Friday, January 26, 2007
"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.
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