Friday, January 26, 2007

Mini Me

"Big surgeons make big incisions," said the visiting professor at our Saturday morning conference on deaths and complications. He could also have chosen to say "incisions heal side-to-side, not end-to-end," which was another aphorism professors liked to repeat, with the same implication: for safety's sake, the bigger the incision the better. In a training program -- especially in the ancient times in which I trained -- the point was made often. When open incisions were the only game in town, and when a young surgeon-in-training found him- or herself in difficulty, the first thing the attending was likely to do was to enlarge the cut. And, as I said in a post a while back, there's nothing quite like stepping up to the table and making a bold and generous incision; especially when carrying it through skin and fat and fascia in one glorious and heraldic (if medieval) stroke. By contrast, poking little holes in a belly for inserting scopes is like peeing sitting down.

So I grew up making big incisions, with no second thoughts. Until I thought third: you can indeed make them larger, so why not start small and -- assuming the ability to anticipate before causing a problem -- enlarge if necessary. Bigger wounds hurt more, and are more traumatic, requiring more energy to heal. More pain, more tiredness, slower recovery. Made sense to me. So I changed direction. Rather than go to extremes and start tiny, I simply began to make incisions for all the operations I was doing smaller and smaller over time, heading to an unknown end-point. And that's how I invented mini-cholecystectomy (cholecystectomy = gallbladder removal.)

Well, I suppose I can't claim I invented it. Like several good ideas I've had over the years (another post?), I've come up with a few things up with which others seem to have come as well. My kind of good ideas, evidently, aren't the kind to stop the world from turning: if I think of them, so do others. But there are a few things -- taking gallbladders out through tiny incisions among them -- that I just started doing before there were professors publishing articles about them. (You can read more about these things here.) In the case of "mini-cholecystectomy," it evolved in my practice simply by steadily decreasing the size of the cut from an initial eight inches or so, to six, to four, to three, to two and, eventually to one or one-and-a-half. Somewhere along the line, I had significantly to change techniques: for one thing, no OR light shines through my head into such a hole, so I started wearing a surgical headlight. For another, I ordered some very narrow bendable retractors, figured out different ways of inserting packs, used different methods of teasing the gallbladder away from the tissues that sometimes surround it. I figured out how to "walk" my way down the gallbladder with long instruments, exposing the important anatomy at its bottom end using a thin suction catheter. The patients recovered very rapidly: instead of the typical three to five day stay (when I trained, it was closer to a week), I was sending patients home happy in a day or two. Then one. Eventually (I admit it was only after the laparoscopists came along -- which happened a while after I'd perfected my version) nearly all of my patients went home the same day, and ultimately I did most of my gallbladder surgery at a free-standing surgery center.

I thought more than once that I should write it up. What kept me from doing so, mainly, was the realization that I'd evolved the technique gradually, going from a very wide view to a harrowingly narrow one over enough time to be confident in what I was doing. If someone tried it straight off, I feared, they'd booger the bile duct, lacerate the liver and generally trash the technique. Whatever else is true about it, it ain't exactly easy, especially when it's hard.

After a few years, papers began appearing, especially in England. Some even called it "mini-cholecystectomy," which is the term I'd begun using in my operative reports, having never heard it elsewhere. Since laparoscopic gallbladder removal had pretty much taken over the world, and since I steadfastly resisted it (I took the courses, I could do it easily and enjoyed it), I was pleased that these reports confirmed what I'd been saying to colleagues: mini was way cheaper than laparoscopy, and was otherwise the same in terms of patient discomfort and recovery. And mind you: these reports were defining "mini" as an incision less than eight centimeters. That's more than three inches!! With incisions half that size, my patients had less total incision than the lap patients with their four holes, and less pain. Still, I feared writing it up. (Interesting note: in at least one study comparing lap- and mini-chole, the patients were randomized after going to sleep, into one group or the other. Everyone received a bandage large enough to cover either a mini hole or the spread-out four holes, so neither the patient nor the nurses taking care of them knew from looking which they'd had. Same results in each, except for lower mini costs. Cool study! This was when patients were staying in the hospital, and had they had "my" operation, I'm guessing they'd have gone home sooner than the laps.)

At one point, I entertained the idea of hooking up a video camera to my headlight and recording the procedure, developing some sort of presentation to teach it. Hell, charge for seminars!! But I didn't. I did have some pictures taken, at the request of a couple of OR nurses, having been invited to give a talk about the procedure to a regional meeting of AORN, the association of operating room nurses. Had nice slides, the last one of which showed, for all to see, the incision covered by two half-inch steri-strips. They were impressed. The slides that got the most murmurs, however, were the ones that compared the nursing set-up: for the lap-chole, a table covered with tubes, trocars, all sorts of very expensive instruments. For mine, a couple of long clamps, two three-quarter inch retractors, a few of the usual surgical instruments used since the Red Sea parted, and a clip applier.

Is laparoscopy a step forward? Absolutely! For many operations, it's an unmitigated marvel. And the technology has advanced at light-speed. Is it over-hyped? Yep, in my opinion. When you can take out a gallbladder through a one-inch incision in twenty minutes or less, as an outpatient; when you can resect a colon through a three-inch incision in forty-five minutes or less and have the patients go home in two days, I can't think of a reason to do it laparoscopically for thousands of dollars more/pop. Clearly, however, I lost that battle a long time ago: there's billions of bucks behind the hype. The public thinks it's the only way, and surgeons would rather learn the cool stuff. Despite the opportunity to save a gazillion dollars a year, the chances of my approach taking hold are ze-fricking-ro. I'll say this, though: in my little corner of the world, as time went on I had patients coming to me because they'd heard what I was doing and preferred one small hole.


ERnursey said...

I would imagine it would be nice not having the pain in your shoulder from the gas they use in the laparascopic procedures.

Anonymous said...

" . . . like peeing sitting down"? Dr. Schwab, that's a sexist remark if I've ever heard one. Are you implying that the only good surgeons are male, because they have an appendage that allows them to pee while standing up? Women can, too, but we choose not to, as it dribbles down ours legs and fills up our shoes.

End of rant . . . and I'll still come back to your blog, as I enjoy it so much.


Sid Schwab said...

I figured at least one person would take it that way, but I left it in. I meant it to be funny. I meant it in relation to what I do, not what anyone else does. For me, peeing sitting down lacks certain, uh, sensory feedback. If I'd said it's like dancing with a puppet instead of a person, it would not mean that only the good surgeons can dance.

Anonymous said...

eh, don't worry about it, sid. Your blog will still do fine with out catherine.

Cathy said...

Wow, I think I would have liked you doing my GB removal. I had a lap one. I had to stay for one day because I required a JP drain. But, I will say this. Out of 8 surgeries it was by far the easiest recovery I ever had.

When I went home the next day I was off pain meds and I returned to work half days at 3 days post op and full days at 1 week. I wish all surgeries were this easy to snap back from.

BTW, what is wrong with peeing sitting down? I do it all the time...:)If your wife gets mad at you and sews all your flys shut, so will you!

Anonymous said...

Ah yes, a "boogered bile duct".... having had the opportunity to personally experienced one, and the landslide of complications that followed.... Looking forward to a future post on the subject.

beajerry said...

"like peeing sitting down" too sexist?
I'll never forget an elderly gentleman I helped to the bathroom who cried out in genuine anguish, "God! I have to sit down to pee...just like a woman!"

Anonymous said...

What are you people on about with this sexist business? Sid is a guy, and hes comparing the situation to his life. Women have never peed standing up so they don't know what theyre missing. But thats besides the point; how stuck up do you want to be? Its a damn joke.

Nice post Sid. =)
Long time reader, first time commenter.

Catherine said...

Yo, guys, I meant my comments as a joke, too. And if I were truly trying to be anonymous, I wouldn't have signed my name.


Chrysalis Angel said...

Don't worry Catherine, I knew you were joking when I read it. I just love the stuff he comes out with. What a great sense of humor. There are times he has had me literally doubled over. I've even called over my fire guy, if he's here, to read him. I also gave my surgeon his web site address and told him - Sids a must read. Best to all here.

scalpel said...

Gee, I'd eagerly copied the "peeing sitting down" quote and was planning on posting a witty comment about how it made me laugh so hard that I almost did so myself. Then I was disappointed to see the comment had already been kicked around the table. Oh, well.

Great post. :D

#1 Dinosaur said...

A non-peeing comment:

For better or worse, Sid, you are correct that your technique will never catch on, but you have also pointed out why: it's a technique refined over years, building on skills originally perfected in a much bigger hole. Surgeons coming up today are learning the lap techniques, and not the open ones (at least not to the point that you learned them) that are the basis of your mini ones. Also, the nature of technology is to come down in price over the years, so eventually those lap supplies and machines and equipment will become less outrageous. Your techniques will remain cheaper, but the differential will narrow.

Sid Schwab said...

One of the great things about blogging is seeing what people pick up on, and how comment streams (streams?. Huh huh. He said streams, in a peeing thread) evolve their own... flow. I didn't take offense, Catherine: the "fills up our shoes" made it all quite clear. My reply may have under-reflected that. I still like the analogy.

But my point here is that over time, blogging has made me consider each word I write with more care. That's a good thing. It improves my writing, some of which -- especially earlier on -- can get careless. So this stuff (huh huh, he said stuff...) is great. With rare exceptions that have led me to hit the delete button, I love any and all comments. I've gotten more than a couple of good ideas for future posts from them, among other things. The whole thing is really quite amazing. I can tap away in a little corner of the planet, and by some inexplicable electron dance, all of this just happens.... Very cool.

drcharles said...

interesting points. i wonder how you feel about blunt dissection when working your way down through the layers of the abdominal wall. it would seem that it preserves fascial integrity along lines of natural strength? i guess i'm thinking about my limited experience with c-sections.

DocInKY said...

As I vascular surgeon, I think of some reports a few years back from University of Wisconsin with mini-laparotomy aneurysm repair. Home in 2-3 days and had the 'real operation' via a 4-5 inch incision. Alas, today Endografts are 'in'.

I agree with smaller incisions in general, but there are still times to extend an incision for exposure. A recent below knee femoral popliteal bypass that had to go from the popliteal to the very distal tibial peroneal trunk due to calcium comes to mind.

Great post.

jean said...

i might be facing a gallbladder removal in the near future.

you've made a convincing point, dr. sid.

how do i go about asking a doctor if they do mini-cholecystectomy? just call the office and ask?

love your blog. it's a must read everyday.

Sid Schwab said...

Dr Charles: I think blunt dissection is excellent technique, in part for the reason you suggest. It works most magically when in exactly the right plane, at which point things tend to open themselves readily to the finger, or whatever tool you are using. A few cell-layers make all the difference.

docinky: no argument there!

Sid Schwab said...

Jean: It's not very likely you'll find people doing it, especially in the US. Laparoscopic surgery has pretty much taken over. The good news is, it's an excellent operation. The "mini" is, mainly, a lot less expensive. But you can be confident that in experienced hands, "Lap chole" will turn out great for you.

Anonymous said...

I had a lap chole after two previous open laparotomies and compared to them, the lap chole didn't even seem like real surgery. I only missed a half day of work - the pre-op, surgery and post-op time. I cannot imagine how this could be beat as far as recovery time. Take heart Jean, the lap chole, in the hands of a skilled surgeon and a determined patient, cannot only be minimally invasive but minimally disruptive in your life.

SeaSpray said...

Hi Dr. Schwab - if I ever had penis envy it was only because you guys can pee almost anywhere at anytime if need be - down right convenient!

Last August I was scheduled for a Mag 3 renal scan and the Doc had placed a foley in me prior to the test. I was also drinking a lot of water and there was a delay in getting into nuclear for the test.

I had to urinate (notice - I am using the BIG word - urinate - indicative of how much I REALLY had to go) and stepped into the bathroom to do my thing - through the foley, like a guy standing up. Ok,I thought. This cool - it's definitely easier. But, then... it was taking so l-o-n-g, so I started looking around at the walls and the ceiling and the floor..and was actually getting BORED! The urine was STILL streaming out! I was just about to start whistling or humming to occupy myself when finally it dribbled to a stop. :)

This would've been accomplished yesterday if sitting down!

Now,maybe with male plumbing it streams out with more pressure and so maybe it is a tie.

Is there a urologist in the house that can answer this? :)

Nothing personal - but I will keep my girl plumbing any day! :)

Sid Schwab said...

seaspray: See, you're describing the situation well into "maturity." In youth, you can part water with the stream. The catheter in no way reproduces the gestalt. We all dribble through tubes. In youth, there's power to the pee-ple.

SeaSpray said...

Ha!Ha! Thanks Dr. Schwab - this inquiring mind can rest now. :)

Dr. Rob Oliver said...

Having been trained by some excellent surgeons in the open "mini" approach all I can say is that personally I found it to be a horrible compromise between open & laparoscopic approaches as it affords signifigantly less exposure to highly variable anatomy then either. Failure to expose the anatomy properly has been identified repeatedly as the reason for inadvertant bile duct injury.

Sid Schwab said...

I stated it was difficult. I didn't state -- but it's true -- that in the several hundred I did, I never injured a bile duct nor had any other significant complication. And during those years I saw a few bile duct injuries created by laparoscopists. It's a matter of learning how to take care. But, once again, I evolved it slowly; and as I said, I never tried to teach it to others. Those who do it generally make a larger incision than I, which ought to be safer.

Bongi said...

you have really tweaked my interest. i would love to get a detailed description of this schwab mini lap. but for now i'll simply start making smaller incisions (south african rural state hospitals not yet on lap choles).

by the way, all the comments about big surgeon big cut and heals from side to side etc, they're all in general use by our professors here. that gave me quite a laugh.

deb hansen said...

realistically, does one have to go outside the U.S. to have a non-lap mini-chole done in 2012 ?

Sid Schwab said...

deb, I really can't answer that, but it's a good question. Fact is, lap chole has become pretty much standard everywhere. I'd guess there are surgeons doing mini-chole, but I don't know how to find them. Sorry.

And, really, the main reason I kept doing the mini is because of cost difference. Safety either way is high; if I needed my GB out, I'd be fine with having it done laparoscopically, since I'd have trouble doing it on myself.