Surgeon's goals: Smaller incisions
Megan Alexander — Staff WriterArticle Photos
Editor's Note: Second in a series on innovative surgical care taking place at Fairmont Medical Center.
The conversation in the hall at Fairmont Medical Center almost sounded like two kids talking about their favorite video game. It was almost nonchalant, but not enough to hide the enthusiasm bubbling underneath.
It went something like: "Hey man, did you try the ...?"
"Yeah, dude, but don't bother. Once you get to this level, there's really no difference ..."
Except in reality, the two characters don't use words like "dude" or "man," and instead of boys, picture two grown men looking unmistakenly like medical doctors in their white coats.
So what actually happened? Dr. LeRoy Hodges was asking Dr. Hyun Kim, a fellow general surgeon, if Kim had tried using 3-millimeter instruments instead of the 5-millimeter he typically uses for a particular minimally invasive surgery.
Minimally invasive operations, a branch of laparoscopic surgery, are "characterized by the use of telescopes attached to video systems for image guidance, with tissue manipulation done by using thin instruments inserted through small incisions," according to Dr. Nathaniel Soper, editor of the Minimally Invasive Surgery Community on the American College of Surgeons Web site. (Laparoscopic surgery pertains to operations within the abdominal or pelvic cavities, whereas minimally invasive procedures performed on the thoracic or chest cavity are called thoracoscopic surgery.)
"We're right at the infancy of this whole branch of surgery," Kim said, believing almost any abdominal operation will be possible someday with minimally invasive surgery.
Kim has been performing MIS since his residency in 1989.
"In the old days, we used to make a huge incision," he said.
Now the goal is smaller and fewer incisions resulting in quicker healing, less pain and minimal scarring.
The biggest advent for MIS was gallbladder removal. The process is described in "The Gallbladder Surgery Book," a detailed pamphlet that shows four small incisions in the abdomen. Carbon dioxide is then pumped into the area to lift the abdomenal wall away from the organs and give the surgeon room to work. The inflated wall also gives a clear view of the gallbladder through the laparoscope, a tool with a light and a 5-milimeter camera to display images on a video monitor. Surgical instruments are inserted through the other incisions, one for retraction and the other for dissection. The gallbladder is detached from the liver, drained of its contents and then twisted as it is pulled out of the body.
Kim, for the past five years, has been doing the procedure with only three 5-milimeter incisions, and the rest of the surgeons at Fairmont Medical Center are trying this method as well.
"I don't think there's anywhere in the U.S. that does that," he said, referring to the size and number of incisions he uses.
Kim admitted he likes to "push the envelope," but he also acknowledged the limitations. The smallest instruments on the market are flimsier than what he would like, and besides, "There's a point when you say, (what's the difference in) 3 millimeters versus 2 millimeters?"
As progressive as Kim is with minimally invasive procedures, he is more hesitant about embracing other types of laparoscopic surgeries, particularly NOTES - natural orifice transendoscopic surgery - surgery performed through body orifices such as the rectum, throat or vagina.
"NOTES is the big 'in' thing these days," he said. "... It's very difficult to do."
Kim took a course on NOTES and wasn't impressed with the risk factors or the equipment.
Robotics are another change happening in the field.
"No matter how steady you are, no one's hands are as steady as a robot," Kim said.
Robots are also good for tight areas where there is little room to work, like prostate removal. But robotics - at this point in time - aren't feasible for most medical facilities.
First, it's expensive. Darla Nelson-Philipp of the Fairmont Community Hospital Foundation looked flustered just imagining how much money the foundation would have to raise to buy a robot.
Second, it's big. Everything has to be lined up perfectly and once the surgery begins, there's no way to get a different perspective or realign the equipment.
"Like anything else, units will get smaller and less expensive," Kim said. "We'll see. I predict in the next 10 years, the majority of surgeries will be done by robotics."
