The Human Influence: Revolutionizing Veterinary Surgery

An Interview with Dr. Jeffrey J. Runge

Jeffrey J. Runge, DVM, Diplomate ACVS, has the unique honor of being our first The Back Page interviewee that has a feature article in the same issue (The Cutting Edge: Introducing Reduced Port Laparoscopic Surgery, page 14). As Dr. Runge and I discussed the article last fall, he extended the invitation for my colleagues and me to visit the Matthew J. Ryan Veterinary Hospital at University of Pennsylvania (Philadelphia) and watch surgeries in their new, cutting-edge surgical suite.

We finally coordinated schedules and were able visit in December. What followed was one of the most enjoyable days of my life! Becoming part of the comings and goings of a busy surgical preparation and operating area (and also touring the critical care ward) was an opportunity that gave me a window into the inner workings and demanding days of a high-volume veterinary hospital.

Dr. Runge’s specialty is minimally invasive surgery, specifically surgery that uses state-of-the-art techniques, such as the reduced port platform. While he describes these surgical developments in detail in his clinical article, this column gives us a chance to learn about how human surgical techniques were adapted to veterinary patients as well as why Penn’s new surgical suite is one of a kind. — Kelly Soldavin, Editorial Director

You’re a boarded specialist in surgery that has gone on to collaborate with medical doctors to adapt minimally invasive surgery techniques, including reduced port laparoscopy, to veterinary patients. How did you become interested in this area of surgical medicine? 

During my residency I recognized the potential benefits of the techniques and some of my mentors recommended that I expand my education outside the walls of our institution—the small animal veterinary hospital at Penn. Fortunately, the University of Pennsylvania has an outstanding medical system, and after making special arrangements, I was given the opportunity to attend rounds, observe surgery, and even use Penn’s simulation training facility at the School of Medicine.

I began attending human laparoscopic surgical conferences, and it was at these venues that the reduced port platform was introduced by the pioneers in this field. From the beginning, these human clinicians were excited about collaborating and it was not long before we were doing cases together. Since that time the collaboration has evolved into clinical research, lecturing, and also training seminars.

What are the differences between the reduced port platform in humans versus veterinary patients? 

One of the biggest differences is that the size of our patients in veterinary medicine is typically much smaller compared to human patients. Most of the equipment we use is made for humans, so occasionally the size of instrumentation may not be best suited for our smaller patients. It is very useful for us to utilize the techniques and smaller instruments used in pediatric laparoscopy.

Do you see minimally invasive surgery becoming part of a general practitioner’s repertoire of surgical skills?

Certainly; even as of now there are many general practitioners utilizing minimally invasive techniques, such as laparoscopy, endoscopy, and arthroscopy. Unfortunately, it is a tremendous financial commitment to purchase the necessary equipment; that alone may be a limiting factor when it comes to minimally invasive surgery becoming mainstream. Another limiting factor is the steep learning curve associated with gaining the knowledge needed to use the equipment and perform the surgical techniques.

The Matthew J. Ryan Veterinary Hospital at University of Pennsylvania recently completed a state-of-the-art surgical suite. Can you tell us about it? 

The veterinary hospital’s new, state-of-the-art Buerger Family Minimally Invasive Surgery Suite allows us to offer a comprehensive array of minimally invasive surgical procedures for both companion and exotic animals. It is outfitted with the same advanced technology found in the world’s top human hospitals.

Integrated Surgery
We are very fortunate to have an integrated operating room—it’s a tremendous resource. Most people have never heard of integrated operating rooms; the word integration actually refers to functionally connecting the operating room to its environment. Simply stated, it brings all the necessary information directly to the tips of the surgeon’s fingers:

• Patient information
• Audio and video recording
• Surgical and room lights
• Camera images
• Radiography and ultrasonography
• Magnetic resonance imaging (MRI) and computed tomography (CT) images
• Any other medical resources, such as endoscopic images, that may be needed for a particular procedure.

We are using the OR1 system (karlstorz.com) as the foundation for our integration; this platform lessens the complexity of a hospital’s most complicated environment—the surgery suite. Specifically, the integration platform gives our surgeons and other members of the surgical team control of the laparoscopic scopes, overhead video cameras, flat screen monitors, and all medical imaging associated with the patient streamed to the surgery team in real time.

Procedures & Equipment
The suite allows us to perform any minimally invasive modality, including:

• Arthroscopy
• Laparoscopy
• Thoracoscopy
• Interventional radiology
• Minimally invasive fracture repair (MIPO).

The suite is equipped with the latest telescopes and instruments for performing a broad array of minimally invasive surgical procedures on animals of various sizes. For example, our new smaller-sized pediatric telescope enables me to perform delicate dissection on small patients or even exotic species.

The integration equipment within the suite also transmits this information from various video and data sources and routes it to multiple locations both inside and outside the operating room. The suite is linked with the hospital information systems and radiology, and allows the clinicians to access critical patient information and medical images.

Cutting Edge Communication
One of the most amazing features about this suite is that its video conferencing capability allows surgical images to be sent anywhere, allowing true telemedicine for:

• Real-time collaboration with referring veterinarians
• Sharing information with colleagues at the Philadelphia (small animal) or Kennett Square (large animal) campuses
• Use in the classroom for teaching purposes.

How does this cutting edge design influence the current standard of care for surgery? 

I think that anytime you have the most advanced, up-to-date equipment available, it forces you to push past your previous comfort limit. If we apply this to medicine, the same is true—it pushes the standard of medical care higher.

This suite enables our veterinary clinicians to utilize some of the most advanced technology available for surgical care. I feel very fortunate to have this type of resource available for my patients.

When should a general practitioner refer a patient for specialized surgical care?

That is a difficult question to answer because cases are referred for many different reasons. Many of
the cases referred to us for minimally invasive surgery take place because we do these types of procedures on a fairly regular basis and have the infrastructure to do them successfully, including the:

• Equipment necessary to do the cases
• Experience needed to perform the surgery, due to handling these types of cases regularly
• Ability to ensure a safe and controlled procedure, thanks to our superb anesthesiologists
• Facilities to provide care for critically ill patients in our world-renown intensive care unit.

This type of infrastructure provides comfort to referring veterinarians and owners because they know the patient is receiving the most advanced level of care we can provide at our hospital.

What surgical advancements/improvements do you foresee taking place over the next few years?

I think that we should expect some dramatic advancements on the minimally invasive front:

• We may see the NOTES (natural orifice transluminal endoscopic surgery) platform emerge as a viable alternative to laparoscopic surgery.
• I am also interested to see if robotic surgery will have a place in companion animal procedures.
  In veterinary medicine we typically follow the trends occurring in human surgery. Since these modalities are taking place now in humans, it may be safe to say that they are headed our way too.

Jeffrey J. Runge, DVM, Diplomate ACVS, is a lecturer in small animal surgery at University of Pennsylvania School of Veterinary Medicine. He specializes in companion animal and exotic species surgery and focuses on laparoscopic and thoracoscopic minimally invasive surgery. Through ongoing collaboration with leading human laparoscopic surgeons, Dr. Runge and the University of Pennsylvania School of Veterinary Medicine have become leaders in veterinary reduced port surgery. Dr. Runge’s group applies newer human laparoscopic single-site techniques, such as single port access (SPA), single incision laparoscopic surgery (SILS), and laparo-endoscopic single-site surgery (LESS), to minimally invasive surgery for companion animals. Dr. Runge lectures internationally on both single port and multiport laparoscopic surgery.