This document discusses the impact of new technologies in surgery, highlighting both benefits and risks. It summarizes the development of key technologies like laparoscopy, endoscopy, and stapling devices. While these technologies increased efficacy, safety, and improved surgical outcomes, they also pose hidden dangers. Costs have risen substantially without clear evidence of benefits. Additionally, overreliance on technology and industry influence can undermine appropriate, sustainable healthcare systems. The document calls for more rigorous evaluation of new technologies and adoption of sustainable, cost-effective models of medicine.

1. The impact of the new technologies
in surgery: lights an shadows
Appropriateness and Sustainability
Pier Paolo Dal Monte MD
Bologna
Italy
1° Congress of the
Eurasian Colorectal Technologies Association
Guangzhou
November 13-15. 2009

2. The more sophisticated the
machine, the more barbaric the
worker
Karl Marx

3. The new technologies in surgery
30 years that changed the world
The “technology tree”
New diagnostic tools
US,
CT,
MRI,
Digestive endoscopy
New surgical instruments
Staplers
Endoscopes
Haemostasis and dissecting devices
Minimally invasive instruments
Safety for “old procedures”
Feasibility for “new
procedures
Better indications
(precision, target)
(NOTES):
Efficacy
Safety
Less invasivity
Better results
Less trauma
Shorter hospital stay/faster recovery

4. 1) Imaging
New technologies
2) Suture/anastomosis: stapling devices
3) Access: Endoscopic surgery
minimally invasive surgery (laparoscopy)
digestive endoscopy
4) Haemostasis/dissection: physical (energy)
chemical/biological (glues)
5) Meshes/stents
6) New devices for proctological conditions
7) Frontiers: Robotic Surgery, NOTES, Single Access Laparoscopy

5. Suture/anastomosis: stapling devices
History
1946
V.F. Gudov: 1° vascular stapler
1960
Androsov, Belkin Kalinina: Cut and suture
staplers
Gastric resection
Perioperative mortality reduced from 10,4 to 3,6%
Anastomosis time: 50% less
Dehiscence reduced from 20-25% to 5-10%
Gritsman J.J. :Mechanical Suture by Soviet apparatus in gastric
resection Use in 4000 operations. Surgery 59 (5): 663-669, May 1966
70’s
(USSC)First single use devices

6. Suture/anastomosis: stapling devices
Advantages
• Standardisation of the technique
• Reduction of operative time
• Better feasibility for “difficult“ anastomoses
(oesophago-gastric, colo-anal)
• “Endo-staplers”: feasibility of laparoscopic colo-rectal
surgery
Disadvantages
• Cost
• Waste managment
• Not applicable as widely as the hand
suture

7. Access: Digestive endoscopy
1868, Kussmaul performed the first esophagogastroscopy on
a professional sword swallower, initiating efforts at
instrumentation of the gastrointestinal tract
1928-1932 Schindler-Wolf: semi-flexible gastroscope
1954 H.Hopkins- N.Kapany: fiber-optic image transmission
1957 Hirschovitz: 1° fibersope (gastroscope)
1969 Olympus: 1° colonoscope

8. Access: Digestive endoscopy
1) Accurate diagnosis
Image enhancement
EUS
2) Operative treatments
Haemostasis
ERCP
Excision
Dilatation
Palliation
Clips
Injective catheters
Argon Plasma
Laser
Sphincteretomes
balloons
Advantages

9. Access: Laparoscopy
1977, First Laparoscopic assisted appendicectomy was
performed by Dekok. Appendix was exteriorized and ligated
outside.
1983, Semm, a German gynaecologist, performed the first
laparoscopic appendicectomy.
1985, The first documented laparoscopic cholecystectomy
was performed by Erich Mühe in Germany in 1985.
1987, Phillipe Mouret, has got the credit to perform the first
laparoscopic cholecystectomy in Lyons, using video
technique. Cholecystectomy is the laparoscopic procedure
which revolutionized the general surgery

10. Access: Laparoscopy
Outcomes (colorectal cancer)
Equivalence LS-OS
In oncological clearance and cancer-related
mortality
Liang Y, Li G, Chen P, Yu J. Eur J Surg Oncol. 2008 Nov;34(11):1217-24
Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J.Cancer Treat Rev. 2008 Oct;34(6):498-504.
Abraham NS, Byrne CM, Young JM, Solomon MJ. NZ J Surg. 2007 Jul;77(7):508-16
Schwenk W, Haase O, Neudecker J, Müller JM.. Cochrane Database Syst Rev. 2005 Jul 20;(3)

11. Access: Laparoscopy
Outcomes (colorectal cancer)
Better outcomes for LS
Operation time: LS > OS (30-60min)
Blood loss: LS<OS
Pain: LS<OS
Bowel function: LS<OS (1-1,6 days)
Hospital stay: LS<OS (1,6-3,5 days)
General morbidity:LS<OS (24 vs 31%)
Postoperative hernias): LS<OS (13vs33% at 5years)
Kuhry E, Schwenk W, Gaupset R, Romild U, Bonjer J.Cancer Treat Rev. 2008 Oct;34(6):498-504.
Abraham NS, Byrne CM, Young JM, Solomon MJ. NZ J Surg. 2007 Jul;77(7):508-16
Schwenk W, Haase O, Neudecker J, Müller JM.. Cochrane Database Syst Rev. 2005 Jul 20;(3)
Laurent C, et al. Br J Surg. 2008 Jul;95(7):903-8.
Reza MM et al. Br J Surg. 2006 Aug;93(8):921-8
Guillou PJ, et al. Lancet. 2005 May 14-20;365(9472):1718-26

12. Access: Laparoscopy
Economics (colorectal surgery)
Comparable cost between lap and open access
Vignali et alAnn Surg. 2005 December; 242(6): 890–896.
Park et al.World J Surg (2007) 31:1827–1834
Noblett et al.Surg Endosc (2007) 21: 404–408
Dows et al.Dis Colon Rectum. 2007 Jun;50(6):908-19
…But this is true only for the countries with high
labour cost.

13. Haemostasis/dissection:
Phisical (energy)
•1926.First use of electrosurgical device (Harvey Cushing)
1980’s-1990’s
Computer controlled Bipolar electrosurgery
Ultrasound dissection
Argon Plasma coagulation
Laser
RF

14. Robotic surgery
In 1985 a robot, the PUMA 560 brain
biopsy using CT guidance.
In 1988, the PROBOT, developed at
Imperial College London, was used to
perform prostatic surgery.
Further development of robotic
systems was carried out by Intuitive
Surgical with the introduction of the da
Vinci Surgical System and Computer
Motion with the AESOP and the ZEUS
robotic surgical system

15. Advantages:???
Robotic surgery
Developement of a new approach with possible
Improvements in surgical technique
Possible applications in remote surgery
(war surgery, space)
Routinary use?: Expensive
>operating time
Organisation

16. Natural Orifice Transluminal Endoscopic Surgery
(NOTES):
Natural Orifice Transluminal Endoscopic Surgery
(NOTES) is an emerging experimental alternative to
conventional surgery that :
Eliminates abdominal incisions and incision-related
complications
Combining endoscopic and laparoscopic techniques
in order to access the peritoneal cavity by means of
mouth, anus, or vagina

17. NOTES: Potential advantages
Absence of incisional complications including pain,
hernias and external wound infections.
Novel advanced technologies and instruments must
be developed specifically for NOTES.
The most promising potential advantages:
development of new instruments both for
laparoscopy and digestive endoscopy

18. Assessment of the new technologies
Undiscussed
technique advancement
(revolutions): Endoscopy
Laparoscopy
Undiscussed
technical advancement: Staplers
New dissection/cauterisation
devices
Chemical/biological Haemostasis
Meshes/Stents
?:
Robotic
Notes

19. The technical progress have brought many
undoubted advantages .......
Safety for “old procedures”
Feasibility for “new
procedures
Better indications
(precision, target) Efficacy
Safety
Less invasivity
Better results
Less trauma
Shorter hospital stay/faster recovery
…but there are some shadows..

20. The hidden dangers of technology
“Surgical” issues
Different technical skills:
Different surgical training
Young surgeons sometimes are not
trained enough in “old techniques”
“Fashionable”: “New is better”
Acritical preference of the new
techniques

21. The hidden dangers of technology
“Surgical” issues
Tecnology “addiction”: Surgeons risk of relying too much
on the technical tools
Organisation problems: The new technologies require a
more complex organisation

22. The hidden dangers of technology
Ethical and economic issues
Industry “pressures”: Conflicts of interest
Biased studies (results,
pathophysiology)
Cost /benefits issues: Enthusiastic adoption of a new
technique before scientific
evidence
Increase of costs for healthcare: Tranfer of money from the
taxpayer to the industry
Non sustainability for the
system
Industry driven instead of surgeon driven technological progress

23. The hidden dangers of technology
Industry “pressures”: Conflicts of interest
Biased studies
(results, pathophysiology)
Example:
Is “rectal redundancy syndrome” just
another way to name haemorrhoids ?
(and related DRG)

24. The hidden dangers of technology
Cost /benefits issues: Enthusiastic adoption of a new
technique before scientific evidence
Faecal incontinence
Injectable bulking agents
Artificial anal sphincter
Sacral nerve stimulation
The introduction of new technology is encouraging, both in
the evaluation and treatment , and it is hoped will advance
these muchneeded procedures.
Despite this plethora of exciting advances, a stoma still
remains the best option in patients with severe fecal
incontinence
Jarrett ME, et al. Br J Surg 91(12):1559-1569, 2004

25. The hidden dangers of technology
Increase of costs for healthcare: Tranfer of money from the taxpayer
to the industry
Non sustainability for the system
In the United States the estimate is that from 40% to 50% of
cost increases can be traced to the technological factor,
similar in Europe.
The net result has been an average general system-wide cost
increase of 10%-15% a year for the past several years, and
with no end in sight
D. Callahan Sustainable Medicine: Two Models of Health Care
Giannino Bassetti Foundation - 2005

26. “Technological” Healthcare
The contemporary model is based on infinite
progress
The constant introduction of new, and usually
more expensive, technologies and the
intensified use of older technologies.
Unlimited, infinite, vision can not be paid for with
finite funds

27. Sustainability-Healthcare
Costs versus benefits (marginal returns)
In economics, diminishing marginal returns refers to how the
marginal contribution of a factor of production usually
decreases as more of the factor is used.
David Ricardo. On the Principles of Political Economy and Taxation (1817)
Diminishing returns to increasing complexity
J. Tainter, The collapse of complex society 1988)

28. Sustainability-Healthcare
Diminishing marginal returns
Productivity of the U.S. health care system, 1930-1982.
Productivity index = (Life expentancy)/(National health expenditures
as percent of GNP).
J.Tainter, The collapse of complex society ,1988

29. Health indicators in industrialized countries
Rank Country Infant
mortality
rate
(X/1,000)
Under-five
mortality
rate
(X/1,000)
3 Japan 3.2 4.2
4 Sweden 3.2 4.0
9 Switzerland 4.1 5.1
11 Belgium 4.2 5.3
12 France 4.2 5.2
13 Spain 4.2 5.3
14 Germany 4.3 5.4
16 Austria 4.4 5.4
17 Australia 4.4 5.6
19 Netherlands 4.7 5.9
22 United
Kingdom
4.8 6.0
23 Canada 4.8 5.9
25 Italy 5.0 6.1
28 Cuba 5.1 6.5
33 United States 6.3 7.8
Rank Country
Life expectancy
at birth (years)
1 Japan 82.6 79.0 86.1
4 Switzerland 81.7 79.0 84.2
5 Australia 81.2 78.9 83.6
6 Spain 80.9 77.7 84.2
7 Sweden 80.9 78.7 83.0
10 France 80.7 77.1 84.1
11 Canada 80.7 78.3 82.9
12 Italy 80.5 77.5 83.5
16 Austria 79.8 76.9 82.6
17 Netherlands 79.8 77.5 81.9
20 Belgium 79.4 76.5 82.3
22
United
Kingdom
79.4 77.2 81.6
23 Germany 79.4 76.5 82.1
37 Cuba 78.3 76.2 80.4
38 United States 78.2 75.6 80.8
United Nations: World Population Prospects,2006

30. Health expenditure versus life expectancy
Health Expenditure
Country % GNP Pro Capita (intl $)
2000 2006 2000 2006
USA 13,2 15,3 4570 6719
Switzerland 10,3 10,8 3265 4179
Belgium 9,1 9,9 2514 3673
Austria 9,9 10,2 2858 3608
Nederlands 8 9,4 2337 3481
Germany 10,3 10,6 2670 3465
France 10,1 11 2542 3420
Sweden 8,2 9,2 2283 3162
Australia 8,3 8,7 2271 3119
UK 7,1 8,2 1846 2815
Italy 8,1 9 2061 2631
Japan 7,7 8,1 1967 2581
Spain 7,2 8,4 1536 2461
Cuba 6,7 7,7 353 674
WHO: World Health Statistics 2009

31. The contemporary model
of scientific medicine
A. Goals
-- unlimited scientific progress and technological
innovation regardless of their long-term cost
–- medical progress and technological innovation
are allowed to set medical goals and to
change and redefine those goals

32. The contemporary model
of scientific medicine
B. Outcomes
Considerable medical progress and creation of
massive medical-industrial complex
Powerful bias toward:
-- cure rather than care
-- technological interventions rather than health
promotion/disease prevention

33. The contemporary model
of scientific medicine
Result:
Unsustainable economic pressures on all
health care systems

34. Conclusions
Technologies must be much more toughly
evaluated
Evaluation is generally aimed only at the
efficacy , not at its likely economic impact.
That impact needs to be evaluated as well

35. Conclusions
Sustainability
We do not have at present sustainable health care
systems in any country.
Constant medical progress, adding to costs, and
aging populations, also adding to cost, guarantees
they will be unsustainable
If medicine is unaffordable, it can not be equitably
distributed; only the wealthy will be able to get it.

36. A Sustainable system?
The quiet conscience is an
invention of the devil
Albert Schweitzer,
The philosophy of civilization
What about the rest of the World?

37. Rank Country
A Sustainable system?
Life expectancy at birth
Life expectancy at
birth (years)
Both Male Female
1 Japan 82.6 79.0 86.1
2 Hong Kong 82.2 79.4 85.1
3 Iceland 81.8 80.2 83.3
4 Switzerland 81.7 79.0 84.2
5 Australia 81.2 78.9 83.6
6 Spain 80.9 77.7 84.2
7 Sweden 80.9 78.7 83.0
8 Israel 80.7 78.5 82.8
9 Macau 80.7 78.5 82.8
10 France 80.7 77.1 84.1
Rank Country
Life expectancy at
birth (years)
Both Male Female
185 Rwanda 46.2 44.6 47.8
186 Liberia 45.7 44.8 46.6
187 Congo D.R.. 44.7 43.3 46.1
188 Afghanistan 43.8 43.9 43.8
189 Zimbabwe 43.5 44.1 42.6
191 Lesotho 42.6 42.9 42.3
192 Sierra Leone 42.6 41.0 44.1
193 Zambia 42.4 42.1 42.5
194 Mozambique 42.1 41.7 42.4
195 Swaziland 39.6 39.8 39.4
United Nations: World Population Prospects,2006

38. A Sustainable system?
Rank Country Infant
Infant mortality
mortality
rate
(X/1,000)
Under-five
mortality
rate
(X/1,000)
1 Sierra Leone 160.3 278.1
2 Afghanistan 157.0 235.4
3 Liberia 132.5 205.2
4 Angola 131.9 230.8
5 Mali 128.5 199.7
6 Chad 119.2 189.0
7 Cote d'Ivoire 116.9 183.2
8 Somalia 116.3 192.8
9 Congo, D.R. 113.5 195.9
10 Guinea-
Bissau
112.7 194.8
Rank Country Infant
World: 49.4 73.7
mortality
rate
(X/1,000)
Under-five
mortality
rate
(X/1,000)
186 Korea, South 4.1 4.8
187 Switzerland 4.1 5.1
188 Czech
Republic
3.8 4.8
189 Finland 3.7 4.7
190 Hong Kong 3.7 4.7
191 Norway 3.3 4.4
192 Sweden 3.2 4.0
193 Japan 3.2 4.2
194 Singapore 3.0 4.1
195 Iceland 2.9 3.9
United Nations: World Population Prospects,2006

39. Causes of death in developing and developed countries
Causes of death in
developing countries
A Sustainable system?
Number of deaths
Causes of death in
developed countries
Number of deaths
HIV-AIDS 2,678,000
Ischaemic heart
disease
3,512,000
Lower respiratory
infections
2,643,000
Cerebrovascular
disease
3,346,000
Ischaemic heart disease 2,484,000
Chronic obstructive
pulmonary disease
1,829,000
Diarrhoea 1,793,000
Lower respiratory
infections
1,180,000
Cerebrovascular disease 1,381,000 Lung cancer 938,000
Childhood diseases 1,217,000 Car accident 669,000
Malaria 1,103,000 Stomach cancer 657,000
Tuberculosis 1,021,000
Hypertensive heart
disease
635,000
Chronic obstructive
pulmonary disease
748,000 Tuberculosis 571,000
Measles 674,000 Suicide 499,000
Who 2009

40. A Sustainable system?
Tanzania: 50000:1
Zambia: 50000:1
Italy: 230:1
Cuba: 170:1

41. Sustainability of the “World
Healtcare system”?
Modern technological healthcare is a
reality only for 1/3 of the world
population…

42. …a small part of the
World is like this…
Can we call sustainable
a situation where…

43. …While a greater part
Is like this?

44. Technique has arrived at such a point in
its evolution that it is being transformed
and is progressing almost without
decisive intervention by man.
Jacques Ellul
La tecnique enju du siecle

45. Thank you for your
attention
Shadows