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Minimally Invasive Surgery Remakes Face of Medicine

Procedures are less painful, with faster recovery times

FRIDAY, Feb. 4, 2005 (HealthDay News) -- When it comes to advances in surgery, smaller is often better.

Not long ago, a torn ligament in the knee, or even a frayed cartilage, was a nightmare scenario for a patient, fraught with the prospect of open surgery, followed by painful recovery and rehab lasting many months. Knees were generally never the same afterward.

Then about 30 years ago came the revolution -- arthroscopic surgery, now known as scoping. It marked the beginning of the era of minimally invasive surgery, an approach that in various forms has essentially spread from head to toe. Since then, tens of thousands of patients every year have popped back from surgery in days instead of weeks or even months. All this because minimally invasive operations use the tiniest of incisions, aided by cameras and surgical tools in miniature.

"Almost every organ in the human body has become accessible to the surgeon's camera and scalpel," said Dr. Marelyn Medina of Rio Grande Regional Hospital in McAllen, Texas, a member of the public relations committee of the Society of Laparoendoscopic Surgeons.

At first, traditional surgeons reeled from the innovation, made possible by fiber-optic technology, and many retired rather than learn their craft all over again. But patient demand for less-painful surgery prevailed, and minimally invasive surgery is now mainstream, routinely taught to young surgeons of various stripes and, among others, cardiologists. Depending on the organ and approach, it has other names, such as laparoscopic, thoroscopic or endoscopic procedures.

Other developments also simplified surgery to the benefit of a patient's quality of life. Short-acting anesthesia enabled the expansion of outpatient surgery. Catheter-based procedures such as angioplasty -- not really surgery at all -- supplanted much open coronary-bypass surgery and other scalpel-based operations. Then cardiac surgeons developed techniques to do many coronary-bypass procedures laparoscopically -- the so-called keyhole coronary bypass. Now, even heart valves are replaced with minimally invasive procedures.

For emphysema patients in the late stages of the disease, the open-surgery for lung volume-reduction is now being done in several centers as a minimally invasive procedure via an endoscope.

Early on, flexible fiber-optics led to the colonoscope for colon-cancer screening. At the other end, endoscopes let doctors do upper GI exams with ease under light sedation.

In the knee, the then-new fiber optic technology allowed surgeons to watch on a television monitor while a small telescope, an arthroscope, peered inside the joint via one of three tiny incisions instead of cutting the whole knee open. Surgeons watching on a TV monitor used tiny instruments inserted through the second incision to cut, trim or tie. The third incision was for a cannula -- a small flexible tube -- that flushed sterile fluid through the joint. As orthopedic surgeons' hand-eye coordination improved, they devised new techniques that gave new life to once-doomed knees with ruptured anterior cruciate ligaments.

After the knee came the gall bladder, the target of one of the most common major operations in the United States, called a cholecystectomy. It's a rare gall bladder these days that isn't removed with the aid of a laparoscope. In the debate over whether to adopt the minimally invasive procedure, traditionalists argued that it was more complicated, took longer and was, as a result, more expensive and riskier. Patients pointed to the rapid near-painless recovery. Patients' quality of life won the debate in a walk.

A cholecystectomy is still not a walk in the park, but many patients go home less than 24 hours later, some the same day. With traditional open surgery, a five-day hospital stay was the minimum. With experienced surgeons, the overall laparoscopic complication rate is less than 2 percent.

"Laparoscopic cholecystectomy's tremendous success, along with the flood of new technology into general surgery, stimulated surgeons to apply laparoscopic techniques to treat other gastrointestinal diseases," said Dr. Garth Ballantyne, director of minimally invasive surgery at Hackensack University Medical Center in Hackensack, N.J.

"Many other organs can now also be approached in a similar manner," added Rio Grande Regional Hospital's Medina. "These include the stomach, intestines, pancreas and spleen, kidneys and all the female organs. More recently operations have also been developed for diseases of the bladder and the prostate in men."

Proving its worth is a so-called catheter-based procedure using only tiny incisions in the groin -- much like angioplasty -- to repair abdominal aortic aneurysms, the potentially fatal weakness of an area in the major heart artery. In a European trial, the procedure had a lower short-term death rate than a full open operation. The minimally invasive procedure is called endovascular repair, involving a patch or tube threaded upward from small incisions in the groin to strengthen the weak area.

The trial included 345 patients with a telltale bulge in the aorta, indicating a weakness and risk of rupture. This condition causes an estimated 15,000 deaths in the United States every year. It is the third leading cause of death in men over age 60.

In the study, 171 patients had conventional surgery, with the weak spot being patched through a large abdominal incision. Another 174 patients underwent endovascular repair.

Eight of the patients who had conventional surgery died in the following month, a mortality rate of 4.6 percent, said a report in the New England Journal of Medicine. Only two of those who had endovascular repair died, a mortality rate of 1.2 percent.

In the orthopedic world, prolapsed disks in the spine may be suctioned out of the back via a small tube inserted through the incision.

Removal of diseased or malignant kidneys has also become a common procedure.

In another arena, ophthalmologists have developed techniques to do cataract surgery in minutes, with recovery measured in hours, compared with weeks in the past.

More information

The Society of Laparoendoscopic Surgeons explains the procedures in more detail.

SOURCES: Marelyn Medina, M.D., Rio Grande Regional Hospital, McAllen, Texas; Garth Ballantyne, M.D., director of minimally invasive surgery, Hackensack University Medical Center, Hackensack, N.J.; Jan D. Blankensteijn, M.D., professor, vascular surgery, Radboud University Hospital, Nijmegen, The Netherlands; Kenneth Ouriel, M.D., chairman, surgery, Cleveland Clinic Foundation; Frank A. Lederle, M.D., professor, medicine, Veterans Affairs Medical Center, Minneapolis; Oct. 14, 2004, New England Journal of Medicine
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