Surgery still can be scary for a patient, but with the major advancements that have happened over the past half-century, operations are now safer than ever before.
Surgery is nothing new. Scientific evidence indicates that people were cutting into the human body to repair problems nearly 5,000 years ago.
But during the past 100 years, the practice of surgery has undergone radical advances, so much so that the day may come when traditional open-incision surgery becomes obsolete, much as it was presented on “Star Trek.” Through innovative technology, highly effective methodology and the development of medicines, the field of surgery is saving and improving more lives than ever before.
Minimally invasive surgical techniques are among the innovations changing the practice in ways previously unimaginable.
Dr. William Cunningham, a board-certified OB/GYN at SwedishAmerican Hospital in Rockford, says he uses both robotics and laparoscopy when treating his patients, depending on the specific situations. He uses laparoscopy primarily for tubal ligation (sterilization), cyst removal, hysterectomies including removal of the ovaries, and to treat ectopic pregnancies such as those that occur in the Fallopian tubes that connect the ovaries to the uterus.
“I use the modality that best suits the patient’s particular needs,” he says. “Both are done within the abdominal region but treatment is assessed based on the progress of a disease, the size of the uterus, adhesions from past treatments and endometriosis.”
The more complex and challenging the surgery, the more likely Cunningham is to choose robotics over laparoscopy.
“Robotics allows more articulation. Because it’s closest to using my actual hands, it’s the best choice when the patient has other issues,” he explains. “Plus, with robotics, I have a three-dimensional view of the field in which I’m operating. With laparoscopy, I have a two-dimensional view similar to looking at a television screen. I lose depth perception that is essential to working in complicated conditions.”
Cunningham says that other criteria for choosing the appropriate methodology include the surgeon’s experience and skill level.
“We must maintain ourselves at the level in which we are most comfortable and competent, and not jump into robotics simply because it’s the coming thing.”
Laparoscopy has been used widely for many years, he adds. The past 10 years have seen significant advances in its uses primarily because it has proven to be safe and because the number of skilled providers has grown.
“Laparoscopy is pretty much available everywhere. It would be hard not to have it readily available,” Cunningham says. “And its benefits to patients are numerous. It’s not just safe but also offers a very low risk of infection, less blood loss and less collateral damage to surrounding tissue. Patients endure less pain and recover far more quickly than they did with the open-incision surgeries of past years.”
Patients should be informed about what to expect and select a good provider who is comfortable with the technology and able to use it safely.
Almost immediately after the minimally invasive techniques of laparoscopy took hold, robotics emerged, says Dr. Ancil Philip, a general surgeon at SwedishAmerican Hospital.
“We purchased our first da Vinci robotic surgery system a little more than a year ago,” Philip says. “I personally use it two to five times weekly. The demand is such that we are considering adding a second daVinci in order to better handle the surgical schedule.”
Philip often uses the da Vinci to remove diseased organs such as gallbladders. He also uses it to repair hernias and treat cancerous tumors throughout the abdominal and intestinal areas.
“Some of the earliest users of the da Vinci system were urologists, to remove prostates, for example,” Philip says. “Now the da Vinci’s uses have expanded greatly to include surgeries throughout the body.”
Asked what it takes to be trained on the da Vinci, Philip’s answer is surprising.
“First we have to complete robotic online modules,” he says. “Next we are sent for a short course, usually one to two days. As surgeons, we typically already have a lot of experience with laparoscopy prior to working with modular robotics. We even have simulated exercises that are like playing computer games to help us get accustomed to robotic techniques.”
Once training is completed, surgeons are expected to start using robotics within two weeks to a month.
“As a resident at UW-Madison, I hadn’t had any robotic experience,” he says. “Unlike laparoscopy, which is rigid, the da Vinci acts like a wristed extension, allowing us to move as naturally as if it were our own hands and arms. The visualization of fine details is also superior.”
Philip believes the future use of robotics in surgery is nearly limitless. With the refinement it brings to the field, some minimally invasive surgeries have evolved from four small incisions to one.
“I have used the da Vinci system to remove organs using one small incision, right in the belly button where it practically disappears. There’s not even a scar,” he says. “Right now, the da Vinci is usable for thoracic heart and lung procedures as well.”
The majority of robotic surgeries that Philip performs are done on an outpatient basis. Only between 15 and 20 percent of these patients are admitted for such complex surgeries as colon resection to remove cancer.
“What I find even more advantageous with the da Vinci is that it is built ergonomically,” Philip says. “It’s comfortable for surgeons to use for extended periods of time. This in turn allows us to focus on the surgery and not on any pain or stress we might be feeling. I believe this is important for both the surgeon and the patient.”
Minimally invasive techniques have also become vitally important in the treatment of damaged or diseased joints. Dr. Daniel Sellman, a board-certified orthopedic surgeon at Beloit Health System, says that arthroscopy and laparoscopy both use fiber optic cameras placed through small incisions for better visualization inside the body. Laparoscopy looks inside the abdominal cavity at internal organs, while arthroscopy looks inside major joints.
“Arthroscopy allows me to clearly see, on a monitor, inside major joints and to perform procedures to remove damaged structures or repair injuries,” Sellman says.
Sellman describes this procedure as an extension of his fingers through small incisions. Traditional surgeries require larger incisions, frequently causing more surgical complications.
“Arthroscopy was developed in the 1970s and has evolved into an effective surgical tool for the orthopedic surgeon,” Sellman says. “In arthroscopy, I make a few very small incisions for placement of cameras and tiny working instruments to accomplish the surgical goal.”
Sellman adds that this technique has become a mainstream surgical modality for knees and shoulders. Arthroscopy also may be used effectively for treatment of the wrist, elbow and ankle. In the past few years, hip arthroscopy has evolved to treat disorders before they lead to hip arthritis.
“At the shoulder, arthroscopy is used for repair of major structures including stabilizing and moving rotator cuff muscle tendon tissue,” Sellman says. “Other structures that are frequently repaired with shoulder arthroscopy include the labrum and ligaments inside the shoulder to treat disorders such as instability or dislocation.”
These injuries can occur from athletics or repetitive activity combined with the aging process, he says.
“The goal of every major surgery in a joint is a solid, stable repair,” Sellman says. “Frequently, this can be accomplished with arthroscopic techniques – but not always. Open surgery of major joints still has an important role to play in fixing damaged structures. Again, the goal is a solid, stable repair with the least amount of tissue damage and morbidity.”
Sellman says the utility of arthroscopic surgery in major joints is an ever-evolving field, hotly debated among orthopedic surgeons nationwide.
“At the knee, arthroscopic surgery has become the gold standard for many surgical procedures,” Sellman says. “These include anterior cruciate ligament surgeries or meniscal repairs. These surgeries are commonly performed for treatment of sports-related injuries.”
Sellman adds that the public clamors for more and better minimally invasive technology to decrease morbidity. Arthroscopic surgery will continue to evolve and remain a mainstay in orthopedic surgery in the long term, he says.
“But the public can be misled,” Sellman cautions. “Many sources of information readily available to patients on the internet can be misleading. It’s advisable to seek out the opinion of a trusted, reliable orthopedic surgeon to better understand your problems before committing to a major surgery.”
The goal of all these orthopedic surgical procedures is to restore function, improve mobility and relieve pain, Sellman says.
Surgeons stress that any time the body is incised, it is considered surgery, no matter how small. That concept includes implanting devices within the chest area to control and maintain heartbeat.
Dr. Edward A. Telfer, a board-certified electrophysiologist at OSF Saint Anthony Medical Center in Rockford, specializes in keeping the heart beating not only in rhythm but also at the proper speed. To enable patients to maintain a constant, appropriately paced heart rate, he uses pacemakers or internal defibrillators, both of which have been used for many years. A third, relatively new option is a subcutaneous defibrillator.
“The difference among these is that a pacemaker does just that,” Telfer explains. “It recognizes when the heartbeat is too slow and stimulates the heart to speed up to the right number of beats per minute. An internal defib recognizes not only when the heart is beating too fast but also when it is out of rhythm. It shocks the heart back into sinus rhythm.”
The newer device, the subcutaneous defib, is implanted differently but reacts just as quickly as the regular defib even though it senses the rapid heartbeat (atrial fibrillation) and arrhythmia through a different pattern. For that same reason, it also acts more specifically and delivers more appropriate shocks.
“A standard internal defib is installed with leads running through veins to the heart,” Telfer explains. “It senses out-of-sync heartbeats the way a person would look at a bunch of flying birds and count them before deciding they made up a flock. The subcutaneous defib ‘sees’ a pattern similar to sky, then notices that part of the sky is dark. It immediately assesses that this is a flock of birds and reacts swiftly.”
The subcutaneous defib is about the size of a cellphone. It’s implanted in the patient’s back, just behind the arm. Instead of the leads running through veins, they’re strung under the skin along the ribs, then anchored on the patient’s sternum. It does not come in contact with the heart the way the pacemaker and regular defib do.
“The subcutaneous defib is a good choice for younger patients, or very active older patients, because leads can break or be pulled out of position in a more active person,” Telfer says.
Also, speed is vital.
“People don’t drown because their lungs fill up with water,” he says. “They die because their brains are deprived of oxygen for too long. The quicker the heart is shocked back into sinus rhythm, the faster the blood carries sufficient oxygen to the brain. This prevents strokes, among other damaging conditions.”
With today’s advanced pacemakers and defib devices, especially the subcutaneous, which does not come in contact with the patient’s bloodstream, the infection rate for implanting them using minimally invasive methods is extremely low, between 1 and 2 percent.
“These surgeries can be done using a local anesthetic or a general one,” Telfer adds. “One isn’t better than the other. It depends on what the patient and surgeon are most comfortable using. All three of these are considered minor surgical procedures. We sedate patients according to their needs, and under certain circumstances we hospitalize them overnight to monitor them and provide pain medications if necessary.”
Patients are seen at one-month, then at three- to six-month intervals, depending on the type of device and the individual, Telfer says.
When surgery is not an option because of a patient’s other morbidities, such as diabetes and congestive heart disease, there are other new ways to treat difficult diseases, including lung cancer.
Today’s cancer treatments are much more refined and effective than in the past.
Dr. Iftekhar Ahmad, radiation oncologist at OSF Saint Anthony Medical Center’s cancer center, says a newer modality called stereotactic body radiation therapy (SBRT) has proven to be effective against lung tumors when the patient’s cancer is in earlier stages but surgery is not an option.
“SBRT is a fairly recent refinement of radiation therapy,” Ahmad says. “We used it at OSF on our first patient about four years ago. The premise is to give the patient the highest possible dose in a small area with minimal collateral damage to surrounding organs and tissue, which results in few side effects.”
Ahmad explains that SBRT is used mostly on lung cancer at this time, but its uses are expanding. Standard or conventional radiation treatment for lung cancer is given daily for six to seven weeks, which can result in less-effective treatment, risky side effects and poor long-term outcomes. Because of the risks, radiation therapy is tightly controlled so it won’t exceed acceptable limits.
SBRT is sharply focused on the tumor.
“The radiation in SBRT is given in four to five treatments over two weeks,” Ahmad says. “High doses are delivered with pinpoint accuracy. I can say with confidence that the patient will suffer few, if any, long-term side effects and have better survival compared with patients treated with conventional radiation.”
Ahmad explains that it takes a team of medical specialists to perform SBRT because of the advanced technological nature of the treatment.
“Radiation therapy, medical dosimetry, and radiation physics are all involved because every aspect has to be carefully calculated and the patient has to be positioned in an exact fashion,” he explains. “Getting the dose exactly right is critical to the patient’s welfare and quality of life.”
Once the dose is calculated, the patient is immobilized in a special device that keeps him or her totally still while the radiation is delivered, says Ahmad.
“We put a plastic sheet over the patient and vacuum all the air out so it is snug,” he says. “The patient is comfortably held in the device, which molds to the body. I am present for the entire procedure, watching the patient’s chest motion. If the patient is breathing too hard or needs to cough, we stop the treatment, wait until the patient recovers, then restart it. Each high-dose treatment takes between five and 10 minutes.”
This painstaking care shields the patient’s healthy tissues, treating the cancer while minimizing potential side effects.
Asked if he foresees a time when this type of treatment could replace surgery, he says, “It’s too early to say but the research is continuing. In five to 10 years, anything could be possible. For now we are focusing on patients who are not surgical candidates. We continue to look for new ways to apply this technique and I am proud that OSF Saint Anthony Medical Center continues to be the radiation leader in the Northern Region, being the only facility to offer SBRT.”
While some of what surgeons and specialists are able to do today would have seemed like science fiction not that long ago, the fact is that the future may offer even more radical and powerful tools to not only improve upon surgical techniques but actually replace them. And when that day comes, the multiple benefits of minimally invasive surgeries – less pain, less blood loss, lower infection risk and swifter healing – will improve even more.