The Next Generation

Lessons from the First Brigham "Lap Chole" in Training Future Surgeons

Eric Sheu, MD, PhD

By Eric Sheu, MD, PhD
PGY5, Department of Surgery

On February 22, 1990, in what is now a storage closet in the operating room suites, the first laparoscopic cholecystectomy at the Brigham was performed.  Neither operating surgeon had previously observed a laparoscopic cholecystectomy in person.  They did not practice the operation in a simulation center.  Yet, the operation was a success, and within a few months, 50 more "lap choles" were performed here at the Brigham.  

Twenty-seven years ago, the German surgeon Erich Muhe performed the first laparoscopic cholecystectomy. The success of this operation sparked a surge in the use of minimally invasive techniques in general surgery, reducing the morbidity of many operations without compromising outcomes. The story of the first Brigham lap chole illustrates the process of surgical innovation and spread and offers some lessons on how we train our future academic surgeons.  

In late 1989, the French presented a video of their laparoscopic cholecystectomy at the SAGES meeting with a follow up publication in the Annals of Surgery. Interest spread rapidly in the U.S., including at the Brigham with Dr. David Brooks and Dr. James Becker. Brooks and Becker arranged to visit a surgeon at the University of Maryland to observe him perform the operation.  The first visit was grounded by a Nor'easter that closed Logan.  A rescheduled attempt was scuttled when Maryland's chief of surgery bumped the scheduled case at the last minute for his own urgent case.

The winter forecast must have been bleak, as Brooks and Becker decided to sign up their first patient anyways.  Brooks had watched several VHS videos of other surgeons performing the operation.  With that preparation, they dove in. The operation took six hours, as they learned to operate in a new two-dimensional video-scopic world with relatively primitive instruments and optics. Nevertheless, the operation and patient both fared well. News crews followed and soon thereafter, patients were lining up for the procedure.  By the year's end, Brooks was performing virtually all of his gallbladders laparoscopically, and the staff throughout the General and GI Surgery division were adopting the technique, such that half of all the procedures at the Brigham were done laparoscopically.  

Surgery's history is marked with similar forward surges as surgical innovators pushed the border. Many Brigham trainees have led these advances: Dr. Robert Gross, performing the first PDA ligation at Children's Hospital while his chief was out of town; Dr. Robert Bartlett, taking ECMO from the lab to bedside; and, of course, Dr. Joseph Murray, leader of the first successful organ transplant. When you speak to Brooks today, he traces the confidence to try that first lap chole directly to his training as a Brigham "super" chief, a defining year spent after residency where one was responsible for all the ward cases.  Many former super chiefs recount performing nearly 1,000 cases, of all types, in that single year. 

Today, the trend in surgical training and practice is towards earlier and greater specialization.  Studies suggest that higher volume surgeons performing the same few procedures leads to improved patient outcomes.  As this dogma spreads, general surgery is going out the door, with fast tracking into specialties ascendant.  After all, does a future cardiac surgeon really need to spend years learning to remove gallbladders with a laparoscope?

Yet I wonder if the pendulum has swung too far towards specialization.  The broad training of past years laid the foundation from which innovation sprung.  Brooks, like other general surgeons, first gained exposure to endo- and laparoscopic techniques while rotating in gynecology as a resident. All surgeons have to learn new techniques and operations through their career.  Many senior surgeons I speak with estimate that over half of the operations common to their practice now, they had never seen, much less performed, as residents.  Is a narrow, concentrated training best to prepare you to learn operations that don't yet exist 5, 10, even 15 years out of residency on your own?

When Muhe finished that first lap chole just over a quarter century ago, I doubt he anticipated the subsequent snowball of advances that now define our modern operating room.  I'm happy to say that I too can't quite imagine what cases I'll be doing or what the OR will look like in 25 years.  But as I enter this, my final year of general surgery residency, I am confident that the Brigham has prepared my classmates and me to tackle the new challenges that await us around the corner.