Personal Health : Going Under the Scope : Health: New tools and ‘keyhole’ techniques require only tiny incisions, making abdominal surgeries less painful and less costly.
When Betsy Ann Jex woke up early one morning in April with a searing pain in her abdomen, she was sure she recognized the cause of her trouble.
A registered nurse, Jex knew that gallbladder surgery would mean up to a week in the hospital, pain, weakness and a long leave of absence from her job in the Beverly Hills Unified School District.
But Jex’s physician had other plans for her.
On April 30, Jex underwent a new procedure called laparoscopic cholecystectomy in which her ailing gallbladder was removed through a half-inch hole in her navel instead of via the traditional route: a 6- to 10-inch incision in her abdomen.
Late that Monday afternoon, Dr. Arnold Seid, chief of general surgery at St. John’s Hospital and Health Center in Santa Monica, inserted a thin fiber-optic tube containing a tiny video camera through Jex’s navel. Guided by pictures transmitted on a video monitor, Seid made three other tiny punctures to insert instruments, skillfully disengaged the gallbladder, drained the bile and pulled the deflated sac out through the naval.
“I was out of bed Tuesday,” says Jex, 58. “By Wednesday, I was ready to go home. I was back to work within two weeks. It is remarkable.”
Jex is the happy beneficiary of new surgical techniques that are rapidly relegating the scalpel to the back of the hospital supply closet.
The benefits of the new less-invasive techniques, called laparoscopic surgery or “keyhole surgery,” are overwhelming: less blood loss, less pain, less money.
“It’s an incredible advance,” says Dr. Joseph Yadegar, a general surgeon at Cedars-Sinai Medical Center. “It’s so much easier on the patient. The laparoscope has opened up the field of surgery. And there is more to come.”
Surgeons are eager to learn the new techniques, says Seid, who teaches the gallbladder procedure at St. John’s.
“I think it’s the most major advance in general surgery in 50 years,” he says. “There is dramatically less pain, less disability, and there are major savings. These patients are out of bed the next day, walking around and eating.”
Surgery using small scopes to see inside the body has been around for more than a decade, most commonly in the fields of gynecology and orthopedics (such as arthroscopy to remove damaged tissue in the knee). Such operations sometimes are called Band-Aid surgeries because the incisions are small enough to be covered with an adhesive bandage.
But enthusiasm for the less-invasive surgery gained momentum last year with announcements that the techniques could replace major abdominal surgery to remove gallbladders and appendixes, treat hernias and bowel obstructions, and offer an alternative to hysterectomy.
“What all these so-called laparoscopic surgeries entail is putting a scope in the abdomen in order to look,” Seid says.
Armed with high-tech German tools, surgeons initially learned to insert a scope, lean over and peer into it--a position that proved uncomfortable during long surgeries. That problem was corrected when a fiber-optic video camera came into use to transmit proceedings inside the abdomen to video monitors in the operating room.
The advent of laser tools allowed surgeons even more flexibility. And the trend was off and running.
Since gallbladder removal is one of the most common surgeries in the country, physicians and hospital administrators have been quick to size up the benefits of the new technology.
Besides the reduced costs and operating-room time, the new surgery eventually will save employers and health insurers millions of dollars, Seid says. At first befuddled by the changes, major health insurers are now paying for the less-invasive surgeries.
“The insurances companies are happy about these procedures,” Seid says. “They are saving money.”
Patients undergoing any of the less-invasive surgeries are usually back to work in one week, doctors say.
Lung surgeon Dr. Akio Wakabayashi of UC Irvine, who uses keyhole surgery for pneumothorax, a condition in which small cysts develop on the surface of the lungs, says his patients return to work in a week instead of the six-week period needed to recover from open-chest surgery.
And Dr. Bruce McLucas, an obstetrician-gynecologist and a founding member of the Society for Minimally Invasive Therapy, an international group of surgeons dedicated to the new techniques, says women are spared six weeks of recovery time by opting for a new surgery that can be an alternative to hysterectomy.
Called endometrial ablation, McLucas removes the uterine lining of women with abnormal bleeding who do not benefit from other therapies, such as drugs. An estimated 200,000 women a year require hysterectomies for this problem, he says.
Using a scope and a special electrode through the cervical opening, McLucas can remove the uterine lining, a thin layer of tissue that lays over muscle, in 20 minutes.
“I’m offering a safer alternative to my patients,” says the Santa Monica doctor. “The patient will wake up and say, ‘I can’t believe you did anything.’ ”
The lack of a major abdominal incision saves the hysterectomy patient considerable discomfort, surgeons say.
“The scar in the upper abdomen is through very strong muscles and produces a heavy scar,” Yadegar says. “There is a lot of pull on the muscles, and it is very painful.”
The entire trend away from the knife might persuade people who are terrified of surgery to seek treatment sooner, says Dr. Stephen Auerbach, a Newport Beach urologist who is using the less-invasive procedure to perform what he calls the “scalpel-less vasectomy.” The new vasectomy procedure involves “less time and less trauma,” he says, requiring only a puncture wound instead of a one-inch incision.
Several new less-invasive therapies, including medications and a balloon catheter used with a viewing device, are making traditional prostate surgery less common, he said.
“As technology improves and it becomes easier, patients obviously want less and less done,” Auerbach says. “There are people who have diseases (in later stages) who are afraid to seek help because they think their only choice is surgery and because they are scared.”
Surgeons also say they expect savvy consumers to demand less-invasive procedures where possible. And confident from the success of the gallbladder procedure, they are considering other uses of the keyhole techniques.
Wakabayashi is exploring the use of a laparoscope and laser to treat emphysema.
“This is a new treatment and is still investigational,” he said. “But my belief is if we can achieve the same results with a less-invasive surgical approach, we should do it that way.”
Seid says he is investigating the less-invasive techniques for appendectomies and hernia repairs.
“The next thing that will be impacted are appendectomies,” he says.
“The patients do extremely well. The patients can leave the hospital the next day. We’ve started doing hernia repairs through these scopes. We’re getting to the point where that is getting beyond experimentation.”
While gallbladder surgery is “a real success story,” some experts feel the enthusiasm for less-invasive surgery may take medicine too far, too fast.
For example, while surgeons have long explored the use of scopes and lasers to clear blocked blood vessels, problems have occurred that should keep certain less-invasive vascular treatments under the heading of “experimental,” says Dr. Wesley Moore, chief of vascular surgery at UCLA Medical Center.
Surgeons have had great success using balloon angioplasty (in which a tiny balloon is threaded through the artery to unclog it) to avoid bypass surgery. But other types of endoscopic treatments can cause scar tissue that reblock arteries, Moore says.
“We have not solved the biological problem due to the recurrence of the blocking,” Moore says. “For this reason we consider all the less-invasive procedures experimental. It should not be considered treatment that is here, right now, as established treatment. Unfortunately, this has been misunderstood by the public and by doctors.”
Moore says he fears some doctors and patients will push certain techniques before adequate research on long-term effectiveness has been established.
“Hospitals have suddenly recognized that they have to have these various techniques available for them to remain competitive,” he says. “All of this is very unhealthy. A kind of competition has developed which I do not think is in the patient’s best interest.”
Experts agree that the revolution in less-invasive produces, particularly the gallbladder procedure, has provided hospitals with exciting new marketing strategies.
“Hospitals are all competing with each other for patients,” Yadegar says. “So any hospital has to be able to offer (laparoscopic) cholecystectomy. Many of them are really not equipped to deal with this technique that well. It has become a marketing tool, and that is a drawback. People are going to use it prematurely.”
The key to good results in any of the less-invasive procedures is patient selection, he says. Some patients might be excellent candidates for a new procedure while others (such as people who have had previous abdominal surgery) might be poor candidates.
“Selection of patients is critical to the success of all these procedures,” Yadegar says. “Unfortunately, I think we will have overzealous surgeons who want to do too much, too early.”
Of course, some physicians will do too little, too late. Yadegar recalls a recent phone call from a friend whose wife had traditional gallbladder surgery six months ago and just found out about the less-invasive surgery.
“He was livid because no one told them about the new technology,” Yadegar says. “He was very, very angry. I think a lot of patients are depending on physicians to tell them about these things.”
Keyhole Surgery Doctors can now remove a gallbladder by making a few puncture wounds in the abdomen instead of opening the abdomen with a scalpel.
Doctors insert a tube with a tiny video camera through a half-inch opening in the navel. The pictures are transmitted to a video monitor in the operating room.
Two or three other small punctures are made in the abdomen to insert various instruments, such as a grasper, suction device, scissors, clips, laser or electro-coagulater.
A laser or cutting tool is used to detach the gallbladder from the liver. The bile is drained and any stones are crushed or removed. The gallbladder, which now looks like a deflated balloon, is pulled out through the opening in the navel.
