Medical Articles in Cayman Islands

Dr. Sarath de Alwis, a consultant/specialist of obstetrics and gynaecology attached to Chrissie Tomlinson Memorial Hospital, has been using the innovative laparoscopic entry technique in Cayman for more than two decades.

Now, doctors at Harvard Medical School are using this method and an article on the technique, called the “Modified Alwis Method”, has appeared in the latest edition of the medical journal Reviews in Obstetrics & Gynecology.

The article stated: “Although we acknowledge that no entry method is foolproof, we have yet to experience an entry–related injury using this method, with the lead author [Dr. Jon Einarsson] performing 450–500 advanced laparoscopic cases per year.”

It continued: “We encourage surgeons to standardise entry techniques as much as possible and to seek guidance from other surgeons if they are encountering frequent complications during laparoscopic entry.” Dr. de Alwis introduced his surgical method to Dr. Einarsson, director of Minimally Invasive Gynaecologic Surgery at Brigham and Women’s Hospital and assistant professor of Obstetrics, Gynaecology, and Reproductive Biology at Harvard Medical School in Boston, more than two years ago.

Laparoscopic surgery is a non–invasive method of entering the abdomen though a small incision to enable a scope to be inserted to view the internal organs.

The entry of the scope, through the bellybutton, however accounts for 40–50 per cent of complications arising out of the procedure.

Minimising injury

“We developed a technique to minimise that type of injury,” Dr. de Alwis Dr. de Alwis at his clinic at Chrissie Tomlinson Memorial Hospital. said. “We showed it to Harvard medical professors; they accepted it and have published it in this journal under the “Modified de Alwis Method”.

“I’ve been using this technique for decades. I started this a long time ago because of the fear of bowel injury,” he explained.

Using the method, Dr. Alwis said he had removed 47 fibroids from the uterus of one patient and 41 fibroids from the uterus of another last month. He performed his first laparoscopy in Cayman in 1995 and has worked with Chrissie Tomlinson Memorial Hospital since 1996.

His method relies as much on his ears as on his surgical skill because he is guided by the sound of negative pressure being made in the abdomen of the patient to determine exactly where to insert his surgical instruments. Dr. de Alwis explained the method in layman’s terms, at his office in the Chrissie Tomlinson Hospital surrounded by members of the team he said were instrumental in the success of the procedure.

Surface tension

“It’s a simple technique. If you stand on your head, the bowels don’t drop because [of] surface tension that holds things together,” he said, licking his finger and touching a piece of paper which he then lifts off the table, attached to his finger. “That’s surface tension,” he explained.

“The bowels do the same thing. They hold onto each other because of surface tension… In the abdominal cavity, that surface tension prevents bowels from dropping and changing position. Using that principle, we put a little gas in and test to hear the response to that negative pressure inside the abdomen.

“With that technique, we are able to say that we are definitely in the abdominal correct place or not, so we don’t have to put trocars in the wrong place,” he said.

Trocars are metal tubes that are inserted in the abdominal cavity during laparoscopic surgery.

Negative pressure

“It is similar to the mouth. If you suck in the lips, when you let them go you hear a noise. That’s the movement from high pressure to low pressure,” he said.

Being able to listen to and identify the exact noise made in the abdomen during this surgery has enabled him to carry out about 10,000 of the procedures. The modified version entails surgeon using monitors and machinery to detect the negative pressure, rather than relying merely on the sound.

With the modified version, a warning alarm will sound and a negative pressure warning will appear on a monitor.

“It is important that in a small country like Cayman, we have a procedure that has been accepted in a leading medical school,” Dr. de Alwis said.

Dr Sarath de Alwis-Seneviratne, a leading consultant/specialist in obstetrics & gynaecology attached to the Chrissie Tomlinson Memorial Hospital (CTMH), has devised a new and effective method of performing the laparoscopic entry surgery that would minimise risks, injury and even death of patients.

This new technique was published in an article entitled “Laparoscopic Entry: The Modified Alwis Method and More” in the Summer 2009 quarterly edition of the ‘Obstetrics & Gynecology – MedReviews’ magazine. Dr de Alwis wrote the article together with professor Jon I. Einarsson of The Harvard Medical School of the United States.

One of the greatest advances in medicine this century has been the advent of laparoscopic surgery, which is a non-invasive way of entering the abdomen through a very small incision to view the internal organs, through the use of a “scope”, called a laparoscope. This type of surgery is also known as “keyhole” surgery and is used for conditions such as ovarian cysts, fibroids, endometriosis, ectopic pregnancies, hernia, certain cancers, gall bladder, appendicitis, etc.

Despite the rapid advances in laparoscopic surgery in the past two decades, the initial entry with the scope into the body has accounted for 40 percent to 50 percent of the complications from the delicate procedure; a number of cases have even resulted in death. Due to this fact, a variety of laparoscopic entry methods have been described and used by doctors, to try to eliminate possible complications.

The article stated, “The basic principle of umbilical entry technique is to take advantage of the negative intraperitoneal pressure that is generated by pulling on the abdominal fascia. We have been performing this technique for several years with good success, but recently heard of a similar technique that has been performed successfully for decades by Dr Sarath de Alwis in the Cayman Islands. In his honour, we have named the technique the modified Alwis method.”

The article concluded, “Although we acknowledge that no entry method is foolproof, we have yet to experience an entry-related injury using this method, with the senior author performing 450-500 advanced laparoscopic cases per year. We encourage surgeons to standardize entry techniques as much as possible and to seek guidance from other surgeons if they are encountering frequent complications during laparoscopic entry.”

Earlier this month, at the CTMH, Dr de Alwis, with the assistance of Dr George Meggs, removed 47 fibroids from the uterus of a patient and reconstructed it. Last week, he removed 41 fibroids and reconstructed the uterus.

Dr Sarath de Alwis has to his credit the first laparoscopically-assisted hysterectomy surgery, with the late Dr Shri Jog, performed in the Cayman Islands, and the first laparoscopic ectopic surgery in 1995.

This article can also be viewed at www.medreviews.com.

The citing of Dr de Alwis for his professional expertise by Harvard is not the first time that he has been recognised for his medical contributions. He was also highly commended by Dr Michael Barrie, a general practitioner at Epsom Hospital, London.

In Dr Barrie’s book “The Surgeon’s Rhyme – A Memoir” first published in 2004, Dr Barrie stated, “How can one change oppressive patients, who make unreasonable demands left, right and centre? How can one, temper the intemperate?” There is a way he says: “Sarath de Alwis-Seneviratne, a gynaecologist with whom I worked at Epsom Hospital, impressed on me the high value of a patient’s belief and expectations. Sarath taught me far more than obstetric techniques.”

He further explained, “He possesses endearing charm and wit every time, bringing round even the most challenging patient to his way of thinking. He has a knack for it and pulls it off perfectly, not just some of the time, but all of the time.”

Dr Barrie relates an instance where he had to look after a special troubled teenager, who was heavily hooked on drugs and was now pregnant with various complications. It was at once clear to him that she would require a special kind of obstetrician – not just a skilled doctor but also someone who would be sensitive to the complexities of the situation, a doctor, who would not malign the patient or pass judgement for the life she led, or vilify her partner for the part he had played in perpetuating her problems. The answer was evident: “I would ask Sarath to look after her. I telephoned him and outlined her case. Not once did I detect a hint of regret in his voice nor hear a soft sigh of reluctance. He was typically enthusiastic, and reassuringly was pleased to have been asked.”

When asked what his guiding principle in medicine is and what makes him happy and fulfilled in his profession, Dr de Alwis replied, “My utmost priority is giving comfort and relief to my patients. I feel a sense of fulfillment whenever I am able to let patients get on in life with dignity. It is also very rewarding being able to treat infertility. Nothing in the world can replace the joy of bringing a baby out in the world.”

Dr de Alwis specialises in treating infertility cases and about 60 percent to 70 percent of his patients comprise this segment. His most recent accomplishment was when he was able to let a 46-year-old woman conceive (without the need for an ‘in vitro fertilisation’ method — IVF) and give birth to a healthy baby, after 28 years of trying. The case of the patient is special because she is a diabetic and on insulin medication.

Dr de Alwis agrees IVF is good but only once all other avenues have been exhausted. ‘In vitro fertilization’ is expensive and the success rate ranges from 9 percent – 60 percent only. In Jamaica it costs around US$6,000 and in the United States from $10,000 – $15,000. At the CTMH, however, the cost of infertility treatment is less than a third of the cost in the United States. But Dr de Alwis still prefers to first use conventional methods like medication and injections, before opting to use IVF. Only a small fraction of his patients have needed to go for IVF. Dr de Alwis maintains a success rate of over 90 percent.

When asked what makes him successful in his profession Dr de Alwis replied, “I am extremely careful and meticulous when operating or treating my patients. I always think that the person I am dealing with or the person lying on the operating table is my mother or wife. It always works for me.” He owes his success to his divine parents, wife Rashantha and son Sacha, without whom he would not have achieved it.

“But I would like to commend all the staff that make up the Chrissie Tomlinson Memorial Hospital. They make my job easier and give excellent support every time. I remember one instance when I requested the latest suture material from a staffer, Shern Williamson. He immediately acted on my request and gave me the best suture material in the world in a week’s time.”

“Not only do I appreciate the staff that makes up the operating team, but also each and every person that runs the Chrissie Tomlinson Memorial Hospital. It’s a team effort. I cannot do everything alone. Credit must be given to the maintenance staff, to the gardener and kitchen helpers; everyone is very efficient and contributes to the warm family atmosphere that brings healing to our patients. Dr Steve Tomlinson likewise believes in the values of dedication, compassion and sincerity,” added Dr de Alwis.

Dr Sarath de Alwis-Seneviratne regularly holds clinic and consultations at the Chrissie Tomlinson Memorial Hospital, including Saturday mornings.