Panagis M. Lykoudis1,2, Jin Ye Yeo3
14th Department of Surgery, University Hospital “Attikon”, School of Medicine, National & Kapodistrian University of Athens (NKUA), Greece; 2Division of Surgery & Interventional Science, Faculty of Medicine, University College London (UCL), London, UK; 3ALES 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: Lykoudis PM, Yeo JY. Meeting the Editorial Board Member of ALES: Dr. Panagis M. Lykoudis. Ann Laparosc Endosc Surg. 2024. Available from: https://ales.amegroups.org/post/view/meeting-the-editorial-board-member-of-ales-dr-panagis-m-lykoudis.
Expert introduction
Dr. Panagis M. Lykoudis (Figure 1) is a Consultant Hepato-Pancreato-Biliary Surgeon, Assistant Professor of Surgery at the National & Kapodistrian University of Athens (NKUA), Greece, and a Honorary Lecturer at the Division of Surgery & Interventional Science, University College London (UCL), London, UK. He started his surgical training at the 2nd Department of Surgery of the NKUA, and completed it at the Royal Free Hospital, London, UK. After receiving his MSc in Surgical Science from the Imperial College London, UK, he obtained his PhD working on the expression of sex hormone receptors in neoplasms of the pancreas, and its correlation with clinicopathological data, with merit from the NKUA.
Dr. Lykoudis’ clinical interests include hepato-pancreato-biliary surgery and minimally invasive surgery. He has presented in national and international meetings, published in peer-reviewed medical journals, and authored book chapters, in the above and several other areas. Apart from ALES, he has been serving as an Academic or Associate Editor for Medicine (Baltimore), the British Journal of Surgery and BJS Open. Dr. Lykoudis is an active member of several international associations including the International Hepato-Pancreato-Biliary Association, the European Association of Endoscopic Surgery, and the International Laparoscopic Liver Society. Since 2018, he has been a Fellow of the Higher Education Academy of the UK.
Figure 1 Dr. Panagis M. Lykoudis
Interview
ALES: What inspired you to pursue a career in hepato-pancreato-biliary (HPB) surgery?
Dr. Lykoudis: Each surgical specialty and subspecialty present their own challenges and beauty. I always thought that HPB surgery, involving diseases and treatment of three unique anatomical structures, is characterized by remarkable diversity. Moreover, the depth of knowledge in terms of the physiology of involved organs has increased rapidly over the past decades, thus renovating the field. Finally, surgical procedures of the liver and pancreas are “notorious” for the demanding skills. In a few words, I would say that it was primarily the challenge. I should also mention the fact that, due to the rarity of associated diseases, and ominous prognosis, the subspecialty does not attract interest in terms of clinical and research involvement, and this is a gap I thought, and still do, I could fill.
ALES: Could you highlight some examples of advancements in minimally invasive techniques for HPB surgery? How has the adoption of these techniques changed the landscape of HPB surgery?
Dr. Lykoudis: The beginning of the answer to this question is fairly easy. Cholecystectomy -which evidence suggests belongs to the repertoire of HPB surgeons - was the procedure associated with the revolution of laparoscopic surgery. In fact, to date, it might still be the least studied and modernized of all laparoscopic procedures. Moving on from the obvious, laparoscopic distal pancreatectomy rapidly became a gold-standard approach. Moreover, laparoscopic procurement of liver grafts from live donors is probably the most recent revolution in laparoscopic surgery. From the opposite point of view, I believe that minimally invasive major HPB procedures will be the last “castle” to fall to the hands of minimally invasive surgery (MIS), hence signaling the end of open surgery. Therefore, HPB surgery introduced the upper and lower limits of MIS.
HPB procedures have traditionally been associated with the highest rate of complications (along with esophageal surgery). Postoperative pain and incisional hernia are two of the most common adverse outcomes, significantly more common in HPB surgery. Implementation of MIS in HPB procedures has significantly reduced both of them. It remains to be confirmed if other outcomes, such as blood loss, hospital stay, and oncological outcomes are also positively affected. I am confident that with time, as we gain experience in MIS, and improve our patient selection criteria, the aforementioned benefits will eventually be confirmed.
ALES: Apart from minimally invasive techniques, what emerging trends or technologies do you believe will significantly impact the field of HPB surgery?
Dr. Lykoudis: I believe that the first trend is that of virtual reality (VR) simulation in laparoscopic training. With healthcare systems facing tighter medicolegal challenges, with shrinking of available surgical time in hospitals, and consequently with minimization of teaching and training opportunities in the operating room, VR simulation is destined to fill a significant gap. HPB procedures are rarer than other types of operations, and associated higher perioperative risks further shrink teaching opportunities. VR simulation has a proven positive effect in minor procedures, such as laparoscopic cholecystectomy and laparoscopic appendectomy, and as we keep exploring its implementation in major HPB procedures, I am confident that VR simulation will demonstrate an even higher benefit.
Another trend is that of Augmented Reality. Tailoring the surgical plane, navigating through vital structures and dealing with complex and challenging tumors, are key components of HPB surgery. Augmented Reality can revolutionize the field by integrating information from imaging studies. Real-time guidance, and visual and haptic alerts when risky maneuvers are performed, are some key concepts of this advancement.
ALES: In addition to research, you are also involved in surgical education. What are some of the biggest challenges currently facing post-graduate surgical education, and how can they be tackled?
Dr. Lykoudis: This is one of the most concerning issues in modern surgery. As I mentioned earlier there are several factors, some traditional and some recently emerged, that negatively affect postgraduate education. The need for rapid turnover of surgical procedures, the arguable need for minimizing complications for both patients and healthcare systems, and the ever-evolving diversity and complexity of surgical procedures are some of the recognized pressures. We should not overlook the need for improved professional/personal life balance, such as doctors’ burnout, equality and diversity issues, or skill decay during an absence for several reasons (maternity/paternity leave, research break etc). Available time, opportunities, and admittedly willingness are shrinking, and unless we devise a bulletproof strategy, we will soon face the problem of inadequately-trained surgeons. Traditional paradigms of workshops and hands-on courses have proven ineffective, and in fact might aggravate some of the aforementioned parameters.
I believe that the introduction of VR simulation for skills training, AI for assessment and feedback, and further clinical centralization to maximize educational effect (among others), are some strategies that will prove invaluable in our effort to tackle those challenges.
ALES: How do you see VR simulation enhancing surgical training in minimally invasive techniques?
Dr. Lykoudis: VR simulation has come to fill pivotal gaps in surgical training. Apart from safety and reproducibility, which transcend all modalities of simulation, VR simulation has primarily improved realism and immersion. Secondly, although the cost of procuring a VR simulator is admittedly high, it is still significantly more cost-effective than other types of simulation, such as cadaveric training or training on animal models. Moreover, it lifts the ethical concerns associated with the two latter examples. VR simulation allows for personalized training, “tuning” level of difficulty and combination of tasks-objectives. It is practically limitless in terms of tasks, procedures, and operations it can cover. Additionally, it can be standardized and implemented in exactly the same way across different facilities and institutions, and I would even dare to say worldwide. But most importantly, it allowed us to obtain metrics, i.e. numerical measures of performance. This has allowed us to use research and implementation strategies such as those we do in clinical practice, as well as to perform translational research in order to delineate the ultimate question of how clinically useful simulation training is. It would be fair to say that MIS did a “favor” to VR simulation, which had limited potential in the field of open surgery, and now is the time for VR to return the favor by helping MIS become safer and more widely adopted.
ALES: What do you think are the best practices for integrating virtual reality simulation into surgical education programs?
Dr. Lykoudis: Over the past decade, researchers have achieved some significant milestones in VR simulation surgical training. I have the pleasure of participating in one of these teams, and we are proud that we have promoted the concept of evidence-based surgical education. VR simulation has existed for more than three decades, but several key components were missing, hence penetration in surgical education was negligible. Through research we have examined, and to a large extent elucidated, how a meaningful curriculum should be shaped and implemented. Best practice involves seamless access to the facility, evidence-based curricula with exercises, tasks, parameters and pass thresholds that demonstrate face and construct validity. It also involves differentiating learning objectives for trainees at different levels of training/expertise. It involves regular practice, following the concept of “interval training” with carefully tailored duration and frequency. It involves integration in the national training scheme, and potentially in assessment and revalidation. It involves constant quality assessment and improvement of hardware, software, and curricula. And it certainly involves trainers who are experts in respective surgical procedures, who have a profound understanding of the principles of virtual reality simulation, and who are of course “trained to train” according to the highest standards.
ALES: What are your expectations and aspirations for ALES?
Dr. Lykoudis: The percentage of produced knowledge in the field of MIS is increasing exponentially, and unfortunately at the moment it has very few “niches” in terms of publication streams. It is generally mixed with the field of open surgery, and this does not really help surgeons when they want to selectively access this information. ALES can certainly serve as a hub for respective knowledge. But it can certainly do more than that. It can lead the field by attracting top-notch, cutting-edge research, through rapid turnover and rigorous peer-review activity. It can promote discussion on ethical and philosophical aspects of MIS, through insightful and impactful comments and opinions by world experts. It can help shape the future of MIS through hosting healthcare policy and cost-effectiveness trials. It can be a hub for both patients and physicians through educational activities. It can essentially be the “place to go” for those who seek precise, up-to-date and reliable resources on MIS.