Monday, November 11, 2013


KISS as we all know stands for Keep It Simple Stupid (or Keep It Simple Sweetheart).  I first heard this in medical school from a surgeon who started his lecture by writing this on the blackboard.

Surgery is easy.

I am not saying anybody can do it but if you get into medical school, graduate, do a surgery residency and do enough of the basic procedures you should be able to function.  Most procedures have already been done before by somebody else, anatomy is relatively constant and tools have been designed to make things easier.  Not only that, you work with scrub nurses who can anticipate what you are going to do and anaesthesiologists who look after your patient for you and provide muscle relaxation.  Surgery should be really boring which is why historically surgeons have tried to make it more difficult by working when they are tired and doing unnecessary surgeries.

And then the laparoscope was born.

Laparoscopy was originally used by gynaecologists mostly for tubal ligations but also for diagnostic laparoscopies.  The anatomy of the uterus, tubes and ovaries is pretty simple and even in the old days, looking thru an eyepiece they could safely and effectively do their work.

It took general surgeons a little bit longer to get on the laparoscopic  bandwagon with the laparoscopic cholecystectomy.  Those of us who worked in the era of the introduction of the laparoscopic cholecystectomy remember this as a dark time in the anaesthesiology world.  Surgeons would go away for a weekend course where they operated on a pig or cadaver and would return raring to get onto the future of surgery.  They would show up in the OR usually with a rep from the company who sold the expensive equipment and a three hour ordeal of fiddling around would begin innevitably followed by the open cholecystectomy.  This would be repeated multiple times over the next year or so and usually multiple general surgeons were learning to do these so you can imagine the chaos in the OR, especially when they realized that it was affecting their elective time and started doing them afterhours.  There were also the common duct injuries, about 20% in the early stages requiring a long tedious repair by another surgeon.

Today laparoscopic cholie is the standard, most surgeons can run one off in about an hour as a day case and nobody would think of subjecting a patient to a subcostal incision.  There are a few problems with the laparoscopic cholie however.  Firstly the cholecystectomy rate has gone up since the introduction of the lap cholie. There are two reasons for this.  Firstly patients faced with the prospect of a painful subcostal incision may decide to just live with the occasional bout of gut grief.  A significant number of surgeries are for assymptomatic gall stones.  Secondly instead of a procedure which keeps a patient in hospital for several days, surgeons now have a procedure which is either a day surgery or at the worst an overnight stay.  And of course the old open cholies which kept patients in hospital beds for days, deterred surgeons from doing them as "emergencies" lest their elective cases be affected by "emergency" cases occupying their beds.  Not a problem with the laparoscopic cholie.  It is now a rare evening or weekend on call that I don't do at least one of these.  Therefore we are doing more cholies and more of them after hours.  And don't forget that even in the most skilled of hands this is a procedure associated with the occasional complication.  What about post-op pain?  It seems that laparoscopic cholie is still pretty painful maybe not as much as open but instead of getting morphine in hospital lap cholie patients go home with Tylenol with Codeine.

Having mastered albeit slowly the cholecystectomy surgeons moved on to other easy procedures that they could now make more difficult.

We have  laparoscopic appendectomy.  These can now be done in about an hour by a competent general surgeon longer if they let the second year resident do it.  Are they any better than the open appy.  Remember most good general surgeons could do these thru a keyhole incision which is about as long as the total length of the four little incisions necessary to do it laparoscopically.  And the length of stay and complication rate is the same as open which costs only one third as much.  At least laparoscopic patients can wear a bikini afterwards if you forget the ugly scar in the umbilicus.   Appendicitis as I tell surgeons is a medical disease now.

Laparoscopic hernia repair is now fashionable as well.  The problem with this type of surgery is that many of the patients who get hernia repairs are older patients with coexisting disease.  Patients you would like to do under spinal or local (or tell them to wear a truss for the rest of their lives).  Instead you end up fighting inflation pressures in the COPDer you are doing under general instead of spinal.  Plus you have to use mesh.  Being in practice many years, I have absorbed many hours of surgical teaching and remember the admonitions of staff surgeons in the 80s and 90s to avoid using mesh whenever possible due to risk of infection.  Either way hernia repair is a day procedure whether done locally or laparoscopically.  Laparoscopic hernia repair costs several times as much.

In the pain clinic I see a lot of post hernia pain.  While one would think this would be reduced with laparoscopic surgery, I still see a significant amount of post hernia pain in patients who had their hernia fixed laparoscopically.

Don't get me started on laparoscopic bowel resection.  The feeling is only now
returning to my bum after the epic-ally long procedure I did last week.  The purpose of laparoscopic surgery is surely to spare the patient an abdominal incision.  Except that the bowel has to come out somewhere which requires a 10 cm long incision to remove the bowel. So you get a surgery which takes twice as much time, done semi-blind and you still end up with a fairly substantial incision.  Incisional pain can be handled of course with an epidural which our surgeons don't like us doing when they get out the laparoscope.

Urologists have gotten into the act with laparoscopic nephrectomies and adrenalectomies.  (Technically as these are retro-peritoneal structures these are not laparoscopies).  We thankfully don't do them at our hospital so my only knowledge is from hearing of the horrendous complications like the urologist who got into the inferior cava doing a laparoscopic adrenalectomy.  Urologists have also gotten into robotic surgery with great gusto despite data suggesting that the complication rate is the same as the open procedure which is cheaper and takes less time.  Plus in order to do the robotic prostatectomy urologists want the patient in extreme head down position which has lead to significant post-op confusion and who knows what long term CNS changes.

Gynaecologists who of course pioneered laparoscopic surgeon have moved on from tubals and lysis of adhesions.  I have recently done two laparoscopies for bleeding ectopics who came to the OR shocky.  My first response when they got out the laparoscopic equipment was, "surely you can't be serious?"  but I am such a wimp.  Bleeding, especially arterial bleeding, looks 10X as bad blown up on the TV screen.  We also have the laparoscopic assisted hysterectomy which is really just a glorified vaginal hysterectomy.  Vaginal hysterectomy which was historically done blind had an incredibly low complication rate.  The last laparoscopic assisted hyst I did came back a few days later because her bowel had been perforated.  And this is just to avoid a Pfanensteele? incision.  I am waiting for my first laparoscopic Caesarian Section and don't think somebody isn't thinking about this.

I could rant on about all the other "minimal access" surgeries being done in other surgical specialties.

I am not against progress, if I had my gall bladder out, I would want it out laparoscopically.  Not so much my appendix and definitely not a hernia repair (I would have this under local).  The thing is, doing something just because it is neat, doesn't justify the procedure and sometimes there is a reason why things have been done the way they were done for many years.

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