Grabbing the wheel : from Philippe Mouret to Moon Surgical

In the early spring of 1987, a private practice surgeon in Lyon, France, took a leap that changed surgery forever. It impacted our surgical instruments, how our operating theatres are organised, and how our clinical procedures are performed.

His name was Philippe Mouret, and his leap ? Laparoscopic Cholecystectomy.

Laparoscopic Cholecystectomy is one of the highest volume procedures globally. Every minute in the US and EU, three patients go under to have their gallbladder removed using a laparoscopic technique (1, 2). This surgical intervention has now become as routine as flying across the Atlantic.

But it was not always this way.

In the 1970s, Cholecystectomy and surgery overall were traumatic and risky. They required large incisions, high complications rates, and extended post-operative stays. The perception then was that 'the longer the incision, the better the surgeon'.

Luckily, Philippe Mouret didn't buy into that ideology.

Dr. Mouret had performed rotations in gynaecology in the 1960s, which had adopted a new approach called laparoscopy. Laparoscopy is a procedure that uses small, slender cameras and long instruments to work inside the body through a series of small incisions. Having been thoroughly convinced of the benefits of laparoscopy and because he shared his practice with a gynaecologist, Dr. Mouret had both the conviction and the tools available to try something new.

"My patient suffered from both gynaecological disorder and gallstones, and she begged me to do one procedure that would treat both, so I did."

His first attempt was successful. So successful that it surprised even the patient. On the first post-operative day, he found his patient fully dressed, with the belief that her gallbladder had not even been removed, and with the intention to leave the hospital !

Although fellow French surgeons Francois Dubois, and Jacques Perissat had also started using the technique, the general surgery world remained in disbelief; and the French team received numerous rejections of their journal publication submissions.

It was not until the 1989 Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Conference that things changed. Professor Perissat appeared at a small booth with videos of his technique, which reportedly attracted a larger audience than the speakers in the main auditorium.

Within three years, Laparoscopic Cholecystectomy was incorporated into general surgery, and more extensive clinical studies led to its rapid development and adoption; Minimally Invasive Surgery (MIS) was born.

Today, the laparoscopic technique reduces postoperative pain, accelerates recovery, improves cosmetic results, and shortens hospital stays. Thanks to these benefits, it has spread rapidly worldwide, covering over 8.2 million procedures annually in the US and EU (3); it is the standard of care in many cases.

For a Laparoscopic Cholecystectomy, you can walk into the hospital at 8 in the morning, have an organ removed, and be home by noon, eating ice cream with your kids. You return to regular activities within days. The laparoscopic approach has transformed medicine and the quality of life for hundreds of millions of patients.

But the transition was not easy.

For this paradigm shift to happen, surgeons and operating theatre teams have had to reinvent themselves. Thousands of papers were published suggesting the methods and techniques needed to minimise patient risk and keep procedure times short and reliable. Diagrams from these papers look like playbooks from a football game.

An operating room resource had to be allocated to simply hold and reposition the camera (laparoscope) to capture what the surgeon wanted to see appropriately. It is a critical job that allows the surgeon to see the tip of their instruments when dissecting a 1mm artery. 

Similarly, an extra hand was necessary to expose the tissue of interest so that the surgeon, with his or her two hands, could use active surgical instruments at the targeted site and treat it as needed.

The result ? The surgical assistant.

The surgical assistant’s job was supposed to be simple. Often a surgeon-in-training, they had two primary responsibilities :

1.       Hold the laparoscope camera steady, and adjust its position to keep the ideal surgical view for the surgeon

2.       Using an instrument (often a retractor), help improve the exposure of the surgical scene while holding up organs or pushing back tissue.

It is anything but straightforward.

Imagine holding a foot and a half-long scope in one hand and a retractor in another. Now imagine having these instruments at arms at length and positioning them accurately for the surgeon inside the patient's belly.

Now imagine you have telepathy and super-powered focus, so you can see through the surgeon's eyes, anticipate what the surgeon wants to see and act before they ask. Now, imagine doing that for an hour, or more.

You get my point.

It is ergonomically taxing, and the surgical assistant must remain focused or risk having the camera float off position. It is a tough job and can easily be affected by a poor night of sleep or a little too much caffeine.

The surgeon constantly feels like a driving instructor, pestering the student and frustrated about not being able to take control. Slightly anxious about what might happen if the person driving were to make a sudden, uncontrolled turn. It often gets to a point where surgeons grab the ‘wheel’ to move the camera themselves.

The result is that surgeons are incredibly dependent on their team. Walking into an OR and seeing your favorite faces is the difference between a good day and a bad one. Surgical procedures are smoother when the best team is on; there are fewer complications and fewer delays.

Today the US healthcare system is in crisis with eroding reimbursement, escalating administrative burden, increased co-morbidities, and lengthened surgical training. This is leading us to a future where quality care cannot meet demand. Inefficiencies in the OR are just something we cannot afford. Surgeons need technology and teams that they can depend on, that deliver reliability and simple workflow wherever they operate. They need to feel they are in control, in order to provide their patients with appropriate and efficient care, every day. 

At Moon Surgical, we are tackling this problem head-on. Like Philippe Mouret, we have recognised an entirely new approach to surgery. Over the next few months, we will begin revealing our progress and sharing the steps of what has been an incredible journey of innovation and discovery.

Stay tuned.

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(1) Nezam Afdhal MD, FRCPI. Complications of Laparoscopic Cholecystectomy, UpToDate , 2020 

(2) Hans-Jörg Mischinger, Sugery of the Gallbladder, European Surgery, 2021 

(3) iData Research, Laparoscopic Device Global Market Size, 2020