparoscopic Urology in Borneo
Laparoscopic Urology in Borneo
Laparoscopic Urology in Borneo
Laparoscopic Urology in Borneo
Laparoscopic Urology in Borneo
Laparoscopic Urology in Borneo
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Laparoscopic Urology in Borneo


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  • 1. Commonwealth of Urology Laparoscopic Urology in Borneo Dr Teng Aik Ong MBBS, FRCSI, MS, FEBU, FRCS (Urol) Email; 1
  • 2. Commonwealth of Urology Introduction In July 2008, Sarawak General Hospital, Kuching, Malaysia, had the honour of inviting Dr Barry Maraj, consultant urologist, London, to visit the Unit of Urology in Sarawak General Hospital for one week. Dr Barry Maraj is a friend of Dr G.C. Teh (Fig 1), Head of Urological Service, Sarawak. They first met during an advanced laparoscopic training course in Strasbourg in 2006. Like Dr Teh, Dr Maraj was the first urologist to introduce and practice major laparoscopic surgery at his hospital. The aim of the visit was to share ideas and experience in laparoscopic surgery in urology. It was hoped that this exercise of “the East meeting the West” would enrich both the parties and promote long term collaboration. Dr Maraj is already an honorary member of the Caribbean Urology Association (CURA) and attends on a regular basis as the senior faculty member at their laparoscopic workshops. Fig 2. A view of distant mountains Fig 1. Dr Barry Maraj (right) and Dr from Sarawak General Hospital. G.C. Teh. Background Sarawak is the largest state in Malaysia situated at the north-western part of the Borneo Island. It has a population of over 2.4 million spreading across an area of 48,000 square miles which is mostly covered by virgin tropical jungle. Sarawak General Hospital, situated in Kuching (Fig 2), the capital city of Sarawak, is the largest hospital in the state. Dr G. C. Teh is the only consultant urologist in the public service sector who serves the whole state for the past 10 years. There are two other urologists in Kuching: one in private practice (Dr Clarence C.M. Lei, former President of the Malaysian Urological Association) and one in the University Malaysia Sarawak (Dr T.A. Ong). Sarawak General Hospital is a recognized urological training centre for the Board of Urology, Malaysia. Currently, there are two advanced urology trainees in Sarawak General Hospital (Dr A. Balan and Dr M.S. Lim). Despite the geographical disadvantage of being in a relatively “far away” land of Borneo, Dr Teh and his team had developed laparoscopic urology in Sarawak in the past few years. More than 150 laparoscopic urological procedures had been performed in Sarawak General Hospital since the second half of 2004. With the recent acquisition of the Da Vinci Robotic System in May 2008, the Urology Unit of Sarawak General Hospital had performed more than 10 robotic assisted urological procedures within the first six weeks. 2
  • 3. Commonwealth of Urology Advanced Laparoscopic Workshop In conjunction with Dr Barry Maraj’s visit, the Unit of Urology had organized a five-day workshop on advanced laparoscopy in urology (7-11 July 2008). Additionally, the workshop incorporated teaching geared towards senior urological trainees and theatre nurses involved in laparoscopic surgery. We, in the Unit of Urology, of course had to do a lot of negotiating and “sweet-talking” in order to secure theatre slots from the other surgical disciplines for the whole week. I am sure you, as a reader, could easily appreciate that this was not an easy task! The programme was as followed: Date Activities 7 July, Monday Lectures: Physiology of pneumoperitoneum, patient preparation & positioning, ports placement, basic laparoscopic instruments, energy sources, basics in robotic surgery and video demonstration of common laparoscopic urology procedures. (Various speakers: Dr Barry Maraj and Dr G.C. Teh and Dr M.S. Lim) 8 July, Tuesday Live surgery: Three cases of laparoscopic nephrectomies for non- functioning kidneys (Fig 3 & 4) (Two retroperitoneal and one transperitoneal approaches) 9 July, Wednesday Live surgery: Two cases of laparoscopic pyeloplasty (Fig 5 & 6) (of which one was performed with the Da Vinci robot) 10 July, Thursday Live Surgery: Two cases of laparoscopic adrenalectomies (one for Cushing’s syndrome, operated with the Da Vinci robot, Fig 7; another for Conn’s syndrome, Fig 8). Video discussions: Laparoscopic techniques. 11 July, Friday Hospital CME Lecture: “Surgical training in UK” by Dr Barry Maraj. Live Surgery: One case of robot assisted retroperitoneal radical prostatectomy (Fig 9 & 10). The workshop was chaired and run by Dr G.C. Teh who also performed both laparoscopic and robotic surgeries. During the week, Dr Barry Maraj: • Performed a retroperitoneal nephrectomy and a retroperitoneal adrenalectomy (for Conn’s Syndrome). He demonstrated the tricks of retroperitoneal laparoscopy to the trainees who were most impressed by his delicate skills. • Demonstrated common laparoscopic procedures performed by him in Whittington Hospital, London. This offered a different perspective compared to the practice in Sarawak General Hospital. 3
  • 4. Commonwealth of Urology • Shared his experience and knowledge on the various aspects of the Intercollegiate FRCS Urology examination. The Malaysian Board of Urology had a well-established assessment system for Malaysian urology trainees since 2000. The official training period for Malaysian urologist is four year. All Malaysian urology trainees are required to pass the board examination at the end of the 3rd year of training (consists of MCQ, long and short case viva). For further improvement and bench-marking, the Malaysian Board of Urology is currently working closely with Royal College of Physicians and Surgeons of Glasgow to introduce some elements of the Intercollegiate FRCS Urology examination into the Malaysian assessment system. The input from Dr Barry Maraj was indeed very timely for Malaysian trainees as the formats of Malaysia and UK questions are very different. • Delivered a Friday Common CME Lecture on “Surgical training in the UK”. Dr Barry Maraj spoke in front of a packed lecture hall on the various issues pertaining to surgical training in UK, starting from the “pre-Calman” to Calman, then “post-Calman” reforms. Of course, the problems and abandonment of MTAS (the Medical Training Application Service) was also discussed. This lecture delivered an important message to Malaysian policy makers to learn from the success and failure of the UK system in order not to make similar mistakes (do not re-invent the wheel!). Fig 3. Renogram Fig 4. Laparoscopic retroperitoneal nephrectomy by Dr confirming non function Barry Maraj. of right kidney from chronic pyelonephritis. Fig 5. Retrograde pyelogram; dilated renal pelvis of ig 6. Obstructive renogram (green line: right F kidney) 4
  • 5. Commonwealth of Urology Fig 7. CT showing right adrenal tumour Fig 8. Specimen of adrenal tumour (Conn’s (Cushing’s syndrome). syndrome). Fig 9. Robotic assisted radical retropubic Fig 10. Dr Barry Maraj and Dr Lei (left) at the prostatectomy by Dr Teh (in console.) Da Vinci Robot console. During the Live Surgery workshop, Dr Barry Maraj also had the opportunity to witness a couple of emergency urological procedures in a neighbouring theatre, i.e. a case of laparoscopic Tenchkoff catheter readjustment (Fig 11 & 12) and a case of encrustation of a 5-month old JJ stent (Fig 13 & 14). Dr Barry Maraj was informed that stone disease is the number one urological problem in Malaysia. In fact, ALL urology trainees in Malaysia will complete their training fully competent in Endourology. On top of being “good plumbers”, we have to be great “stone drillers” as well! Fig 11. Tenchkoff catheter entrapped in Fig 12. Laparoscopically freed Tenchkoff catheter stitched above the bladder (by Dr 5 M.S. Lim).
  • 6. Commonwealth of Urology Fig 13. Encrusted and migrated JJ Fig 14. Freed JJ stent (by Dr A. Balan). stent. Conclusion of Visit The week of Dr Barry Maraj’s visit coincided with the Rain Forest Music Festival in Kuching. This is a yearly event that showcases traditional and modern music from countries across the world. With the huge influx of foreign tourists, Dr Barry Maraj was indeed very lucky to secure a hotel room for a week! On the other hand, I am sure Dr Barry Maraj had enjoyed the festive atmosphere surrounding the city of Kuching. The urology team of Sarawak General Hospital benefited significantly from Dr Barry Maraj’s visit (Fig 15 & 16). The exchange of ideas was certainly a stimulating experience. We are looking forward to many more visits of similar nature in the future by foreign experts to enhance the teaching and learning of the “art of urology”. Fig 15. Dr Barry Maraj delivering his lecture Fig 16. The whole team (from right to left): Dr on “Surgical Training in UK”. Chew (SHO in urology), Dr Balan, Dr Lei, Dr Teh, Dr Maraj, Dr Ong, Dr Lim, Mr Hamka (senior medical assistant in urology). 6