The Misgav Ladach Method - Maximum Effect- Minimum Damage

Under the aegis of MASHAV, Israel's Ministry of Foreign Affairs Centre for International Cooperation, knowledge and know-how are transmitted through courses, workshops and individual training programs, given - in Israel and abroad - in fields as diverse as agriculture, community development, cooperation and labour studies, education, science and technology, rural development and medicine and public health. Much of MASHAV's success lies in the way it is able to attract professionals and experts in these fields, with years of experience and impressive backgrounds, to run these courses - to lecture, teach and train.

Dr. Michael Stark, Director of the Misgav Ladach General Hospital in Jerusalem, is one of those experts. He has perfected a state-of-the-art birthing method for performing Caesarean sections that is proving to be safer and simpler than those performed in the traditional, conventional manner. Named after the hospital where it was first introduced, the Misgav Ladach Method is now being used in medical centres in Switzerland, Sweden, Italy, Germany, United States, Russia, Ethiopia, Kenya, Tanzania, Zambia, Uganda, India, Pakistan, China and Peru.

A Caesarian section (C-section for short) is defined as "the surgical removal of the foetus (the unborn infant) from the uterus (womb)." Its use is indicated when either or both the mother and the unborn infant are at risk and normal delivery is then both dangerous and often impossible.

Dr. Stark insists that he did not "invent" the Misgav Ladach Method although he must be credited with the way he "took ideas from many different sources" and put together an impressive package of refinements.

"Essentially," he stresses, "the method is a synthesis of several techniques, notably those developed by Prof. S. J. Joel Cohen, formerly of South Africa, whom I met in 1972 in Vienna where I was a rotating intern and he was a guest lecturer. I had previously read about his work and was deeply impressed by his methods, especially his time and motion studies in gynaecological operations." Later Dr. Stark would meet Prof. Joel Cohen again in Israel at Beilinson Hospital when Prof. Joel Cohen became Head of Obstetrics and Gynaecology "and I had the privilege of working with him."

"The Misgav Ladach Method is basically quite a simple one," explains Dr. Stark, "which eliminates many of the conventional steps taken in traditional Caesarian sections. The result: The procedure takes very little time, simply because fewer steps are performed. I use the Joel Cohen Method of opening the abdomen. A traditional C-section may take from a half to a full hour. Using our method, the operation lasts from 8 to 15 minutes, with the infant often emerging in less than one minute.

"In summary, the operation is much less traumatic for the mother than a traditional C-section and her recovery is extraordinarily rapid." Proof of this claim came when Shalom's reporter talked with one of Dr. Stark's patients, a woman who, less than 24 hours before the meeting, had had her fourth Caesarian. "It all went so fast," she exclaimed. "After just two minutes I heard the baby crying. (N.B. "In actual fact," reports Dr. Stark, "it was 50 seconds.")

"After my first Caesarian, a traditional one performed in the USA, I had terrible pain. Then I was hooked up to an infusion apparatus and for two days couldn't eat or drink normally. I was also in bed for almost a week. The operation yesterday was entirely different, an exciting experience in so many ways. I could eat and drink everything immediately after it and, within a few hours I was up and around, could even bend down and pick things up off the floor."

Dr. Stark points out other benefits to the mother. "Not only does she have less pain and thus less need for painkillers, but there is less if any fever following the operation and thus less need for antibiotics. There is a shorter period for the return of normal bowel functions, fewer adhesions to the peritoneum (the membrane that lines the cavity of the abdomen), less scarring to the abdominal layers and less bleeding. The rapidity of the operation also means that less anaesthesia is required. Overall there are fewer short and long-term complications."

The benefits to the patient carry over to hospitals and their personnel. First, since there is less cutting, less bleeding and less suturing with fewer instruments, there is less of a chance of surgeons sustaining a wound during the operation. This is especially significant in settings where there is a high frequency of HIV (the virus that causes AIDS) and nurses and doctors run the risk of getting the virus from a patient. With the Misgav Ladach Method, this risk in minimized. Second, the speed with which the operation can be performed due to fewer steps saves both operating room and staff time.

The story behind the Misgav Ladach Method is as fascinating as the method itself. Michael Stark is an accomplished pianist, a graduate from the Jerusalem Conservatory of Music. "In music," he says, "I regards myself as an aesthetic minimalist, one who is always looking for the most simple techniques, for the way to play as smoothly and as effortlessly as possible. Thus when I began to search in the literature for ways to improve C-section operations, I looked for material written by those whose approach was minimalistic - in theory and practice.

"My ideas, my whole general approach is based first of all on this philosophical principle of surgical minimalism. I believe in using only those surgical manoeuvres that are vitally necessary, those which are least disruptive to the tissues. If you can do something simply, you don't need to do it in a complex way. That is why, for example, I suture the uterus with one layer rather than two and close the abdomen with two layers rather than the traditional five."

Although Dr. Stark claims that the Misgav Ladach Method is not an original concept, there are original elements in it which he has designed. The way he sutures the uterus is one. So too is a special needle he has invented, as well as a unique method for handling the urine bladder.

Dr. Stark also follows another philosophical principle: Work in harmony with the body's anatomy and physiology. "Thus," he explains, "in the Misgav Ladach Method, the level of the skin incision and the levels of separation of the recti muscles are carefully chosen to be well away from muscle insertion sites. The result: Less force is needed at separation and there is less disruption to the vulnerable blood vessels and nerves near the site of the muscle fixation, similar to the way it is easier to pluck the strings of a string instrument in the middle rather than at the far ends."

The Misgav Ladach Method is currently being tested in multi-centre randomized controlled trials in Sweden, Italy and Kenya. Non-randomized comparative studies have already been done in Israel and Switzerland.

Sweden has played a dominant role in spreading the word about the method to low-income countries. The Swedish medical journal NU, in which a lengthy description of the method appeared, has been sent to 119 countries. "In Israel we ourselves are actively in contact with 22 countries," reports Dr. Stark. He has personally visited many of them - lecturing, operating and observing other doctors put into practice the method they have learned from him.

For the past two years many of Dr. Stark's trips abroad have been within the framework of Israel's program of international cooperation. Some of his on-the-spot workshops, such as those held in Hungary and Slovenia, were only two to three days long. Nevertheless, they were sessions of intense and concerted activity. Much was accomplished as doctors watched Dr. Stark operate and then followed suit, performing under his direction C-section operations according to the Misgav Ladach Method.

Last fall (1996) MASHAV sent Dr. Stark to China where in eight days of marathon activity he gave workshops and lectured on C-section and gynaecological oncology in two cities - Beijing and Daxing - for hundreds of doctors. This trip was followed by a return visit by two of Chinese professors from the first academic hospital in Beijing who came to the Misgav Ladach Hospital for further training.

This winter (1997) Dr. Stark's schedule included visits to Georgia, Kyrgistan and Kazakhstan where, accompanied by a Russian-speaking doctor from Israel who served as his interpreter and assistant, he again introduced the method that is being lauded the world over.

Letters have arrived testifying to the efficacy of the method. A doctor in Karachi, Pakistan, for example, wrote how reading about the Misgav Ladach Method in a medical journal led him to use it. "Already," he wrote, "I have performed 51 C-sections following the guidelines given in the journal. I work on a busy hospital that has very limited resources, as does the very low socio-economic population we serve. I find this method fast, with minimal blood loss and with minimum expense for hospital and patient. This is a significant and useful advantage for any hospital in any country, but especially for hospitals such as ours which have limited resources."

Similarly enthusiastic was a doctor from Bihar, India. In his letter he wrote that he had performed his last 5 C-sections according to the Misgav Ladach Method, again after reading about it in a medical journal. "I feel that it is the single most important development in obstetrical surgery since Munro-Kerr discovered the lower-segment incision in 1911."

And from Uganda a doctor ended his letter with the following words: "I have only praise for the way the method is so painless - for doctor and patient."

Dr. Stark began work on what it is known as the Misgav Ladach Method over 10 years ago. It soon became an on-going evolutionary process of constant refinement and improvement "with the last major change made just five years ago." This does not mean, however, that he has ceased to search for new improvements, for ways to make it even safer, simpler and more efficient - for he hasn't.

In the world of music, great artists constantly search for ways to re-interpret the pieces they play, continually strive to perfect their performance. Those Michael Stark admires the most are those who, as he, seek out the simplest techniques to achieve maximum effect. He has transferred this concept to his work in medicine, with effective and salutary results.

Equally noteworthy, he is an inveterate world traveler, deeply committed to sharing his knowledge with doctors all over. His missions abroad typify the way Israel, long a leader in the field of international cooperation, helps others to help themselves.

Caesarian Sections: A Historical Background

The Caesarian section is an extremely old surgical procedure. Historians record that it was known as far back as 715 B.C. At that time, Roman law, "lex cesaria," advocated its use as a way of removing a baby from the womb of a mother who had just died in order to bury the two separately and on rare occasions to save the life of the baby.

Legend has it that Julius Caesar was delivered by a Caesarian section in 100 B.C. Hence, the reason for its name. In actual fact, the name really derives from the earlier law.

The first such operation where it is known that the mother and baby both survived was in 1500 in Switzerland, but this was a rare case. In the late 1700s and early 1800s, there are records of Caesarian sections being used in cases of obstructed labour as a means of trying to save the lives of both mother and child. Success rates were extremely low. Although occasionally the child survived, the operation was virtually always fatal for the mother.

Gradually, as surgical and anaesthetic techniques improved and as antiseptic and aseptic methods became standard, the first Caesarian sections were done where the lives of mother and baby were assured.

Although the Caesarian section underwent various refinements, until the 20th century the maternal death rate following the operation was estimated to be 75%.