At 54, Steve Kirchner felt that having a hip replacement was a foregone conclusion. He wasn't happy about it.
He so badly wanted to avoid the trauma of the standard operation that when he heard about a specialist who was performing minimally invasive hip replacements, he decided it would be worth traveling to Chicago to get the surgery done. The experimental new procedure involved two 1 1/2 -inch incisions - much smaller than the traditional 12 to 18 inches - and worked around muscles and tendons instead of cutting through them.
He explained his decision to his doctor, Frank Ebert, assistant chief of orthopedics at Union Memorial, and got a surprising response. Ebert told his patient he had started performing the new operation.
"I asked him, `How many have you done so far, Doc?' " says Kirchner. "He said, `One.' "
Such is the speed of the keyhole surgery revolution. A little more than a year later, Ebert has become an old hand at the minimally invasive operation. He and his colleagues have done hundreds since then.
Blink, and you've missed new procedures, new techniques and new technologies. Surgeons can now perform everything from coronary bypasses to hernia repairs through keyhole-sized incisions, using fiber-optic lights, miniaturized cameras, video monitors and specially developed instruments to cut and suture.
Kirchner, who lives in Fallston, decided to be Ebert's second minimally invasive hip replacement. He went under the knife three weeks later and was walking on crutches the next day. By the third day, he had recovered enough to go home.
Once home, he took nothing stronger than Tylenol for the pain, was driving in two weeks, and went back to his job as a Community College of Baltimore County administrator in three. Total recovery can take months, not weeks, with the standard surgery.
"I don't even think about my hip anymore," he says.
Going home quickly
Minimally invasive operations have been compared to advances in surgery as important as sterilization and general anesthesia - which may be overstating the case. The benefits are less pain, smaller scars and a faster recovery time, but not necessarily a better result.
"It's important to recognize the relative equivalence of the two [standard and minimally invasive hip replacement] three to five months after the procedure," says Ebert. "What you're trying to improve is the early quality of life."
Patients, in other words, like being back on the golf course six weeks after their operation. And, no surprise, they like the other benefits as well. John Kearns, 55, had severe heartburn -- so severe he decided to have surgery to correct it, a procedure called fundoplication. His surgeon, Dr. Mark Talamini, is director of minimally invasive surgery at the Johns Hopkins Medical Institu-tions.
"I saw friends with a big zipper in their chests, and I didn't want to go that way," says Kearns, who lives in Crofton.
Through five tiny holes, Talamini wrapped the floppy upper portion of the stomach around the lower part of the esophagus to decrease the amount of acid and stomach contents that could reflux into the esophagus. He also sewed closed a hiatal hernia. Carbon dioxide gas was pumped in to expand the abdomen, making it easier to see and to manipulate organs.
Four days later, Kearns says, "I feel like a truck hit me, but I'm home." His worst pain is in his shoulders from the gas still being absorbed into his body.
Booming since 1989
The techniques had been around for years, usually as a diagnostic tool, but minimally invasive surgery really took off in 1989, when surgeons started using it to remove gallbladders.
The explosion of interest was unique in the history of surgery, says Barbara Berci, director emeritus of the Society of American Gastro- intestinal Endoscopic Surgeons (SAGES), which specializes in these procedures.
"It was industry-driven and patient-driven," she says.
Patients were so anxious to reduce the trauma of surgery that they would leave their doctors and seek out ones who were performing the new operations -- even in cases where they were largely experimental or were riskier than "open" or standard surgeries. That in turn spurred surgeons to take courses in the new procedures. In the early '90s, there was a mad rush for training. Continuing education seminars were oversubscribed. Between 1990 and 1992, attendance at the annual meeting of SAGES went from 200 to 1,000.
In the years since, laparoscopic (as the surgery is called in the abdomen) procedures have been developed to perform hysterectomies, do spine surgery (through the patient's front) and gastric bypasses, remove spleens and colons, treat endometriosis and diverticulitis, and harvest kidneys from live donors. Arthroscopic (as minimally invasive procedures in joints are called) surgeries to repair knees, shoulders and wrists seem almost ho-hum.