Khalid Amer1, Jin Ye Yeo2
1The Cardiovascular & Thoracic Centre, University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK; 2JOVS Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. JOVS Editorial Office, AME Publishing Company. Email: jovs@amepc.org
This interview can be cited as: Amer K, Yeo JY. Readers’ Choice: Author Interview with Dr. Khalid Amer. Journal of Visualized Surgery. 2025. Available from: https://jovs.amegroups.org/post/view/readers-rsquo-choice-author-interview-with-dr-khalid-amer.
Expert introduction
Dr. Khalid Amer trained as a general surgeon in Khartoum, Sudan, and then sought super specialization in Cardiothoracic surgery in the UK. After completing 6 years of training in Cardiff, Wales, he obtained the specialty degree of FRCS(C Th), approved by the four Royal Colleges. After a short period in Bristol, Dr. Amer settled in a pure thoracic surgical position in Southampton. He was introduced to video-assisted thoracic surgery (VATS) by chance, but he managed to turn around the Southampton Thoracic unit into one of the most active minimally invasive units in the UK. VATS lobectomy was introduced in 2004, shortly followed by VATS Systematic Mediastinal Nodal Dissection. Dr. Amer introduced VATS decortications, diaphragmatic plication, and the use of VATS in thoracic trauma to the Southampton Thoracic Unit. In 2016, the subxiphoid VATS approach was established as routine for extended thymectomy. In 2017, it was possible, for the first time, to safely suture by VATS a 10X10 cm Bovine pericardial patch to cover a large pericardial defect resulting from lung tumor invasion. His team established the combined minimal access neurosurgery and VATS for dumbbell neurogenic tumors invading the intervertebral foramina. His minimal access throughput increased from 10% of all operations in 2004 to 85% of all operations by 2016. He hopes to be remembered for his work in describing the anatomy of the recurrent laryngeal nerves in the chest from a thoracic surgical perspective.
Dr. Amer’s article, “Thoracoscopic approach to congenital diaphragmatic hernias in adults: Southampton approach and review of the literature”, published in our journal, has received an outstanding readership and entered the journal’s Most Read Article List.
Figure 1 Dr. Khalid Amer
Interview
JOVS: You have had a distinguished career in cardiothoracic surgery. What first drew you to this field?
Dr. Amer: I have always wanted to be a ‘heart’ surgeon since the age of 8 years, inspired by my uncle, a famous and successful cardiologist. I wanted to emulate his experience and gain the respect of my peers and society. Neither my uncle nor my father talked me into this career, not even once. They let me do what I liked as long as I was good with my school grades, and I never disappointed them. After graduation from Khartoum University, I pursued training in general surgery and obtained an MD in general surgery. Shortly thereafter, I joined the sole unit of cardiothoracic surgery at Shaab Hospital in the capital, Khartoum. During that time, the only trained Cardiothoracic surgeon, Ibrahim Mustafa, died following a terrible accident. There was no one to serve the population of 60 million in this specialty, and I felt it was incumbent on me to fill in his shoes. I came to the UK in 1992 and sought training in the specialty of cardiothoracic surgery and completed my training in Cardiff, Wales. I planned to return to Sudan, but fate had other arrangements. Sudan was riddled with war, and my family decided to stay in the UK.
JOVS: Looking back on your career, what were some of the most defining moments or challenges you faced, events, or surgeons you met that shaped your future?
Dr. Amer: I took an additional out-of-program year, learning a little more about esophageal surgery at Heartlands Hospital, Birmingham. There, I met someone who reset my mind about thoracic surgery, Mr. Joseph Marzouk, an inspiring surgeon who convinced me that thoracic surgery could be mastered inside out, back to front. More than anything else, I was so impressed with his evidence-based approach to decision-making. The quotations of evidence from scientific publications were effortlessly at the tip of his mouth. I made my debut in VATS in Heartlands Hospital at the time keyhole surgery of the chest was just starting in the UK as a diagnostic biopsy procedure, together with the introduction of Talc pleurodesis. After finishing training, I was faced with a career-defining decision. By the year 2000, it was exceedingly difficult to get a substantive consultant post as a double practice in cardiac as well as thoracic surgery. One had to choose between the two. My own predilection was 50:50 as I loved both equally. It transpired that a consultant thoracic surgical position became vacant at Southampton Hospital, and I did not hesitate to put in an application. The words of Jo Marzouk jumped to mind: “A good center does not make you a good surgeon, but a good surgeon can make a good center.” I was starting from a good position. Luck played a major role in introducing me to VATS. A young lady representing Ethicon, Johnson & Johnson, invited me to attend a short course in VATS lobectomy proctored by Bill Walker, the father of VATS in the UK. The course was in Hamburg, and delegates got to perform VATS lobectomy on live anesthetized pigs. I had never been to Hamburg before, therefore my acceptance was swift and ardent. Attending Bill’s presentation was mind-boggling. I knew then that I would never be the same again. Nothing prepares you for meeting such great legends. Bill helped me set up the Southampton VATS program, which was a great success. It soon proved to be the second-largest center for VATS lobectomy in the UK after Edinburgh. Surgeons all around the world were intrigued by VATS and regarded it as the future of thoracic surgery. I was surrounded by a hard-working team, without whom my achievements would not have been possible. The natural maturity from a rookie to a pioneer was invisible and imperceptible. I was always of the opinion, “Don’t be the first to do it, but don’t be the last to follow.” That changed. VATS was an uncharted territory, and history was being made. I was conscious of the risks and the opportunities but always prioritized patients’ safety. My progress in VATS at Southampton was slow but steady. I adopted the motto of the Great Britain cycling team: “Success is the addition of marginal gains.” By pure chance again, I met Professor Nomori, a Japanese disciple of Professor Naruke, at a conference at Edinburgh organized by Bill Walker. Professor Nomori gave me seven CDs containing the last operations performed by the Late Professor Naruke. Watching these videos changed my life. Apart from the meticulous artwork of the master, the nodal dissection stood out. I kept asking myself a consequential question: “Why do the Japanese keep this knowledge close to their chest?” At that moment, I decided to know the inside out, back to front, through in through, left, right, and center about nodal dissection. This tedious endeavor took me to the All India Institute for Medical Science (AIIMS) in New Delhi, and with the help of Professor Zamir Khan and Professor Rajinder Parshad, we engaged in dissecting freshly embalmed human cadavers. This was a golden opportunity to decipher one of the most important mysteries in chest surgery in general, and nodal dissection in particular, the Recurrent Laryngeal Nerves. The three of us would spend hours dissecting the nerves in the chest after all the delegates had left for dinner. That laid the basis for the safe dissection of nodes in the chest without the dreaded complications of vocal cord paralysis.
JOVS: What were some key advancements or shifts in the field of cardiothoracic surgery you have witnessed over the course of your career?
Dr. Amer: Despite moving to pure thoracic surgery, I kept abreast of cardiac surgery. I think the advent of self-expanding drug-eluting stents for the coronary arteries has substantially affected revascularization heart surgery. As a result, the workload for cardiac surgeons has been substantially reduced. At the same time, VATS lobectomy became popularized by surgeons around the world, such as Tony Lerot, Bill Walker, Tsugo Naruke, and Rob McKenna, amongst others. Surgeons were discovering new indications for VATS with alarming speed. Suddenly, the industry of minimal access equipment was expanding like never before. The advent of robotic surgery is a huge development, and in my opinion, it will replace VATS once the issue of cost is superseded. In the field of lung cancer surgery, we will witness major changes soon. Surgery of the chest will follow the historic path of breast cancer and become more conservative. We will see target VATS or robotic-assisted thoracic surgery (RATS) segmentectomies and subsegmentectomies with intraoperative nodal flow cytometry. Hybrid treatment with surgery, chemotherapy, radiotherapy, and immunotherapy will be bespoke and tailored to specific targets.
JOVS: How did you balance the demands of service provision with innovation and research throughout your career?
Dr. Amer: With difficulty. I was lucky to have been surrounded by a dedicated team of anesthetists and theatre assistants. More importantly, my registrars were deep into collecting data and writing abstracts for conferences. Innovation is never attributable to a single person. The line managers, on the other hand, kept harassing us about the waiting list and the expensive stapling devices I started to use. One of my mentors, Mr Breckenridge, used to say, “You shouldn't make a business out of a service”, and this tallies with the words of Aneurin Bevin, the first health minister of the NHS in 1948; “the NHS should be free for all at the point of service”. The question is asked: Can we afford it? Supposing the answer is “No”, what does that mean? Simply, it means we consciously chose to live in the dark ages and let technology pass us by.
JOVS: In your article, "Thoracoscopic approach to congenital diaphragmatic hernias (CDH) in adults: Southampton approach and review of the literature," the topic of CDH in adults is relatively niche. What sparked your interest in exploring this condition in adults?
Dr. Amer: Not by choice. The subject, as you mentioned, is niche and rare. A thoracic surgeon in the UK is likely to get about 0-3 cases referred during his or her entire career. I was blessed to have two referrals within three months. Louis Pasteur once said, and I quote: “Chance favors the prepared mind”. At the time of referral of the first case, I had a relatively good experience in diaphragmatic VATS surgery. A review of the literature and a few operative videos on YouTube were sufficient to make up my mind. I must say this is not the whole story. Those two cases were discussed with my upper gastrointestinal tract colleagues, who by far outwit my modest keyhole experience. They backed me up, and at the time of the operation, they were on standby in a nearby theatre, ready to take over and convert the procedure into an abdominal approach. Of course, the patients were fully briefed. One of the very hard exercises that I have been very consistent with is to tell the patient that I have never done this operation before but have enough experience to do it.
JOVS: The thoracoscopic approach has become more widely adopted in various surgical fields. In your experience, how do outcomes with thoracoscopic repair compare to traditional open or laparoscopic surgery for complex cases like CDH in adults? Are there any long-term considerations that surgeons should be aware of?
Dr. Amer: You are right. As always, the arbiter between chest versus abdomen is randomized trials. Unfortunately, the numbers are too small to set up a meaningful trial. Auditing one’s results and follow-up of patients for a long time is what I tend to do. The repaired diaphragm is notorious for becoming thinned out with time, and long-term complications can occur. Historically, the abdominal approach has stood the test of time. Suggesting a thoracic approach got me into trouble in the first case, as it ignored the already tried and tested. Nonetheless, in my opinion, the thoracic approach has more merits than the abdominal one. Only time will tell.
JOVS: As you look to the future of cardiothoracic surgery and the treatment of congenital diaphragmatic hernias in adults, what advancements or innovations are you most hopeful for?
Dr. Amer: Robotic surgery is already here. This is the future of thoracic surgery, no doubt, especially the uniportal robotics using the octopus arm with different devices coming out of one arm. The hand-wrist motion ability within a limited space makes stitching the diaphragm child’s play. Nevertheless, cost is a major impediment to the widespread robotic practice.
JOVS: Finally, as a retired surgeon and accomplished researcher, what advice would you give to new generations of minimal-access thoracic surgeons?
Dr. Amer: Seeking a combined cardiac and thoracic surgical qualification is no longer practical. You do not have to be a very clever person to be an accomplished thoracic surgeon, but you need to work smarter and harder. We are living in the golden age of thoracic surgery. VATS and RATS are opening Pandora’s box, and history is being written as we speak. One should follow the technology closely but respect one’s judgment. What works in the hands of your boss might not work in your hands. Get rid of taboo practices and always question, “Is there a better way to do this?”. Research is vital to keep abreast of your own results; it is difficult but mandatory. Surround yourself with achievers, and remember that teamwork brings happiness to the unit. Update yourself with the knowledge of the hospital guidelines for introducing new procedures and invasive techniques. It will save you a lot of grief. The clinical governance and ethical committees are there to help you be on the right side of the law. Nevertheless, one should not be disheartened by these processes and keep the balance between patient safety and innovation. Finally, always remember that success is the summation of marginal gains.