An Open and Shut Case

The Story of Keyhole or Minimally Invasive Surgery

John Wickham

• Publisher: WSPC (EUROPE)
• Year: 2017
• ISBN:
  9781786341747
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

-->

Keyhole surgery has been made possible through the rapid development of various medical technologies, first pioneered in the 1970s. Revolutionary in the way it reduced the risk, surgical complications, healing time and scarring compared to open surgery, keyhole surgery soon became the preferred method throughout many surgical specialities.

Here, John Wickham, the 'godfather' of robotic surgery, reflects on a life spent in research, discovery and struggle for innovation in order to make keyhole surgery widespread, accessible and available to patients. An Open and Shut Case tracks the evolution of surgery in the later parts of the 20th century, from initial surgical training in the 1960s to the rapid growth in the field of minimally invasive techniques throughout the 1970s and 80s in many specialities, precursors to the techniques used today. It concludes with a look at the effect of the National Health Service on the practice of medicine and nursing in the UK throughout this time.

Perfect for surgeons and those interested in the history of surgery and surgical techniques, it also focusses on lessons learnt, both good and bad, when dealing with the management of public health.

--> Contents:

• How, Why, What?:
  • School and War
  • National Service in the Royal Air Force
  • Undergraduate Training
  • House Appointment at Hill End Hospital, St Albans Herts
  • The Anatomy Demonstrator
  • Junior Surgical Registrar
  • Middle Grade Surgical Registrar
  • Senior Surgical Registrar
  • Fulbright Scholar USA
  • Resident Surgical Officer St Paul's Hospital
• The Adventures of the Fully Trained Surgeon!:
  • Consultant Urologist, St Bartholomew's Hospital and St Paul's Hospital, London
  • Synopsis of the Various Phases of the Development of My Surgical Competence
  • The Building of the Department of Urology, St Bartholomew's Hospital and Start of Private Practice
  • Ancillary Events: Regional Renal Hypothermia and the Intrarenal Society
  • Consultant Urologist, King Edward VII Hospital and the London Clinic, Civilian Consultant to the Royal Air Force
  • Dialysis and Renal Transplantation
  • Disaster: Acute Pancreatitis
  • Personal Life in the 1980s and Stowe Maries, Westcott, Surrey
  • The Percutaneous Nephrolithotomy and the Endourology Society and Courses at the Institute of Urology
  • A Slight Deviation — Gall Stones
  • The Dornier Extracorporeal Lithotripter, The Academic Unit, University of London and Retirement from Barts
  • Instalment of the Dornier Lithotripter at Welbeck Street, London and the Stone Centre
  • Minimally Invasive Surgery and the Organisation of the Academic Unit
  • The Concept of Minimally Invasive Surgery
  • The Society of Minimally Invasive Surgery, Then Therapy! SMIT
  • Closure of the Stone Centre and the Move to Devonshire Place and the London Clinic
  • Closure of St Peter's Hospital and the Institute of Urology and Transfer of the Rump to the Middlesex Hospital
  • Guy's Hospital: A New Lease of Life
  • The Probot
  • Postretirement from the NHS and Spreading the Word on Minimally Invasive Surgery
  • Syclix — Now What Was I to do With My Time?
  • The Answers to the Initial Three Questions
  • The National Health Service and Its Impact on Medical Ethics
  • The Final Words

--> -->
Readership: Perfect for surgeons and those interested in the history of surgery and surgical techniques, as well as health service policy makers and managers.
-->Keyhole Surgery;Robotic Surgery;National Health Service;John Wickham;St Bartholomew's Hospital;St Paul's Hospital;Surgeon;Surgical Education0

PART I

How, Why, What?

Since retiring, I have been asked on several occasions three questions:

Firstly, why did you become a surgeon? The short answer is — Not by any deliberate plan, but by following a path that spontaneously appeared in front of me.

Secondly, how did you become a surgeon? The short answer — With a little difficulty and effort.

Thirdly, what was it like to be a surgeon? The short answer — The most truly satisfying combination of a practical and intellectual activity that I can conceive and that I had the privilege to participate in.

The long answers deserve a degree of expansion and require a personal biographical record which at times may be boring, but hopefully may be interesting. The reader must be the judge.

The period that I record refers to the four decades when I worked in Medicine and Surgery in various capacities from 1950 to the 1990s.

Much has been written of the developments in surgery arising from military experiences during the two world wars of 1914–1918 and 1939–1945, but I refer to events that I experienced in United Kingdom civilian practice.

This period coincides with the establishment of the United Kingdom National Health Service and the changes in medical and nursing practice that this induced.

Chapter 1

School and War

Firstly, let me share my earlier background and how I was steered into a medical career.

No one in my family had been medically qualified although several had been in the nursing profession. I was born in 1927 in Chichester, West Sussex to a middle class family. My father was involved in what would now be called Event Management, namely the organisation of social events such as wedding parties, garden parties, racing parties, balls and other similar events. The business was based in West Sussex in Chichester, and had other branches in Bognor Regis, and Littlehampton while my grandfather conducted the other part of the organisation in Surrey with facilities based in Weybridge, Reigate and Dorking.

It was a complete disaster in 1931–1933 when both my grandfather and father died within 18 months of each other bringing the whole organisation to a sudden halt. When all was sorted out, there was a small income for grandmother and mother which just managed to achieve financial stability.

After my father died at the age of 42 from pneumonia and pulmonary embolism, I lived with my widowed mother in a flat on the seafront in Littlehampton in Sussex (see Fig. 1.1) from 1937 until we moved away from the seafront in 1941 because of coastal bombing and other military events. For instance, two large naval guns were mounted on the promenade directly opposite to our flat which on the two occasions they were fired acoustically shattered a number of windows on the seafront houses. A second event which galvanised my mother and thrilled me was the sight from our front window of a Messerschmitt Bf109 followed closely by two Hurricanes at about 200 ft which had to pull up to avoid buildings at the end of the harbour! Few memories remain of these years, but a feeling of sadness seemed to pervade the family home. One other complicating factor comes to mind. I apparently developed ringworm of the scalp from putting on the school cap of a child suffering from the disease. My poor mother became frantic as all the medication appeared useless. An aunt who was a Sister at the London Hospital consulted a Dermatologist who recommended a course of epilation radiotherapy. My mother had to sign a declaration that if no hair grew again, the hospital would not be responsible. I had the deep X-ray treatment and I was cured and happily my hair grew again until my early twenties when it gradually disappeared again. As one of my chiefs remarked being bald would put another £50 on any consultation in Harley Street! This was much later.

Fig. 1.1. South Terrace, Littlehampton, Sussex.

I had attended a rather indifferent local preparatory school aged 8–9 and any thought of public school to follow was not possible. To my surprise, I managed to pass the entrance examination to Chichester High School for Boys in 1939, a Grammar school set up by the Sussex County Authorities in 1922. The staff were excellent and all had university degrees. I think we had a good education with at least half of our sixth form of 30 or so pupils proceeding to University, quite unusual at that time and, of that number, seven went to Oxford or Cambridge.

As an average student, I passed my Oxford School Certificate in 1944 with credits in English Language, English Literature, Mathematics, Physics, Chemistry and Biology with enough grades to advance into the sixth form.

I had been more interested in Science than Arts and I was offered a choice from two groups of four subjects: either Pure and Applied Mathematics plus Physics and Chemistry or Botany, Zoology, Physics and Chemistry. As my mathematical abilities were limited, I opted for the latter four subjects and was unknowingly steered towards medicine as a career.

World War Two was proceeding noisily during most of my time at school and living on the south coast in Sussex provided quite a few, if not dangerously exciting moments. My daily journey to school by train pulled by an old-fashioned steam tank engine was in its own right quite an adventure. I left home at 8.00 am and caught the train at 8.15 am for the slow journey to Chichester. Along the route, we picked up other boys attending the school from Bognor Regis and surrounding villages. En route there was plenty of opportunity for sport such as placing smaller boys in the luggage racks, unscrewing and removing the rather nice adverts for seaside summer holidays on the ‘Sussex Riviera’ from the carriage walls, and dodging the train guard which was not difficult as all the carriages were of the old eight seater compartment type with no corridor access.

On the return journey, there was often much activity from warring aircraft overhead and one afternoon our train was ‘shot up’ by a Focke Wolf 190. There was a bit of broken glass, but no one was seriously injured apart from the engine which was disabled and was sprouting steam from various unnatural orifices. As boys we thoroughly enjoyed the experience arriving home four hours late to be met by groups of anxious mothers. While we were thrilled. ‘Mum we’ve been shot up’, etc. The mothers, white with anxiety, were less impressed.

Another memory was of prisoners of war, usually Italians, being paraded in Chichester station car park at our arrival time, prior to being taken out to local farms to work. On the day Mussolini was reported to have been killed, one of my school friends stood in front of these men saying as he drew his hand, across his throat ‘Mussolini Dead’. Whereupon one of the Italians jumped forward and seized him by the throat and he was nearly strangled before the guards pulled him off. Just like a movie!

At school, our lessons were frequently interrupted by air raid warnings when we had to proceed to windowless, unilluminated brick built structures in the school playing fields. It was impossible to conduct any meaningful instruction here and quite a few hours were given up in joking about in the dark. Some of the masters read us improving literature by torch light, others read adventure stories such as John Buchan which concentrated our attention.

Outside things were much more interesting with dog-fights going on overhead, the odd plane falling from the sky and crashing nearby. Collecting pieces of crashed aircraft or other armaments was a common form of currency. ‘I’ll swap you a bit of Heinkel III for a piece of Spitfire’, etc. One could pick up spent cannon shell cases and the solid cannon shells themselves which had been fired by the fighters overhead and which had fallen all around in the street avoiding the potentially explosive ones! I still have one in front of me now. Another sport was to collect the unburnt casings of incendiary bombs which were made of a combustible alloy, file the surface off and then pack the shavings mixed with horticultural sodium nitrate into a piece of old metal pipe. Press the contents well down and with a short spirit soaked cotton fuse set light to the whole thing, get out of the way and wait for quite a decent explosion! No one I knew personally was damaged but bad injuries were often reported. There were so many explosives and explosions occurring around the area that the odd small one was not even noticed. I was at this time a member of a local boy Scout troop and we were invited to become messengers for the local Home Guard riding around the district on our bicycles. This was quite interesting as the Littlehampton Home Guard was the nearest organisation to the Warmington-on-Sea group that one could imagine. The CO being the local accountant and very similar in looks and demeanour to Captain Mainwaring of Dad’s Army fame.

Chichester was 3 miles distant from RAF Tangmere one of the most important fighter bases in the country flying Hurricanes and Spitfires during the Battle of Britain so there was much to watch. We all went to school with our gas masks in cardboard boxes for a year or so, but as the local battle faded these were no longer considered necessary.

A number of bombs fell on Littlehampton, one at the bottom of our road which killed the local church minister and his family. I remember looking out at the sky and seeing what looked like a snow storm which was caused by the church hymn books being thrown into the air by the explosion. So, the War was very prescient and possibly dangerous although as boys we found it exciting.

In 1941–1944, I slept in a so-called Morrison air raid shelter a steel table-like structure placed in our dining room. I would do my homework on the table surface and then move down below to sleep. I seldom felt frightened and despite food rationing I was never hungry but missed the odd sweets.

In 1942, the school Air Training Corps was inaugurated and as for many of us our main aim at the time was that of becoming Spitfire pilots we joined eagerly! We attended lectures and drills and an obsolete Hawker Hart biplane was placed in the main school quadrangle over which we used to crawl and sit in the cockpit to feel we were half way there. We were given an old aircraft engine on which we were instructed in basic mechanics taking it apart and reassembling it several times. On occasion, we were taken to Tangmere to see the real thing — great excitement! Marching and parades were a bore, but we were very proud to get into our uniforms.

As the war proceeded, a number of the younger Masters were called up and old and distinguished teachers were brought out of retirement. These continued to give us, in retrospect, a very good teaching experience. There was no unruly behaviour, discipline was strict and I managed to pass the necessary terminal examinations.

The main focus of the battle by 1944 had turned towards the preparations for the ‘D’ Day invasion. About 10 weeks before the day, our part of the coast to a depth of about 10 miles was cordoned off in an area stretching from the river Arun in the west and to the Wash in Norfolk to the east. Littlehampton was therefore included in the process and access was controlled. The surrounding streets gradually filled up with military vehicles and troops. Army lorries and tanks were being waterproofed and exhaust pipes extended to be above water level. At this time, all households were asked to billet members of the armed forces. We were asked to house the CO of the local Air–Sea Rescue base at Littlehampton located in the harbour. I was delighted by this and chatted to this man about being in the Air Training Corps. He said ‘If you would like to come out on one of the Air–Sea Rescue launches, put on your uniform and it will be permitted.’ Accepted like a shot!

So, on a number of occasions within a week or two before ‘D’ Day, I was sailing up and down the Channel seeing the preparations for Mulberry Harbour and the fleet of landing craft, etc. I was allowed to steer the boat, test fire the twin Browning machine guns and the cannon at the rear. The boats had three 500 HP engines could reach nearly 50 knots and almost outrun the German E boats. Totally exciting and much to boast about to my friends at school. My mother was not desperately keen on this idea.

The evening before ‘D’ Day was startling. At about 8.00 pm we heard this noise of multiple aircraft engines. We went outside and wherever one looked in the sky there was a vast Armada of Dakotas and other large aircraft towing Horsa gliders. This went on for hour after hour — a most impressive demonstration of military might. Things were actually happening at last!

Thereafter as the landings became established the focus of the war activity moved away from the south coast and the level of excitement dipped. School now began to take first place and Higher School Certificate was looming.

How all this experience contributed to my future educational prospects as a surgeon is perhaps a little dubious. Thoughts of the Spitfire pilot element quickly faded and the new school Rugby Club became our primary focus of extracurricular activity together with the usual pursuits of tennis, swimming and cycling. Female attentions had yet to divert us!

The two years in the sixth form passed quickly and I succeeded in gaining my Higher School Certificate with first MB exemption. It looked as if I was being committed to medicine and the idea of becoming a GP in a pleasant Sussex practice seemed a very reasonable life style solution. Becoming a zoologist or botanist did not appeal. I therefore applied for a place in Medical School. I was interviewed and turned down at the London Hospital and then tried at St Bartholomew’s Hospital, supposedly the most difficult to get into and not being very hopeful of success. ‘Barts’ as it was usually referred was the oldest hospital in London founded in 1123 and possibly the most famous!

My interview was tough, one of the persons on the Committee of three was the Dean, Sir William Girling-Ball — the prototype for Sir Lancelot Spratt immortalised in the ‘Dr in the House’ series of books and films by Dr Richard Gordon, incidentally a Registrar at the hospital. Almost the last remark to me by Sir William Girling-Ball was ‘For God’s sake speak up boy I can’t hear a damn word you’re saying’ — I’ve blown it!

I’ve had two significant premonitions in my life and I had my first as I walked out under the arch of the famous Barts Square and through the Henry VIII gate into Smithfield. Namely, I would be spending most of my life working in this place with its vast history dating back almost 850 years (see Fig. 1.2).

Fig. 1.2. Henry VIII Gate, St Bartholomew’s Hospital, London.

The early history of the foundation of St Bartholomew’s Hospital revolves around a member of the household of King Henry I named Rahere. He was a man who appeared to have been a social climber and a wit. His name is first noted as one of the minor canons of St Paul’s Cathedral in 1115. The author of this account was himself a monk and considered Rahere’s life worldly and sinful. Rahere realised that he was going in the wrong direction and went on a pilgrimage to Rome to change his ways. Here, he fell ill and prayed to God to cure him and return him to London and petition the King to allow him to build a hospital for the sick poor in the City of London. He was cured, travelled back to London and had a vision of St Bartholomew that he must “build his foundation” dedicated to St Bartholomew in Smithfield, London.

Rahere duly received permission from the King and in 1123 ground at Smithfield (Softfield) was dedicated by the Bishop of London. A house was built for the accommodation of a new monastic order “The Austin Canons” and a building for the sick that The Austin Canons would administer and care for. Rahere became the first Prior of The Austin Canons and died in 1143 and his tomb can still be seen in the Priory church of St Bartholomew the Great nearby.

The hospital developed from a small hospital house and became an important shelter for the sick poor and many children in the city and became an institution of social importance. Nursing was subsequently carried out by Nuns who in due course had their own small church built, St Bartholomew’s the Less, which still exists in the Hospital precinct. In 1539, The Priory was suppressed by King Henry VIII. The hospital just managed to continue but it seemed closure was inevitable. The City corporation petitioned the King to reinstate the hospital with its vital functions. In 1544, the petition was successful and ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Dedication
• About the Author
• Foreword
• Acknowledgements
• Contents
• Part I — How, Why, What?
• Part II — The Adventures of the Fully Trained Surgeon!
• Appendix 1
• Appendix 2
• Appendix 3