Michel Gagner1, Jin Ye Yeo2
1Westmount Square Surgical Center, Westmount, QC, Canada; 2ALES Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. ALES Editorial Office, AME Publishing Company. Email: ales@amegroups.com
This interview can be cited as: Gagner M, Yeo JY. Meeting the Editorial Board Member of ALES: Dr. Michel Gagner. Ann Laparosc Endosc Surg. 2024. Available from: https://ales.amegroups.org/post/view/meeting-the-editorial-board-member-of-ales-dr-michel-gagner
Expert introduction
Dr. Michel Gagner (Figure 1) accepted his first teaching appointment at the Université de Montréal School of Medicine as an assistant professor of surgery (Hotel-Dieu de Montreal), during which time he introduced his skills in laparoscopic surgery. As a pioneer of robotic-assisted surgery, a world-first laparoscopic removal of the adrenal glands, liver, bile duct and pancreas removal by laparoscopic surgery, he eventually made his way to the U.S. to practice at the Cleveland Clinic Foundation in Ohio where he co-founded the Minimally Invasive Surgery Center. There he pioneered the use of endoscopic surgery for parathyroid and thyroid tumors in humans. He then became the director of the Minimally Invasive Surgery Center at Mount Sinai School of Medicine in New York, chair of the laparoscopic division and also earned the title of Franz Sichel Professor of Surgery. There he pioneered telesurgery with Professor Marescaux and Leroy of Strasbourg, the first trans-Atlantic robotic-assisted surgery, published in Nature in 2001. He then became head of the laparoscopic and bariatric surgery section at Cornell University’s Weill Medical College (New York City).
He was also serving as chief surgeon at Mount Sinai Hospital in Miami and professor of surgery at Florida International University, Dr. Gagner also worked at the affiliated University of Montreal’s Sacré-Coeur Hospital, as a senior consultant. He also owns the Westmount Square Surgical Center, a private clinic specializing in bariatric surgery for weight loss and metabolic surgery for type-2 diabetes. World-renowned for laparoscopic and bariatric surgery related to weight loss, the Clinic of Dr. Gagner, which is located in Montreal, specializes in the laparoscopic sleeve gastrectomy which he pioneered in 2000, as well as laparoscopic duodenal switch, which he was the first to perform in 1999, and various new innovative endoscopic treatments for obesity, type-2 diabetes, and gastro-intestinal tract disorders.
Figure 1 Dr. Michel Gagner
Interview
ALES: As a pioneer in laparoscopic techniques for adrenal glands, liver, bile duct and pancreas surgery, what initially inspired you to specialize in laparoscopic surgery? What aspects of laparoscopic surgery keep you most engaged?
Dr. Gagner: When I did my residency in general surgery in McGill University, laparoscopy was not part of the training. I got into surgery in 1982, and everything was open surgery. I was interested in liver, pancreatic, and complex biliary problems so I got a 2-year fellowship, the first year in liver surgery in Paris and another year in pancreatic-biliary problems at Lahey Clinic Medical Center in Burlington, Massachusetts. When I returned to be a staff at Montréal, everything was mostly open surgery. But while I was in Paris, I heard that Dr. Francois Dubois was starting to do cholecystectomy by laparoscopy and Dr. Eddie Joe Reddick had started the year after in the United States. During my fellowship, I was able to go to Nashville, Tennessee to train in laparoscopic cholecystectomy with Dr. Reddick and Dr. Doug Olsen. They took me in as a young assistant at that time and I learned laparoscopic cholecystectomy. When I returned to Montréal, I was able to start a laboratory for teaching myself new techniques and I taught courses on laparoscopic cholecystectomy to surgeons in eastern Canada and eventually, we did courses in more advanced techniques, such as fundoplication, colon surgery, and other types of techniques, and eventually teach laparoscopic adrenalectomy, splenectomy, and techniques for other organs.
ALES: Could you share pivotal experiences that led to your innovations in laparoscopic and robotic-assisted surgery? Were there specific challenges or breakthroughs that stood out?
Dr. Gagner: As I was a hepato-biliary surgeon, I started to use laparoscopy for gall bladder surgery, since it is part of the ‘hepato-biliary’, and also learned how to avoid bile duct injury because I was repairing bile duct injuries coming from laparoscopic cholecystectomy, where I was at the University of Montréal, which is a major hospital. I started to use laparoscopy as a staging tool for liver tumors and pancreatic cancer to see if there was any extension that would prevent me from doing a laparotomy and avoid major surgeries in these patients. I began to do all kinds of maneuvers and learn how to expose the pancreas and liver and eventually we did some liver and pancreatic resection by laparoscopy. I must say the advent of the first laparoscopic stapler, which was crude, was only 30mm long but it was surgical which allowed us to do some preliminary resections and reconstruction. The stapler was not that great because it resulted in a higher leak rate needing sutures to reinforce. And at the same time, I teamed up with engineers Prof. Richard Hurteau and Dr. Eric Begin at the University of Montréal to do a robotic arm to hold the camera. We were the first ones to have a voice-activated robotic arm to do laparoscopic cholecystectomy at the time.
When I moved to Cleveland, I teamed up with Computer Motion and they were working on a prototype called ZEUS. ZEUS is a multi-armed robot similar to what you see now. In 1995, we had the first prototype out of California, and in 1996 into the Cleveland Clinic and this led to experimentation on how to use the robot in various platforms. We thought that it was best for small sutures, such as 5 0, 6 0, 7 0, cardiac surgery, thoracic vascular surgery, and perhaps for small duct-like pancreatic-biliary anastomosis, so we thought that this was the best application and my colleague Dr. Falconi who was a laparoscopic gynecologist used it to do tubal reanastomosis and fine microsurgery in the pelvis. When I moved back to Mount Sinai, New York, I collaborated with Dr. Jacques Marescaux and started courses in endocrine and bariatric, and we had a vision - a possible collaboration to do transatlantic long-distance surgery but I convinced him to acquire another ZEUS in Strasbourg, we had one in NY city, and were able to do the first animal experiment and after that, led to the first transatlantic remote surgery by the use of similar robots.
ALES: In your opinion, how do minimally invasive techniques influence access to bariatric surgery, particularly for patients with complex cases or in underserved regions?
Dr. Gagner: Worldwide, we have about 750 million people with type 2 diabetes and another half a billion people with obesity and weight problems. These numbers are rising and not decreasing. We have to see if new drugs GLP-1 agonists will make a dent on these numbers, but the problem is that there are many underserved areas everywhere in Asia, Africa, Middle East, and even Latin America, and in isolated populations in the Pacific. I would like to have more democratized and safer treatments, which are goals of magnetic surgery, such that the price of being able to do the treatment will be very low and will replace the high costs of drugs. I think this will be a possibility in underserved populations.
ALES: Can you discuss any emerging techniques or technologies in bariatric surgery that you find particularly promising?
Dr. Gagner: I am working on magnets and I think that magnets are for anastomosis, not only for bariatric metabolic surgery but also for other gastrointestinal applications and I think the application is where the focus is going to be. For robotic surgery, hopefully there will be smaller, faster, and more intelligent robots that are less costly, but magnetic surgery is going to go in its parallel ways and eventually fuse with robotic surgery.
ALES: What aspects of bariatric surgery and metabolic surgery research do you believe have received insufficient attention?
Dr. Gagner: Medication is receiving a lot of attention from the pharmaceutical industry. I think the combination of surgery and pharmaceuticals is underutilized and this will probably increase over time and the flexible endoscopy in pharmaceuticals is under research and this will continue to progress. I think that is where we will the efforts in the next decade.
ALES: What are your recent research priorities, and how do you hope they will impact the future of minimally invasive surgery and bariatric surgery?
Dr. Gagner: I am developing more magnetic surgery and I think that my efforts for the next decade is to use magnets in various forms and make them safer and more efficacious. They will probably replace stapling and suturing, and as we see the robots making suturing, they are using sutures and techniques that go back to the 18th and 19th centuries. so when we look at compression devices for now as to most, I think this technique is more 21st century.
ALES: How has your experience been as an Editorial Board Member of ALES? What are your expectations for ALES?
Dr. Gagner: I have participated in many new journals and have been part of editorial boards of starting journals and there is always a big excitement to connect with the younger generation and engage them in the editorial board. There is a tendency to get old people like me and I would like to see younger people get invested in the journal and it helps for them to continue to be there to get more diversity. The younger people usually have a lot of new ideas that are worthwhile to look for.