A cut too small to see

With latest in minimally invasive surgeries, doctors debate whether less is more

January 25, 2009|By Stephanie Desmon | Stephanie Desmon,stephanie.desmon@baltsun.com

After less than 30 minutes of surgery, Dr. Gina Massoglia removed Caren Eckwerth's gallbladder by squeezing it out through a tiny incision in her belly button. A colleague followed up with three small stitches in the navel, covering the wound with a Band-Aid.

In a week, no one but her doctors will know the 57-year-old Annapolis woman even had surgery.

An operation that once required a six-inch cut under the rib cage and went on, with the spread of laparoscopy, to be a less-invasive surgery involving three or four small slits is now becoming a practically scarless procedure in the hands of a tiny but growing group of surgeons like Massoglia.

After years of experimentation, doctors in pockets of the country have been announcing the removal of gallbladders, kidneys and appendixes through the navel. Some weight-loss surgeries have also been done through a single incision, as have some hysterectomies.

But as this next generation of minimally invasive surgeries becomes more common - and as a handful of surgeons experiment with the truly scarless removal of organs through natural orifices such as the mouth and vagina - some wonder if there is any benefit to the patient beyond the cosmetic and whether that is enough to justify its growing use.

"We need to determine which is in actuality an advance in health care versus a fad that is not," said Dr. Mohamad E. Allaf, the director of laparoscopic and robotic urologic surgery at Johns Hopkins Hospital. "We need to study it rigorously. Not everything that's new is good. The data may end up showing the only advantage is [cosmetics] and that's that. But we have to ask the questions. ... It's important that we don't use 'less invasive' as an advertising mechanism."

Late last year, Allaf became one of the first surgeons to remove a kidney - an organ roughly the size of a human fist - through the navel. While he has performed about a dozen of the surgeries and is pleased with the results, he said it is too early to tell whether this incremental advance will improve patient outcomes.

Before laparoscopy went mainstream two decades ago, the mantra of surgeons was "big surgeons, big incisions." They needed to open up the body, get their hands in and feel everything as they got to work, performing operations large and small.

But laparoscopic surgeries - done with the aid of a camera and special tools placed in the abdomen - brought about a revolution with smaller and smaller incisions, much less pain and shorter recovery time for patients.

"If you told me 20 years ago I'd be taking a pancreas out laparoscopically, I would have told you that you were insane," said Dr. Adrian Park, chief of general surgery at the University of Maryland Medical Center and a pioneer of laparoscopic surgery. "Many of us can recall 15 years ago and more having everything but tomatoes thrown at us, so strong was the resistance to laparoscopy.

"So many said it was a flash in the pan," he said. But in time, "the data bore us out."

There is no data yet on what is being called SILS, single-incision laparoscopic surgery. Massoglia, who practices at Anne Arundel Medical Center, was invited last year to see surgeons in Tampa remove a gallbladder this way. She wasn't sure it was possible to improve upon gallbladder surgery, a simple, 20- to 30-minute procedure she does hundreds of times a year using four small incisions to allow room for the camera as well as various instruments to help retract and take out the gumball-sized organ.

But after seeing the single-incision operation - and being taught how to do it - she decided she wanted to offer SILS to her patients and removed her first gallbladder this way in October. "The goal is to offer something to the patients without compromising the case you normally do," she said. "Here, it's not taking longer. There's no change in risk. The benefit is, it's scarless."

As a side benefit, she said, her patients aren't complaining of as much pain. And if she finds she is having trouble removing the gallbladder with a single incision or port, or she is worried about a patient's safety, she can always make extra incisions and do the surgery the more traditional way.

The SILS surgery is technically more complex than the standard laparoscopy, which involves a cut in the belly button as well as two or three more ports in the abdomen, none larger than 10 millimeters.

When Massoglia uses just one incision, she must fit her flexible, chopsticks-like instruments through that one hole and maneuver them around, a task limited by the confined space. Better instruments, she said, are coming as this type of surgery catches on.

"There are angles it's hard to see," Massoglia conceded.

As she removed Eckwerth's gallbladder, she was aided by the use of stitches threaded through the skin to hold the gallbladder in place as she dislodged it from its spot tucked in behind the liver. The pricks made by those stitches, smaller than needle sticks, won't even be bandaged.

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