World J. Surg. 25, 967-968, 2001

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WORLD Journal of

SURGERY 9 2001 by the Socidt~ Internationa[e de Chirurgie

Letters to the Editor To the Editor (Dot: 10.1007/s00268.001-0049-9) The article on the history of endoscopic and laparoscopic surgery by Lau et al. (World J. Surg. 21:44, 1997) omitted mention of my work and contributed to its "historical obscuration." The world of surgery would have no knowledge of my work but for the development of the internet (www.netrover.com/-hclarke). In my small private hospital in Port of Spain, Trinidad during the late 1950s I found that with smaller incisions my poor patients were fit to be discharged earlier, thereby avoiding the expense of long hospitalization. I invented instruments and methods to facilitate this surgery. In 1970 in the Department of Obstetrics and Gynecology of the State University of New York at Buffalo I combined my methods and instruments with laparoscopy to initiate this era of modern operative laparoscopy [1]. The techniques and instruments I had developed for laparotomy were found to be useful also and were reported [2]. My instruments and methods were documented on film, presented, published, patented, and marketed by the Ven Instrument Company of Buffalo, New York. Some early demonstrations and presentations were at the 28th annual meeting of the American Fertility Society (1972), the 19th annual scientific meeting of the Canadian Fertility Society (1972), the 19th annual scientific meeting of the American Association of Obstetricians and Gynecologists (1972), the 20th annual clinical meeting of ACOG, in a formal paper (1973), of the 122rid annual convention of the American Medical Association (i973), at the 8th World Congress of Obs/Gyn, as a delegate of the USA to Moscow (i973), and so on.

Later "historical obseuration" of my work began. Academic and financial credit due to me was given to others. Instruments and methods similar to mine were being marketed infringing on my patent rights. (Storz: catalogue no. 26596T Knot Tier for extracorporal knotting). The laparoscopic loop-ligation for Pomeroy tubal resections that I had reported in 1972 and presented and documented on film was applied later to appendectomy by Semm of Germany (1981) with no mention of my prior loop-ligation. In the United States Reddick and Save put their names on my knot-tier and used it for gallbladder surgery (Cooper Surgical). The Levine probe and knot guide by Northgate Technologies (no. 791005) is the Clarke knot-tier. Levine is on the Board of the AAGL. In France the Clarke ligator or knot-tier, umnodified, is called the CICE knot tier or the Clemond-Ferrand knot tyer and is marketed by Storz and sponsored by Bruhat and the C1CE of France. Semm, Bruhat, and Levine have been recognized as the fathers of operative laparoscopy by the AAGL. In England in 1983 John Wickham recognized the advantages of my new concept in surgery and named it "minimal invasive surgery" without giving credit to

my original work. My objections to these appropriations of my work have met with no response. My simple instruments and methods were intended to benefit poor patients of the Third World. Following obscuration of my low cost suturing and tying, which with electrocautery was adequate for the common, less radical laparoscopic procedures, came the marketing of expensive, not cost-effective technology that has hindered the advance of laparoscopic surgery in the Third World, where it is needed most. H. Courtenay Clarke, M.D. Active Staff of Hotel Dieu Hospital Windsor, Ontario, Canada

References 1. Clarke, H. C.: Laparoscopy: new instruments for suturing and ligation. Fertil. Steril. 28:274, 1972 2. Clarke, H. C.: A simple surgical ligator. Arch. Surg. 701:914, 1973

Reply (DOI: 10.1007/s00268-001-0050-3) We thank Dr. Clarke for his interest in our paper, which was published in 1997. The development of endoscopic and laparoscopic surgery has been made possible by the contribution of many individuals; some contribute more, others less. In our paper, because of the limitation of space, it was impossible to mention the names of all individuals whose work has contributed to the field. Thus we had to confine ourselves to those whom we believe contributed significantly. We do hope that Dr. Clarke can understand that omission of the names of some individuals is inevitable. What constitutes a significant contribution to the development is another controversial area. The impact on the change in practice in the surgical world by any individual depends on many factors. The novelty of the idea, the risk/benefit ratio, the ease of application, the financial implications, and patient acceptability are some of the important factors. The way the new idea is popularized and becomes accepted is also important. We do not wish to enter into the argument as to whether Dr. Clarke is the one who developed the taparoscopic procedures and instruments he mentioned in his letter. In the history of medicine, like in the history of any other areas, there is much subjectivity. We believe that we adequately covered the important steps in the history of endoscopic and laparoseopic surgery, in our paper. Whether Dr. Clarke's claim about his contributions is justifiable is up to the readers to decide.

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Letters to the Editor

W.Y. Lau, M.D. A.K.C. Li, M.D. Department of Surgery The Chinese University of Hong Kong Prince of Wales Hospital Shatin, New Territories Hong Kong e-mail: [email protected]

To the Editor (DO~: 10.1007/s00268.001-00Sl-2) I read with great interest the article in the August issue of the World Journal of Surgery titled "Surgeon's approach to the thyroid gland: surgical anatomy and the importance of technique" (Bliss et al.: World J. Surg. 24:891, 2000). It is a timely and excellent review, but a few aspects need discussion. 1. Exposure of the gland: Although the authors mentioned the length of the incision and its position, the question of how far to raise the flap is not addressed. If it is not raised up to the thyroid notch, dealing with the superior pole especially in longer lobes becomes difficult. Use of the anterior Jugular veins (and variations) as a landmark to begin raising the subplatysmal-flaps must be mentioned. These veins can sometimes cause bleeding unless they are dealt with carefully. The question of infiltrating the flaps with a saline epinephrine solution (as practiced by many surgeons) is important. I personally do not use it, as I cannot see any advantage. After raising the flaps the review recommends grasping the gland with hemostats. Can you actually grasp the gland before dividing the investing layer of fascia in the midline? I do not think so. 2. Recurrent laryngeal nerve: The recurrent laryngeal nerve can be damaged easily at three steps: (1) dissection of the lateral lobe near the tubercle of Zuckerkandl; (2) ligation of the inferior arteries; and (3) ligation of the inferior veins. In the review by Bliss et al. Figure 2 demonstrated a transverse ligament (part of the ligament of Berry) tethering the thyroid just above the tubercle of Zuckerkandl. The proximity of the nerve to this ligament is obvious, and it is here that you are most likely to damage it as there is a vein (angular vein of sod, as I call it), that is difficult to ligate. With confidence running high, as the gland is about to be taken out, careless ligation or coagulation can damage the nerve. This point needs stressing along with careful ligation of the inferior veins. When dealing with the inferior arteries, everyone is aware of the nerve and is careful of the other two areas that are the "danger zones." 3. Future directions: The authors state that many thyroid resections may become day surgery. That is a dangerous trend. As we all know, bleeding and hematoma can kill a patient within a few hours. These complications have occurred in experienced hands despite all precautions. Therefore I think a 24-hour hospital stay is necessary for any operation where "preventable death" is a likely complication. Ranil Fernando, M.B.B.S, M.S. Department of Surgery Faculty of Medicine Ragama Ragama, Sri Lanka e-mail: [email protected]

To the Editor (DOI: 10.1007/s00268-001-0052-1) Preservation of the inferior laryngeal nerve is one of the most important aspects of thyroid and parathyroid surgery. Most endocrine surgeons prefer to identify the nerve, rather than avoid it and assume it to be safe [1]. Several techniques using different anatomic landmarks for identifying the nerve or monitoring its function have been reported [2-4]. Each technique requires meticulous dissection for identifying the nerve and dissecting it throughout its course in the neck. We prefer to identify the recurrent nerve just caudal to the point where it crosses the inferior thyroid artery and to dissect it in both directions: caudally to the mediastinum and cranially to the cricothyroid junction. After the thyroid gland is mobilized medially, the connective tissue on the tracheoesophageal space is dissected to identify, the nerve. Spreading rather than cutting this tissue and preserving all tissue is advised until the nerve is definitively identified. At this step of the operation we use a saline jet spray. The saline spray cleans the area and helps spread the fibers of the connective tissue, leaving all nerves and vessels, which can then be easily identified. Most important is that the saline spray also causes thickening of the nerve sheath. If the recurrent nerve is divided into branches, which is not a rare condition, all of the branches are identified with use of the saline spray. Cleaning the area is essential also for parathyroid identification, and it is performed usually by pouring saline. The saline jet spray is more effective than pouring saline because the area is not only washed but also wiped. We have been performing saline jet injection since 1992 using a 20 cc syringe and a 21- or 22-gauge needle. Because of the two possible risks (injury to the operating team and injury to the nerve or vessels due to throwing of the needle, when the syringe is pushed with pressure) we break the needle at a point near its origin. Breaking the needle prevents injuries and enables the saline iet spray to be a more gentle and wider, even with a very strong push with the syringe. Saline jet spray can be repeated several times without complications. Savas Kodak, M.D. Semih AydintuP,, M.D. Division of Endocrine Surgery and Breast Diseases Ankara University Medical School Ankara, Turkey e-mail: [email protected] References

1. Birken, E.A., Falk, S.A., Feins, R. H.: The technique of thyroidectomy by cervical and thoracic approaches. In Thyroid Disease, Falk, S.E., editor, Philadelphia, Lippincott-Ravem 1997, pp. 681-695 2. Katz, A.D.: Extralaryngeal division of the recurrent laryngeal nerve: report on 400 patients and 721 nerves measured. Am. J. Surg. 152:407, 1986 3. Maloney, R.W., Murcek, B.W., Stoebler, K.W., Sibly, D., Maloney, R.E.: A new method for intraoperative recurrent laryngeal nerve monitoring. Ear Nose Throat J 73:30. 1984 4. Peltizzo, M.R., Toniato, A., Gemo, G.: Zuckerkandl's tuberculum: an arrow pointing to the recurrent laryngeal nerve. J. Am. Coll. Surg. 187:333, 1998