(December 5, 2008 - Insidermedicine) On a recent trip to Boston, we caught up with Dr. Daniel Jones, MD, FACS who is Chief of Minimally Invasive Surgery & Bariatric Program at Beth Israel Deaconess Medical Center and Associate Professor of Surgery at Harvard Medical School. Dr. Jones is also Co-director of the Carl J. Shapiro Simulation and Skills Center at Beth Israel Deaconess Medical Center.
What is a Hernia?
A hernia is a hole and you can have the hole in your groin and your bowels and organs can come out of it, or you can have a hole at your belly button and again your belly contents can come in and out of it. A hernia is simply a hole and the way we fix it surgically is we want to either close it shut with stitches (the problem with that is they often come back), or we put a plastic mesh on top or underneath. In laparoscopy we can avoid the big incisions of a laparotomy down your tummy or a big groin incision, if you had to do a laparoscopic groin incision and instead through very small incisions we can peak into the belly and we can lay up a piece of mesh, and it is really great because patients have less pain, faster recuperation, the scars look a little better, if you have a couple of different hernias, say one on the right, one on the left, with the same three small incisions the size of a pencil tip you can go in and fix both sides. Laparoscopic hernia is the way to go. The challenge is that not everybody is trained to do laparoscopy, and you don’t want a surgeon who’s not doing a lot of these doing yours, but if I had a hernia, I would have it done minimally invasive, with the small incisions, by surgeons who are doing a lot of these operations.
What are the advantages of laparoscopy?
In the early 1990s, laparoscopy took off, and the reason it took off is that all of a sudden surgeons could do a series of small incisions and look at a video screen to get the work done on the inside, as opposed to making big incisions which hurt and take a long time to heal. The advantage of laparoscopy through a series of small incisions is less pain, faster recuperation, shorter hospital stays, and quicker return to work.
Does a smaller incision reduce risk?
One of the interesting questions is, as you start to use technology, and you start to operate through small incisions: what are the risks, and does the risk go up? The answer is that it can. We know that will gall bladder surgery when a lot of surgeons went out to do this operation without training, the number of injuries to the common bile duct went up five times. With hernia operations for folks who aren’t doing this all the time the risks go up. So it’s very important with the introduction of new technology that surgeons know how to use it, they have a safe place to train on it, as in the minimally invasive surgery centers in the skills labs, before going out and actually doing these procedures. There are now training fellowships that are a year long specializing in using these small incision technologies. In good hands, these operations are every bit as safe, but in the wrong hands there is a concern.
How does laparoscopy work?
The way laparoscopy works is we first fill the abdomen up with air and this creates a working space that we can look in – imagine a bottle, and we’re going to make a ship inside the bottle; we need that open space. Once the belly is filled with air, the next trick is we need instruments that go in and outside the body. That’s where we take trocars, and you can see they’re about the width of a pencil, we can poke that through the belly and then put instruments in and out through the trocar. This allows us to actually get in and operate. Some people say it’s like working with chopsticks, but these instruments are actually very good at cutting, and pulling tissues, and doing the things that we need to do. We also have a small camera that we look at, just like a movie camera with a lens, and it goes to a monitor that we all see on the screen, and that’s our vision. Through that light source and that camera we can now see with 15-fold magnification we can actually see even better resolution with the camera than I can with my naked eye. So very well we can see the operative field, we can angle our instruments, we can get in there and operate, and we can do this all through very small incisions most of the time.
Who is a candidate for a laparoscopic procedure?
Unfortunately, not everybody is a good candidate for a minimally invasive or advanced laparoscopic procedure. Frequently the problem we have is with someone who has been operated on many many times before and their belly has a lot of scar tissue. Sometimes we can get in there and take down the scar tissue, but other times the safe thing to do is to make a regular old fashion incision.
How much follow-up is necessary after a laparoscopic procedure?
The real irony in minimally invasive surgery is that over the last ten years as surgeons have embraced this technology, patients have done better and gone home earlier, the reimbursement to the surgeon has actually gone down, not because the technique isn’t challenging, but the patients are doing better, and there are fewer follow up visits on average, and the government has said that if you’re seeing folks less afterwards, we’re going to pay you less. So there is truly a disincentive to the surgeon but clearly the motivation of the patient there for less pain and faster recuperation.
Are there any risks for surgical infection?
For a lot of the operations we do using small incisions, the risk of serious infection is less, and it’s because we’re making small holes that heal better. This is just another advantage of small incision surgery.
If I had a hernia…
If I had a hernia, what I would want is a laparoscopic approach though small incisions, because I would want to get back on my feet right away, and get back to work. But I would be careful and make sure that I selected a surgeon who did a lot of these procedures.