In speaking with Dr Yap Lip Kee, a well rounded gynaecologist in Singapore THIS Quarterly discovers that, beneath his soft-spoken exterior, the gynaecologist is a zealous advocate of keyhole surgery and its benefits, having taught and trained extensively for it.

You would expect someone who is a pioneer in a branch of surgery to have brash manners typical of many daring and innovative doctors, However, the distinguished-looking Dr Yap Lip Kee is almost too mild mannered to a fault as he arrives for this interview one rainy evening. Dressed in a pair of deep blue slacks and a long-sleeved shirt with tiny purple-and-white checks, the gynaecologist ushers this writer to the Delifrance café located on the second level of Mount Elizabeth Medical Centre, where his private practice is located. Unfortunately, all the indoor seats are taken, and the inclement weather makes it impossible to sit outdoors unless we are prepared to be soaked to the skin while shouting incessantly above the pitter-patter of the raindrops.

We decide to skip the warm beverage and instead head to his clinic, Gynae Consultancy Pte Ltd. It would be a more conducive place for a chat, since it is about closing time. As we sit by his desk surrounded by charts, equipment, instruments and an examination table, the smell of disinfectant hangs in the air as a cleaner wipes down the office.

Socialist attitude towards medicine

"I started training to be a gynaecologist in the late 1970s, starting in KK Hospital, then Aberdeen Royal Infirmary in the UK.," he says in a quiet voice, adding that he was inducted into the Royal College of Obstetricians and Gynaecologists in 1984. “That was the time when we were acknowledged as a specialist and allowed to practise."

He started his own practice in 1990, "mainly due to push factors". Having always had a "socialist attitude towards medicine", he did not relish negotiating the political minefield that is a public hospital. Working in the National Health Service during his years in Aberdeen reinforced his belief that everyone should have access to healthcare. It was also where he gained a different perspective of medicine. "The Scots are very pragmatic people, and their understanding of the economics of healthcare is that we aim for service to be good, fast and cheap. However, any economist will tell you that only two aims can be achieved at any one time. So if you want it fast and cheap, then be prepared to question the quality," he quips.

Noticing patient trends

Dr Yap had initially wanted to pursue orthopaedics, but decided to specialise in obstetrics and gynaecology because he liked the idea of helping two people at once. However, he has given up delivering babies to concentrate on helping women with gynaecological problems. "The reality is that obstetrics is unpredictable, and I feel terrible each time I miss a delivery. It’s as if I have failed to deliver on a promise," he admits. "And with much of my work being in the operating theatre, I have to ask colleagues to stand in for deliveries." In addition, he is involved in chairing Singapore Medical Council Disciplinary Tribunals, which can last for hours and take weeks to complete. "With this, I felt it best to not commit to something I cannot literally deliver."

About half his patients see him for menstrual problems or abnormal uterine bleeding. "They are common all over the world," he observes. Being a conscientious medical professional, he clarifies, "Actually, I should say that abnormal uterine bleeding is not a condition; it is a symptom. People see a doctor because of the symptom, but the causes vary."

While he has not noticed women from a specific race or region getting particular conditions more than usual, he concedes that women with African ancestry are more prone to abnormal bleeding due to uterine fibroids. "It is most likely a genetic predisposition," he surmises.

Another interesting trend he mentions has more to do with social engineering than a medical condition. He could never find a candidate in China on whom to demonstrate corrective surgery for stress incontinence, which is leakage of urine when a woman coughs or laughs. This usually occurs after a woman has given birth normally.

In discussions with local experts, he learnt that this was because of the onechild policy in China, which meant parents wanted perfect children - opting for birth by caesarean section seems to ensure that situation. "When you have a C-section, the birth canal does not undergo the stresses of vaginal delivery. This results in lack of damage to the bladder and supporting structures, hence no bladder weaknesses."

Whatever gynaecological problems they have, he observes that oriental women tend to come forward more slowly. "I think South and Southeast Asians tend to come forward earlier, while those who delay treatments the longest tend to be those of Chinese origin."

Establishing his reputation

Dr Yap discloses that he usually gets patients via word of mouth or referrals from colleagues. These patients usually need endoscopic or keyhole surgery. "I established my reputation in fertility and endoscopic surgery," he adds.

In fact, he is a little embarrassed when he reveals that he has overheard colleagues referring to him as the "grandfather of laparoscopy". Laparoscopy is another term for keyhole surgery.

He feels the title is unjustified for two reasons. "For one, I am not a grandfather yet!" Dr Yap is married to Rachael, an anaesthesiologist, and they have three adult children. The other is that he feels there are more senior doctors who deserve the title more than he. "I would be happy to be acknowledged as ‘one of the pioneers of operative laparoscopy’," he says with a smile.

He confesses that he always aimed to be among the best, but not necessarily the first, for any procedure. This is because the first tends to make mistakes for others to learn from. "I am happy watching and adopting the best practices," he says. And he learnt from the best in the world during the 1980s, such as the late Professor Kurt Semm in Kiel, Germany, and Dr James Daniel in Nashville, Tennessee, USA.

But what was it about laparoscopy that fascinated him?

"Here was a whole new type of surgery that allowed us to operate by introducing fine instruments through small punctures to do precision surgery aided by cameras, giving us a highly magnified view of the female pelvis,” he marvels. In contrast, the alternative was traditional surgery, which meant making cuts big enough for surgeons to put their hands into the female pelvis and abdomen to remove organs or carry out repairs with traditional instruments and without magnification of the area being operated on.

Steep learning curve

“When laparoscopic surgery was starting out, we were very clear in our minds that this would be the way to operate in the future,” Dr Yap says. “But only if we could master the skills that allow us to avoid complications.” Such complications usually mean damaging nearby organs, most commonly the intestines and blood vessels.

He reveals that many doctors found it difficult to retrain themselves from looking and operating on the target organ directly to operating on an organ viewed on a screen. “This is like playing a video game; you have to look at the screen and try not to look down at your hand controls,” he describes. “When that barrier was overcome and safe techniques were introduced and learned, laparoscopic surgery became the accepted method of surgery for most procedures.”

Dr Yap gives the example of ectopic pregnancy in KK Women’s and Children’s Hospital. In 1990, less than 5% of ectopic pregnancies were treated by laparoscopy; five years later, 50% were treated by laparoscopy while the remaining had open surgery.

This is like playing a video game; you have to look at the screen and try not to look down at your hand controls.

By 2000, 95% of ectopic pregnancies were treated by laparoscopy, making it not only the gold standard, but the only acceptable method of treatment.

International recognition

In 2003, when Dr Yap had just turned 50 years old, he became the youngest president of the International Society for Gynecologic Endoscopy. He was also the society’s first Asian president.

“I had been approached to stand for the post by my mentor, Dr James Daniel, with whom I had been running operative demonstrations in India, Malaysia, Singapore and Thailand,” he recalls. The nomination was uncontested because Dr Daniel had the support of a majority of the members, most of whom had attended an event organised by the Obstetrical & Gynaecological Society of Singapore in 1997 — Dr Yap was chairman of the organising committee and hence was a recognisable face. “I wish to think it was my operative skills that caught the eye, but it was more likely as recognition of organisational abilities. I did not think much about being the first from Asia, apart from the thought that it was an honour long overdue,” he shares.

Still an active member of the International Society for Gynecologic Endoscopy, he is involved in its Training Committee, especially for Asian countries. He was made an Honorary Member in 2016.

Travelling advocate

Dr Yap has travelled extensively to give seminars and demonstrate the use of laparoscopic surgery. It is still the best way to promote its use. “Doctors tend to only believe what they see, hence operative demonstrations in their local hospital is the most effective way of getting the message across that this surgery can be done, and safely,” he insists. “Videos and live telecasts are poor substitutes.”

He feels blessed that he has a supportive and understanding family, which allowed him to travel as frequently as he did. In fact, his medical travels have rubbed off on Rachael and their ophthalmologist daughter, Zhu Li: they both contribute their skills on overseas medical mission trips. “While the children were young, at least one parent was always around, but now that they are young adults, we are able to travel more together, and not just on professional assignments.”

Diagnostic vs operative laparoscopy

Introduced by general surgeons to Singapore in the early 1960s, diagnostic laparoscopy was used to ‘look and see’ and did not have a significant role. Simple operative laparoscopy in the form of tubal ligation was offered at KK Hospital in the 1970s, and was a significant tool to control Singapore’s population.

The 1980s ushered in new equipment and the ability to perform complex surgery. Treatment of ectopic pregnancies, freeing of adhesions, and removal of ovarian cysts, fibroids and the whole womb became possible through laparoscopy, also known as keyhole surgery.

Towards the end of the 1980s, laparoscopic cholecystectomy was started in France and popularised in the USA. When general surgeon Dr Mohan Chellappa approached me to collaborate in bowel adhesiolysis, we took all the laparoscopic equipment from the gynaecological theatre to the general surgery theatre and removed a gall bladder from a patient. This, we realised later, was the first laparoscopic cholecystectomy in Asia, beating India by a month, Hong Kong by two months and Japan by six months. This led to a two-year lecture tour in the Asian countries between India and China.

When the novelty of that procedure wore off, I concentrated on developing and advancing gynaecological surgery. The team probably did the first laparoscopic myomectomy and hysterectomy in the region. These were not covered by the local press as advances in gynaecological laparoscopy represented evolving technology, whereas laparoscopic cholecystectomy was revolutionary.

Limited role of the robot

Traditional laparoscopic surgery accounts for 98% of gynaecological laparoscopy. Robotic surgery in gynaecology is currently a novelty, not a category. Its use in gynaecology is not value-added and limited.

Open surgery is still an option

Almost all gynaecological surgeries can be done through the laparoscope. However, when your surgeon is happier doing it by the open method, follow his advice; that is what he is better trained for and will hence be safer. The end result is likely to be as good, albeit without the advantages of keyhole surgery. If you have any doubts, it makes sense to seek a second opinion.