Monday, October 09, 2006

On the Other Hand...


The thing about laparoscopy is that it's so impersonal. If open surgery is intimate, as I tried to convey in my previous post, laparoscopy is insulated, stripped of sensation; performed, in essence, outside of and separate from the patient. I like it. Don't love it.

I'm no Luddite; not a troglodyte. I'm enlivened by the innovations that are a part of surgery, and I think it'd make an interesting post at some point to enumerate the ways in which things are different now in the care of the surgical patient, compared to the ice age in which I trained. Unlike some of my fellow elders -- unschooled in video games -- I found the transition to laparoscopy technically easy: the ability to do three-dimensional things while looking up at a two-dimensional screen is not intuitive for everyone. From the outset, for the most part, I could get a skinny instrument to where I aimed, and make it do what I Nintended. It isn't hard to see that certain operations done laparoscopically are better in all ways for the patient. And yet.

In that previous post, I tried to describe what it's like to stand before a person and cut deeply; to reach in and hold and touch. I suppose there's no reason why a procedure has to encompass that kind of drama, nor why a surgeon ought to or needs to have that sense of awe. Still, it's my reality. And it's entirely missing in laparoscopy, which happens to be all I do nowadays, in the OR.

To begin an open operation, you step to the patient's side, receive the scalpel, and go to work. WIth laparoscopy, you screw around with half a dozen hoses and cables -- these go here, those go there. Hook things up, white-balance the camera, adjust the screens. Make sure the settings are correct; there's gas in the tank. Then finally, pick up a pathetic toad-stabber of a knife, and make a little poke. A silly, baby-step of a puncture; like you ought to say "s'cuse me." Then, as enough time has passed already to be half-way through some operations, you fffffffffffill the belly with gassssssssssss, and wait some more, watching as the abdominal wall -- rather than submitting and opening itself to you -- distends like yesterday's roadkill.

Sorry. It's not that bad, really. But there's surely something missing. If you do what you do by watching on a TV, you're almost not there. The patient can't be sensed; it's remote and cold. And it's not just rhetorical: you get information from the feel, the warmth, the tissue resistance, the smell when you are open. Via the scope and its tools, it's transmitted; just pixels. You are in a real sense divorced from it. As with a jigsaw puzzle, or putting together the Christmas toys, it's engaging in another sense. It's the delivery of a skill, the application of rapidly evolving technology, using beautifully engineered tools. As I said, I like it, but in a way very different from open surgery. And whereas it's being used for a number of operations where it really is no better than well-managed open surgery (no safer, more expensive, no shorter recovery), it is a very positive innovation and a huge step forward in many important ways. Nissen fundoplication (to cure esophageal reflux) is clearly one of them.There's something fun about it, in a laboratorical way: placing a suture, cutting and tying it while observing your actions on a screen (despite the annoying time-wasting of constantly sliding instruments in and out of trochar ) is a rewarding challenge, the development of the skill for which is quite satisfying. Still, it would never happen in open surgery, as it does occasionally in laparoscopy, that when you and your assistant are manipulating the same sort of instruments, staring at the TV screen, you ask "Is that me, or you?"

Isn't there something to be said for intimacy? Is there no way in which a meeting is better than a video conference? Will we not have a more important bond if I've really touched you? Truth is, I don't know. Without doubt, the surgeon's relationship is different, in some ways, with laparoscopy. In the long run: probably doesn't matter. Even if it does, we ain't going back. If it did matter, I suppose there'd be surgeons and their patients wandering aimlessly around surgical wards like duckings that failed to imprint on their mothers. And I admit it: other than writing about it with the afterglow of my previous post still warm in my mind, I think laparoscopy is, in fact, a very good thing. Mostly. Much of the time. Usually. If well-chosen.

13 comments:

Moof said...

Dr. Schwab, for you, surgery is a canvas, and you're the artist. And more. You're describing the difference between painting with a brush - knowing when to apply pressure ... knowing when to dab lightly ... the feel of the paint flowing from the brush ...

... rather than knowing how to create a circle in Photoshop, and then knowing how to apply a graded fill ... and knowing which menu item gives what result ...

But you know - I think that being an artist is more in the eye than in the hand, and I have a feeling that you're going to be an "artist" no matter what media you're using ...

Medblog Addict said...

Another great post! I really appreciate the visual aids. Also, thanks for visiting my blog.

CholeraJoe said...

As an internist/pulmonologist/critical care physician, I grew up doing things by remote control - fiberoptic bronchoscopy, right heart catheterization using only pressure wave forms and temporary pacemakers.

My favorite procedure, however was inserting a chest tube, where you can feel what you're doing.

Laparoscopic hernia repair is all the rage now. One surgeon, my age, still does all of his under local. The patients go home in a couple of hours and are back at light work in less than a week. When I develop a hernia, guess who is doing mine?

Sid Schwab said...

cholerajoe: lap hernia is one of those that's on my list of the wrong use of the technology. For one thing, time is showing -- in many series -- a higher recurrance rate. For another, it takes longer, costs way more (in equipment use -- and whereas the cost to the patient is usually the same, since payors tend to pay the same for any method, the higher overhead means less return for the OR -- and is no better tolerated than a properly done open one. Which can be done through a quite small incision, and, using mesh (as is done in the lap model) it is much less painful than the older methods. I never did a lap hernia. Did all my open ones as outpatients, many under local, and, as you describe, people returned rapidly to work. Instructions: do anything you want whenever you want, based on comfort.

#1 Dinosaur said...

Different reaction here:

I confess to having read your previous post with not a little discomfort (in addition to admiration for your writing.) What you call "intimacy" -- cutting me open and reaching inside my body -- I experienced (just reading about it) almost as a violation, which of course it is; it also happens to be your chosen modality of healing.

I'm struck by the asymmetry of the situation: although you may respect the patients for giving you their trust, I guarantee many of them didn't feel they had much of a choice in the matter. All they wanted was for the pain to stop, and for that they tolerated your intrusions. To me, "intimacy" is a two-way street, and I found myself a bit offended at the use of the term in this context.

Consider the pelvic exam: wouldn't it give you pause to hear a gynecologist wax rhapsodic about how much he enjoys the "intimacy"; of patients who trust him so by allowing him to put his fingers into their vagina and hold their uterus and ovaries between his two hands? Don't ever make the mistake of thinking the patients feel this way. They're only submitting to it because they have to, just like your surgical patients.

Regarding laparoscopic surgery, though: if you can make me stop hurting without cutting me open, sticking your hands in me and feeling around all over inside me, tough cookies if it's not as much fun for you.

No offense intended. In fact, it's a tribute to the evocative power of your writing and your willingness to share such visceral emotions.

Sid Schwab said...

dino: I appreciate the thoughtful and provocative reply. Really, since I've retired to surgical assisting only, and as I've written a few things about surgery, I've been thinking a lot about the unique relationship between a surgeon and patient, and about ways of expressing it. To me, it is indeed intimate in at least some sense of the word; and that one human being is allowed to reach inside another is very mysterious to me. I've tried in various ways to express it. I'm not sure any of them captures it well or truly. (If you were uncomfortable with this, you should (but probably won't) see a poem I'm working on. And as to the assymmetry and "trust" issue: that's why I titled the previous post "taking trust." It's actually a reference to a part of my book, in which I say sort of what you said: the patient really has no choice. "Trust isn't given, " I wrote. 'It's taken." I think we don't disagree all that much: it's a question of how to express this mysterious thing, and I'm still working on it.

Danielle said...

Dr. Schwab-
I am currently on my General Surgery rotation. And, in all honesty, and before I forget to tell you...I REALLY like it. I was so afraid that it would be horrible, but I REALLY like it. Sure, the hours suck and I get yelled at by over-worked Residents, but I just like the way you Surgeons think! Anyway, that's not what I was going to post. What I was going to say is that I got through almost a full month of surgery without ever seeing anything done WITHOUT laproscopy. The first night I got to see an ex-lap and we did a midline incision and got to hold the intestine back and feel the aorta pulsation...WOW! What a RUSH! I found both of your posts very interesting to read. Keep it up!

Kate said...

The only laparoscopy I've seen is in pediatric gynecology and I have to say that although all of the surgery was going on inside, there wasn't a moment that I was able to forget about the patient on the table or the importance of the surgery to the patient. It was definitely intimate for me but I can see where you're coming from. Maybe it's because I'm not a surgeon or because I'm only a student, but I can't separate myself from the patient on the table, laparoscopy or no. I also really like puzzles, so maybe laparoscopy was made for me!

Anonymous said...

Gee You sound like Surgen Cuticle in Herman Melvile's White Jacket. A tale of life on a USN frigate in the 1840s.
plus ca change plus rien

Alexandra Lynch said...

I come to this from the viewpoint of the patient. I've had several surgeries over the years, some open and some lapariscopical. And I wasn't so much worried about how it was being done. It was other things. Did he know how very much it meant to me to not be forced into deciding what to do about one more unplanned pregnancy when he held my fallopian tube? It didn't matter for that whether it was his fingers or the laparascopical instruments. I needed him to get this one right. Desperately. (And he did, far as I've seen.) I've had a surgeon who didn't consider his patient- he worked on my foot. Technically competent surgery, but the healing process was hell on me and aggravated some hip damage and such. I care more whether you see me as anything beyond a cash cow coming in with a fat wallet than whether you give me a big scar or a little one.

Sid Schwab said...

alexandra lynch: thanks for the comment. It's an old conundrum: would you rather have a technically great surgeon who's an ass, or a very nice one who's not so good? Of course, in the best of worlds you wouldn't have to choose: you'd get a great one who also sees you as a person and treats you like one. Well, er, uh, like me.

Anonymous said...

Wow! What an honor. That image you posted is from my paper of 2000 summarizing laparoscopic radical prostatectomy. I will say it's very odd to think that what I do is impersonal, as if there is no doctorly artistry in taking care of It’s not surprising. Patients are often men with prostate cancer. Indeed, surgery is an art. Blogging about surgery is an art. And so is writing and thinking about prostate cancer This was an eye opener for me, Dr. Schwab. Thanks.

Sid Schwab said...

anonymous: thanks for the comment and the links. As to your reaction: I was talking as a general surgeon, comparing the sensations and my reactions regarding laparoscopy compared to open, and it followed this post; a personal description.