Surgeries of all kinds are becoming more effective and less invasive, thanks to continuing breakthroughs in medical technology.
The latest and greatest surgical advancement has been, by and large, the ability to perform the same types of surgeries in minimally invasive ways.
“I think it’s virtually expected that things are going to be done with small incisions and minimally invasive procedures,” says Dr. William Cowden, general surgeon and director of acute care and trauma surgery at Mercyhealth in Rockford. “I think people are surprised when they’re not candidates.”
“Ninety percent of our hernias and gall bladder surgeries are able to be minimally invasive, with either a standard laparoscopy or robot,” Cowden adds. “Even compared to a standard laparoscopy, we have better outcomes with pain control and back-to-functional status.”
Even though most surgical techniques aren’t necessarily “new,” there are new facets of many types of operations that are allowing surgeons to offer better outcomes.
“While the basics of surgical therapy remain fairly constant, surgical techniques, instruments and technologies continue to advance steadily,” says Dr. Eileen O’Halloran, surgical oncologist at OSF HealthCare Saint Anthony Medical Center in Rockford.
Dr. Lee McFadden, an orthopedic surgeon who specializes in hip and knee replacements at Beloit Health System, agrees that most surgeons are working through steady advances – and that’s actually a good thing.
“We’re a victim of our own successes,” McFadden says. “The changes we’re making now in hip and knee replacement are incremental in terms of degrees of improvement in the setting of already outstanding products.”
Little has changed with actual cancer surgical techniques, with the exception of performing more minimally invasive surgeries, says O’Halloran.
But the advent and advancement of more effective therapies – including chemotherapy, immunotherapy and targeted therapy – are opening up avenues for more aggressive surgery.
“Cancer therapy is different now than it was 5 years ago and definitely different than it was 10 years ago,” O’Halloran says.
Chemotherapy is a systemic medication that kills almost all rapidly growing cells, good or bad, which is why patients often feel crummy after chemo sessions, she says.
Cancer patients may also seek other approaches, including immunotherapy, which fights cancer cells by activating the immune system. Targeted therapy uses drugs to attack the exact proteins and genes in an individual patient’s particular cancer.
“This era of personalized medicine has given us a lot more options for cancer therapies,” O’Halloran says. “All of these new opportunities to shrink tumors or control tumors that have started to spread will allow surgeons to participate in care again, too.”
While there are some cancers that are not surgical diseases – meaning they are treated with chemotherapy or radiation only, not surgery – those types of cancers are few and far between, O’Halloran says. Leukemia, for example, is a blood-borne disease, and surgery will not help a patient.
But solid organ tumors – liver, colon and breast cancers, for example – usually include some kind of surgical removal.
“Most people are getting surgery at some point in their treatment,” O’Halloran says. “Sometimes it’s upfront; sometimes it’s chemo and/or radiation first and then surgery. It used to be that when a cancer was metastatic – it had spread elsewhere from its original site – you were considered an advanced stage and a cure was no longer pursued. If it had traveled, you had a couple of months to live – we could only control symptoms. Now, if the cancer has spread, I feel we have more options.”
Researchers are constantly coming up with more targeted therapies and better immunotherapies that give doctors a better chance of helping patients, she says. Doctors can send a patient’s specific cancer to a lab and find the specific medications that will kill that specific cancer at a much higher rate than with standard chemotherapy.
“If, for example, a cancer starts in your colon and you see a single spot in the liver on a CAT scan, it’s important for us to realize it’s not just those two spots. The cancer cells are probably traveling throughout your blood stream, but it has essentially set up shop in your liver,” O’Halloran says.
“Doing surgery was pointless before. We could take it out of the liver, but overwhelmingly it wouldshow up somewhere else in a week or two. But with these new chemotherapies, targeted therapies and immunotherapies we have a chance to at least decrease them, if not kill them off.”
One area in which surgeons are allowed to be most aggressive is colon cancer.
“It’s one of the most common cancers in America,” O’Halloran says. “With colon cancer, you almost uniformly require surgery to remove that segment of your colon. But now, if we find out it has spread to your liver, we can do surgery to remove the cancer in your liver, too.”
Hyperthermic intraperitoneal chemotherapy – or HIPEC surgery – is an example of how doctors can combine surgery with cancer therapies to treat cancers in the abdomen.
“We perform an extensive surgery to remove all of the visible tumor in your belly and essentially wash the inside of your belly with heated chemotherapy,” O’Halloran says. “We can be very aggressive with surgery because of these new therapies.”
Similar to cancer surgery, there haven’t been monumental changes in the technical aspect of orthopedic and joint replacement surgery, says Dr. Lee McFadden, an orthopedic surgeon who specializes in hip and knee replacements at Beloit Health System.
However, there have been advancements in perioperative management of patients, or “how we treat them and how quickly they go home,” he says.
Surgeons share the credit for the improvements in pain management and faster mobilization, resulting in recovery times that are drastically different than two decades ago, he says.
“Fifteen to 20 years ago, joint replacement typically resulted in a patient staying in a rehab facility for two to three weeks,” McFadden says. “Now, we’ve gotten to the point with pain management after the surgery – the pain blocks and long-lasting pain medication – we can get most people out the same day or next day. Early mobilization, early aggressive rehab – even in our senior population – is beneficial not just in cost savings, but also in improved outcomes.”
There’s been a big shift over the past decade toward getting people home sooner. Part of that is market-driven: the faster someone is released from the hospital, the lower the cost of their stay, he says, though he notes doctors ensure each patient is released at the appropriate time.
Another reason patients are released sooner is that surgeons are simply becoming better at their jobs, and they’re using materials that provide better results.
“As we’re able to do surgeries more efficiently, we’re more confident in the outcomes, so we’re not quite as concerned about the rare ‘what ifs,’” he says. “Most people do very well. As we continue to reinforce and believe in our own outcomes, we have to ask ourselves, ‘These people do very well – why are we hanging on to them for two weeks?’”
“Materials are lasting longer in the body,” he adds. “There is less chance of having something revised.”
Historically, orthopedic surgeons have operated with materials that run the gamut. Replacements were first made of ivory in the 1800s; then surgeons progressed to stainless steel, McFadden says. Most components today are titanium, ceramic or cobalt chrome, depending on the application.
Ten years ago, hip replacements commonly saw metal-on-metal components, but not nearly as often now.
“That has mostly been abandoned from use,” McFadden says. “Despite improvements in technology and how we could machine the metals to greater tolerances, we still ended up with higher failure rates than what we had before.”
Today, the bearing materials – the actual contact parts of the components – are most commonly metal on plastic or ceramic on plastic.
“Where the rubber meets the road, the plastics we now use for the contact surfaces for hip and knee replacements and inserts in knee replacements have been wearing four times slower for knees and 10 times slower for hips than 15 to 20 years ago,” McFadden says.
One of the few technical changes in hip replacement surgery in recent years has been a shift from a posterior approach to an anterior approach.
“In broad strokes, the difference between post and anterior is, how do you get to the hip once you get to the thigh bone?” McFadden says. “Anterior, you’re coming from the front. It’s touted as a procedure where you’re not cutting certain tendons; you’re spreading tissue instead of cutting, so theoretically, it can be less painful, and the recovery may be faster for some.”
The posterior approach, which includes cutting muscles and soft tissue from the back of the hip, has been performed the longest – since the 1970s – and is still the most commonly performed, McFadden says.
“In the end, the difference becomes, for an anterior approach hip replacement, is it truly less painful? Do you truly recover faster?” he asks. “The answer is: maybe.”
McFadden has performed both procedures, though he primarily does posterior approaches. Functionally, there’s not really a difference between either approach, he says. The rate of dislocation between anterior and posterior approaches is 2-4% versus 1.5-2%.
“In terms of outcomes, if there is any difference, it’s probably that some people may have less discomfort in the first couple of weeks with an anterior approach, but in two to three months, everybody is doing essentially the same,” he says.
“The bottom line is it’s far more important that it’s put in right than how it’s put in or what company’s parts are put in,” he says. “If the components are put in correctly, the difference in outcomes between anterior and posterior approaches is minimal.”
If there was something about surgery that Dr. William Cowden wished his patients knew more about, it would be that robotic-assisted surgery is an option for several types of medical problems.
“Robotic-assisted surgery is not new, but most people are not aware it exists,” says the general surgeon and director of acute care and trauma surgery at Mercyhealth in Rockford.
Cowden is one of four surgeons at Mercyhealth who is robotic-trained on the da Vinci Xi, the newest generation of the popular robotic-assisted surgical platform. The hospital has two of the Xi models, allowing the robotic-trained team to perform double the number of procedures it is suited for, like hernia, colon and gall bladder surgeries, which take place in deep body spaces.
Newer advancements with the Xi have allowed Cowden and his team to dive into more complex hernia and colon surgeries as well.
“There are certain procedures where we’re able utilize the robot, and that really has a lot of advantages,” Cowden says. “We make smaller incisions; there’s easier, faster recovery time; and there’s a lot less pain, particularly for hernia surgeries.”
In the past, hernia surgeries were considered fairly painful operations that required significant recovery time, he says.
That time has been halved with robotic and pain control advances.
Patients need to know that robotic surgery doesn’t imply a robot makes movements of its own.
“The robot is basically an assist machine,” Cowden says. “Basically, we place the instruments within the patient through those small little incisions and connect them to robotic arms. We go to a separate console and use that console like a video game to perform the procedure. We are controlling all aspects of what the robot does.”
The advantage of using a robotic surgical system is multi-faceted. “Our visualization is not only magnified, but significantly better,” Cowden says. “We initially have a TV screen that’s two-dimensional, and with the robotic surgical console, it makes it almost a 3-D image, which helps us be spatially aware of what we’re doing.”
The robotic arms are much smaller than surgeons’ fingertips, which allow them to perform microsurgery as well.
“We can magnify things three to four times bigger than what it normally is to do these micro-dissections and micro-procedures,” Cowden says. “We can also scale down the motions of my arms. So, if I make big circles with my arms, the robot knows to dial it down a certain percent. Again, we’re able to get into tiny little corners, tiny little holes.”
Trying to verbally explain how the robotic system works isn’t easy, or glamourous, Cowden notes. Seeing it in action is really the only way to truly appreciate it.
“There’s a visual component to the robot that makes it look cool,” he says. “Describing it in words is difficult sometimes to make one appreciate the robotic system.”