By Dr. W. Gifford Jones
Would Anthony Eden, the suave, former British Foreign Secretary, have anything to tell today's surgeons? Last year Dr. Jacques Perissat, Professor of Digestive Surgery at the University of Bordeau, France had exciting news for abdominal surgeons. He told the 33rd World Congress of Surgeons that he was removing gallbladders (cholecystectomy) without using the usual long incision. Doctors in North America are currently learning this technique and for some patients it will be a major benefit. But both patients and surgeons should remember Anthony Eden before they become too enthusiastic about this latest operation.
How is it done? The technique involves making four puncture holes in the abdomen varying in size from 5 to 11 millimeters. The laparoscope, an optical instrument like the periscope in a submarine, is inserted through the largest hole. This allows the surgeon to view the abdominal organs and the operative field can be seen as well on a T.V. screen.
Two instruments are then inserted through other holes to grasp the gallbladder. Another is passed through the fourth hole and by electrocauterization severs the gallbladder from its attachment to the liver. The gallbladder is then removed through the laparoscope.
There are several advantages to this technique called, "non-invasive cholecystectomy." The patient isn't left with a long painful incision requiring a week's hospitalization and several more weeks to heal. Patients are normally discharged from hospital the following day.
There's also practically no chance of developing a post-operative incisional hernia since abdominal muscles are not cut. To create the initial holes the muscles are gently pushed aside. This also means a decreased possibility of wound infection.
It's estimated that about one in three patients with a diseased gallbladder could be candidates for this video technique. I'm sure patients will be learning more about "non-invasive cholecystectomy" in days to come and most will hope that their gallbladders can be removed that way.
But there are liabilities with this technique. "Non-invasive cholecystectomy" requires an average of three hours to perform. A surgeon using the traditional abdominal incision can excise the gallbladder in about one hour. Cholecystectomy patients therefore require an extra two hours of anesthesia which must always be taken into account as a risk factor.‘ 0*0*0* The only patients suitable for this new procedure are those who have stones in the gallbladder without any inflammation. It's too dangerous to perform "non-invasive cholecystectomy" on patients where severe inflammation and infection have distorted the normal anatomy. It's also not suitable for those who are markedly obese or high risk patients.
Laparoscopic surgery is not new. Gynecologists have been using this technique for years to diagnose ectopic pregnancy, ovarian cysts and to sterilize women. Similarly orthopedic surgeons routinely use video techniques to remove and repair damaged knee ligaments. Few would argue that these procedures haven't been a great boon to patients.
But there's a subtle difference between repairing a torn ligament in the knee and gallbladder surgery. If a knee operation fails patients are left with a less than perfect knee. And he or she will never know whether the poor result was due to an act of God or the surgeon's lack of skill. Nor will the inadequate result be a life-threatening situation.
Anthony Eden became well aware of what can go wrong with a cholecystectomy. During surgery his common bile duct that carries bile from the liver to the small bowel was inadvertently injured. Eden developed jaundice and became critically ill. He was flown to the Lahey Clinic in Boston where Dr Richard Catell, the famous abdominal surgeon, repaired the injury. But Anthony Eden never recovered his former health and required several more operations because of this surgical error.
One surgeon who performs this technique remarked, "Like everything else you have to get used to the hang of doing the procedure through the laparoscope". There's no doubt that practice makes perfect whether you're hitting a golf ball or operating with a new instrument.
It's not my intention to dampen enthusiasm for a proven and beneficial surgical method. Rather, to remind everyone that Anthony Eden's surgeon was no fool and still got into trouble removing his gallbladder through a large incision.
I hope I'm wrong, but my crystal ball forecasts trouble ahead. Just as there are good and bad plumbers, so there are less than capable technical surgeons. After years of surgery some still encounter trouble even when working through a large incision. That's why I worry that little holes may cause surgeons and patients big problems. Anthony Eden would worry too.
W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of Harvard. Dr. Walker's website is: Docgiff.com
My book, �90 + How I Got There� can be obtained by sending $19.95 to:
Giff Holdings, 525 Balliol St, Unit # 6,Toronto, Ontario, M4S 1E1
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