There Is No BOX: An Alternative Route for Innovative Surgery to Find Its Way to Translation

Abstract

Innovation in surgery and its translation to our patients is difficult and a topic of heated discussions. Defenders of pure innovation claim that too many rules and economic barriers make it very difficult to get novel surgical inventions to the clinical realm. On the other hand, innovation in surgery without prior evidence may not only be difficult to have a patient agree to, but may also be dangerous for the first trial of patients on whom it would be used. I recall the first series on kidney transplantation by the extraordinary pioneer Joseph Murray in 1954. The first 5 dogs he operated on all died with the new technique. Nevertheless, he proposed kidney transplantation to a patient who accepted, recognizing that it would be his only chance to survive. The patient survived the novel operation, and the method was translated to modern medicine. Although that is not the way that translation works these days, some ideas still have the chance to be adapted clinically and represent a true paradigm shift. Without any previous evidence, Theodor Kocher was successful in achieving survival with his groundbreaking thyroid resections in 1883. By recognizing the physiology and modifying the thyroidectomy technique, Dr Kocher saved many lives. Werner Forssmann performed the first heart catheter on himself in 1929, without previous proof of feasibility or safety. For this “recklessness,” he received severe criticism instead of recognition. All 3 eventually earned Nobel Prizes by risking their lives and careers without any kind of evidence. When the idea is far ahead of their time, criticism and punishment are the rule for these late recognized heroes. Most researchers would state that only after strong evidence collected through research, such as prospective randomized studies about a subject, we are then authorized to change our standard to adopt the new standard. Still it protects our patients; it is not fair only because the first and older method or therapy was there before; it has no obligation to prove anything. If it could come in historical timeline at the same time, probably both methods would be performed many years until one prevail . . . not fair. Such a well-conducted controlled study can even prove that the use of parachutes does not statistically reduce death or major traumatic injury when jumping from an aircraft in the first randomized evaluation of this intervention. Nowadays, we experience rare innovation moments that mostly do not come from robotics or fancy technology, but rather from simple, direct ideas. The concept of natural orifice surgery (NOTES), started by Kalloo and Kantsevoy, is a pure, direct, and uncomplicated revolutionary idea. It is now translated to every field of surgery, although conservative and unprepared brains rated that “NOTES is dead.” In fact, we see NOTES in every serious clinic in the world, in every TAMIS-TME (transanal minimally invasive surgery-total mesorectal excision), in transvaginal specimen extraction, in endoscopic sleeve gastroplasty, and the genial applications from Haru Inoue in POEM (peroral endoscopic myotomy) and the Angkoon Anuwong’s revolution giving us the transoral thyroid surgery TOETVA (transoral endoscopic thyroidectomy vestibular approach). Every step by these brave pioneers will stay forever. Conservative critics will not. Natural orifice surgery seems to be dead? On the contrary, it is just a forbidden word. But the idea is there, and it has already changed the world. But how does a new creation appear in the mind of the prepared surgeon? We were taught that the best way is to brainstorm until the many solutions can be listed, and from them we select the best ones to work hard on it. That is also the way to create new jokes in stand-up comedy, the so-called “The Rule of Nine,” when we choose 1 from 9 ideas to develop only that chosen idea into a new comedy line. Yes, this is thinking outside the BOX. But as Kwai-Chang Caine in old Kung Fu series and also in the Matrix trilogy, and from the basis of Buddhism philosophy, we can learn that a special choice of performance can bring the mind to another level. This is beyond the “outside the BOX” dogma. Do not be shy. 835341 SRIXXX10.1177/1553350619835341Surgical InnovationZorron editorial2019