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Ob/Gyr) Prabhat Ahluwalla Advances Mmimally Invasive Surgery

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COVER STORY i

A niATIOMAL imniOVATOR
O B / G Y N PRABHAT AHLUWALIA ADVANCES MINIMALLY INVASIVE SURGERY
By Eileen T. Jevis

SUCCEEDS ini A S M A L L T O W N
Necessity is the Mother of Invention - a very famous quote by Plato that has motivated, inspired, and produced new technologies for centuries. From the telegraph machine to penicillin, scientists, physicians, entrepreneurs, and ordinary citizens have realized a need and, through ingenuity, tenacity, and determination, have invented products that have changed the way we live. visit us online at: www.nyphysicianmagazine.com

COVER STORY

Dr. Prabhat Ahluvvalia lives in the small town of Little Falls, N Y , where he first started to practice as an obstetrician and gynecologist in 1983. Since then, he has become a nationally-recognized innovator in laparoscopy and advanced minimally invasive surgery, changing the lives of many patients and physicians. Ahluwalia's career in minimally invasive surgery began in 1984 when he had a patient with a tubal pregnancy and used a laparoscope to remove it. Ahluwalia explained that in the 80s, the standard practice was to confirm the ectopic through a scope, make a large incision in the pelvis, and remove the tube. The patient would spend an average of five to seven days recovering in the hospital. "It occurred to me that there was no reason

to perform such an invasive procedure with high blood loss, long recovery time, and higher risk of complications," said Ahluwalia. He considered the possibility of

removing the tube through a cannula in a small second incision. He performed the procedure and it worked. " A week later, I had a patient with a large cyst on her tube. Again, I removed the diseased tube through this method. Both patients went home the same day. After surgery, a nursing director joked that someday, I'd be removing a uterus through the navel. That's how my career in minimally invasive surgery began."

Soon after Ahluwalia performed this innovative procedure, he learned from a medical journal that another physician, Cameran Nazath, had attached a video camera to a laparoscope and was able to view in real time the laparoscope's image on a video screen. "I thought there were many obvious benefits, such as better vision, the instrument allowed 40x magnification of the surgical site and also better participation by the surgical team, who were able to watch the surgery while it was being performed on a video monitor," said Ahluwalia. "As a result of the magnification, I was confident I would be able to perform micro-surgery and treat conditions laparoscopically like endometriosis, tubal repair, cancer resection, and fibroid removal, to name a few."

Cory Allen Wagner, M.D.

COVER STORY

In the early 1990s, he innovated a bundle of new procedures, such as assisted appendectomies through the navel. Total Laparoscopic Hysterectomy (TLH) using a uterine manipulator, Laparoscopic Burch Procedure with Total Laparoscopic Hysterectomy, uterine suspension for a tipped uterus, and minimally invasive repair of Vescico-Vagina] Fistula. "The latter innovation reduced recuperation time for patients from six to eight weeks to only one week," explained Ahluwalia. Also in the early nineties, Ahluwalia invented and patented V C A R E , the market's leading uterine manipulator, and has since continued to pioneer a number of laparoscopic outpatient procedures, most recently, the Single Incision Laparoscopic Hysterectomy through the navel. "I developed V C A R E because I could not use laparoscopically assisted vaginal hysterectomies on patients who lacked a substantial pelvic floor relaxation, had a previous C-section, or had large tumors," explained Ahluwalia. "After many days and nights of thinking about anatomical challenges, I went to the hardware store and Toys "R" Us and came home with oil funnels, a Barbie tea set, a saw, and some glue. I worked and reworked the design until I thought I had a prototype that would work and was patentable." When the device was F D A approved, Ahluwalia used it to perform total laparoscopic hysterectomies. For the past nine years, he has performed hysterectomies on an out-patient basis and his patients leave the hospital the same day. "This is in stark contrast to the pre-laparoscopic days when patients endured up to week-long stays at the hospital and large, invasive incisions to the lower pelvis," he said. Today, V C A R E is used in both laparoscopic and robotic surgeries and remains the industry standard. Ahluwalia said that many of these surgical innovations would not have been possible without the support of
New York Physician

Ahluwalia's career in minimally invasive surgery began in 1984 when he had a patient with a tubal pregnancy and used a laparoscope to remove it.

Ahluwalia asked the hospital to purchase a $20,000 camera, but they rejected the idea. Convinced of its benefits, he purchased it from his personal savings. "The investment was worthwhile. I began to use this technology to treat ovarian cysts, adhesions, severe menstrual pain, endometriosis, and other gynecological challenges. The hospital eventually saw the benefits and purchased the technology, along with an $80,000 Co2 laser, which I still use today." Over time, Ahluwalia began making his own contributions to the field of laparoscopy, pioneering minimally invasive laparoscopic alternatives to once incredibly invasive medical procedures such as tubal reanastomosis, presacral neurectomies, total pelvis peritoneal stripping to eradicate endometriosis, bladder drops, and vaginal suspensions. He reintroduced the forgotten procedure of L a Fort's Colpocleisis, but on a minimally invasive basis.

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the hospitals in Central New York, in particular Little Falls Hospital and St. Elizabeth Medical Center, and the physicians who taught him surgical techniques in their field. "As a result of collaboration and training with my colleagues, I became credentialed to do bowel resections, uretroscopy, retrograde pyelogram, uretral stenting, and bladder repair, to name a few," said Ahluwalia. "One of the many benefits of practicing in a small medical community is that there is more collaboration and less anti-competitive practices. Knowledge and skill are shared, not hoarded." This collaboration has fostered synergies. "Today, I teach general surgeons how to remove gall bladders through the navel," Ahluwalia said.

Ahluwalia is committed to sharing his skill and knowledge with others. Since 2002 he has been directing a fellowship in advanced minimally invasive surgery for board certified or eligible trained O B / G Y N physicians on behalf of the American Association of Gynecological Laparoscopy ( A A G L ) and the Society of Reproductive Medicine. In 2011, the American Congress of Obstetricians and Gynecologists recognized him as "Mentor of the Year." Thus far, he has trained 10 physicians and is currently training two fellows in a two-year program. "When I started the fellowship, my focus changed to additional training of O B / G Y N s . " Ahluwalia moved away from hosting surgeons and teaching weekend courses to doctors from other areas when he found that fellowships were more productive. "Doctors attended a course on the weekend with the idea that they could go back and offer the same level of service. People need more than weekend courses to offer safe and effective surgical treatment," he said. Ahluwalia found fellowship programs to be much more valuable investments, especially since many of his fellows

Because GYN training is primarily a surgical residency, students get most of their training in the field.
often join research university hospitals and continue to spread their knowledge. Dr. Corey Allen Wagner is a junior fellow currently under tutelage with Dr. Ahluwalia. "He is one of the great physicians who has dedicated himself to his patients," said Wagner. "As a fellow, I do everything I can to be Dr. Ahluwalia." Wagner said that the training he is receiving from Ahluwaha will give him the expertise to abide by his own medical philosophy. He explained that when a student begins studying O B / G Y N medicine, fifty percent of the training will focus on obstetrics and fifty percent will focus on the field of gynecology. "I saw this training as a good start, but not adequate to become an expert in the field of gynecology," said Wagner. "During my residency program, the majority of time spent, including overnight and weekends, is primarily OB training. I didn't feeling this training translated to the care of patients who are in need of G Y N care." Wagner said that because G Y N training is primarily a surgical residency, students get most of their training in the field. "When you see a young O B / G Y N start their practice, it's primarily focused on OB because patients who see them are in need of OB care," said Wagner. "As their patients begin to have gynecological needs, the doctor begins to gain more G Y N experience." Wagner said that during his two years with Dr. Ahluwalia, he will see the same number of G Y N patients as it would have taken him to see in ten years of general O B / G Y N combined practice. "Minimally invasive surgery is my passion. Working with Dr. Ahluwalia gives me the opportunity to work with complex patient problems

and advanced procedures that most O B / G Y N s don't do because they don't have the technological expertise and experience."

Ahluwalia said that minimally invasive surgery has, for the most part, become standard practice, but there is still some resistance from the medical community. He believes that stems from individual skill levels: "It's challenging unless you do it often and become efficient and skilled." The goal is to achieve more with the least amount of trauma to the patient, explained Ahluwalia. "If we can minimize the trauma by improving our skill set, that lowers the risk of complications, pain, and suffering." Ahluwalia looks back at the advances made in medicine and finds his contributions rewarding. "In the past twenty or thirty years, incisions, and the risk of complications and infections which came from how you access the organs, have been reduced significantly. There were too many hands in the cavity. Popular beliefs was that the larger the incision, the better access and visualization. That's no longer true. Minimal invasive area access is better and safer." Ahluwalia said that on a national level, the complication rate for open abdominal surgery averages ten to twenty percent. In his practice, for the same surgery done with minimal invasiveness, the complications rate has decreased significantly. "In many invasive surgeries, you need a clean field of view. If the patient bleeds, you won't be able to see," he said. "So the secret is, don't let them bleed." Ahluwalia said that he has not had to give a blood transfusion in at least 2,000 hysterectomies he's performed. "The average blood loss in a minimally invasive procedure is about one or two ounces, including surgeries for cysts, cancer, etc."

COVER STORY

But it's not all about procedure with Dr. Ahluvvalia. It's about what's best for the patients and helping them increase their quality of life. One of his most gratifying moments came early in his career. "When I first started practicing as a physician in 1984, a 95-year-old woman came to me with a complete vaginal prolapse. As a result, she suffered extreme urinary incontinence and social isolation in her nursing home. I took her case and performed a Colpocleisis. When I saw her a week later, I asked her how she was. She grabbed me with both arms and cried, 'Now I can play bridge. Thank you.' That experience had a profound impact on me and my practice going forward." Ahluwalia said that since that experience, he sought out complex cases and set ambitious surgical goals. "There was one patient who had a ruptured ectopic. B y the time she got to the hospital, she was in shock. I was on call. If I had opened her up to stop the blood loss, she was going to experience more blood loss. I put a scope in, which took two minutes. I was able to clamp it, and stop the bleeding, which resulted in it no longer being a critical situation." Ahluwalia continues to look for ways to make surgery simpler and safer. He is cuiTently developing tools to advance robotic and laparoscopic surgery. He recently treated an 86-year-old woman with cancer of the uterus, lymph nodes, tubes, and ovaries. After surgery, he was able to fulfill her wish of going home the same day. "These sorts of experiences give me great satisfaction in my profession." AhluwaUa's message to other physicians is that innovation and advancement can happen, even in the smallest medical communities. Through collaboration and knowledge-sharing, surgery can become simpler and safer. And what was once considered avant-garde can become standard practice.
18 New York Physician

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