Monday, March 22, 2010

One is greater than three or four

Here is a recent video about single-incision laparoscopic colectomy, featuring colorectal surgeon Deborah Nagle. The new procedure involves a single small incision made at the navel. A round port allows access for the instruments needed to remove parts or all of the intestine or colon. Traditional laparoscopic colectomy involves three to four small incisions. Fewer incisions can mean fewer scars and less pain after the operation and possibly less chance of infection. Deb answers frequently asked questions about this surgery here.

I am told that BIDMC was among the first hospitals in the country to use this technique. People in other hospitals, too, are likewise experimenting with other approaches to make abdominal surgery less invasive. With the dual emphasis on patient centeredness and "bending the health care cost curve," these kinds of procedures can help head in the right direction.


e-Patient Dave said...

My nephrectomy at BID, with Dr. Andrew Wagner, was laparascopic. It took 3 or 4 incisions (I don't even remember), and it was incredible: an "open" nephrectomy takes months to recover from, and I didn't have that much time - I needed to regain my strength fast so I could start my cancer treatment. With the "lap job," was we called it, I was home in 3 days.

To me it's conspicuous that both my surgery and the method in this video are laparoscopic without a robot. The DaVinci robot marketing people seem to have the public convinced that you can't get the benefits of lap if you don't go to a hospital that has a robot. Big mistake: Dr. Wagner tells me he uses the robot for some cases, particularly prostate cancer, but as this video shows, in the hands of a great surgeon the shorter hospital stay and quicker recovery time can be had without DaVinci.

Engineer on Medicare said...

Laparoscopic surgery appears to increase the risk of undetected injury. Sending someone home a few hours after surgery saves some money if all goes well but an undetected injury of the nature that is more likely to occur with laparoscopic surgery has been implicated in the death of Representative Murtha.

Dr. Soper said the risk for accidental cuts increases with the distorted, depthless vision of the laparoscope.

"You're dependent on a 2-dimensional image," said Dr. Soper. "Because the image is very magnified, you're looking only at a very small part of the (surgical) field, and you don't have a normal sense of feel using 2-foot long instruments."

In contrast, surgeons performing an open-field cholecystectomy enjoy a direct, 3-dimensional, panoramic view, added Dr. McLean. That improved view helps them not only avoid a scalpel accident but also spot any accidents that occur during surgery. In addition, if surgeons are worried about inadvertently cutting an intestine, they can pick it up and gently squeeze it to check for a leak.

Anonymous said...

Well Dave, since you gave me the opening:

The link refers to robotic prostatectomies, but the point is there is no evidence they are better. Remember Paul's post entitled: "Uncle"?

Speaking of health care costs.....


Anonymous said...


You touch on what is a known risk in laparoscopic surgery, and that is impaired visualization and "feel". A pathologist such as myself has the best surgical exposure (during autopsy); unfortunately it is too late for the patient.

However, the salient point in the Medscape article you cited is the 2% morbidity rate in laparoscopic cholecystectomy, compared to a 7.7% rate in open cholecystectomy. These procedures are not done primarily to save $$, but because patient recovery is much faster and the complications of open surgery are mitigated.
Another question which has been raised, however, is that of "indication creep" - e.g., because laparoscopic procedures are easier on the patient, does the surgeon then start performing surgery on people who don't really need it. For instance, do asymptomatic gallstones require removal?

nonlocal MD

Anonymous said...

Paul, perhaps you can catch my sloppiness; I should have included this link with my initial comment to Engineer:


e-Patient Dave said...


Of course, yeah, I recently cited that "Uncle" post here.

I asked my surgeon, and he said yeah, he usually doesn't use it - but (he said) for some prostate cases it's really better because things are so tight in that area.

Heaven knows when/if outcomes data will exist to show any benefit, but this is a point where I say "Y'know what? Somebody's cuttin' me up deep inside? I want his snipping and stitching to go REALLY well."

If that guy could do to my guts what he did, putting all that junk in a baggie and sliding it out, I believe in his skills. And if he says "For THIS job I want this supertool," I choose to believe him. (Even though it varied from what I read on this blog! Gasp.)

Anonymous said...

Dave, I'm a little puzzled. I thought about hashing this out in private by email, but perhaps a public airing will be educational.
Don't get me wrong, trust in your doctor is a good thing, and I certainly would not presume to argue with your surgeon - obviously, I'm not a surgeon, much less a urologist. But your last 2 paragraphs seem to be contrary to evidence-based medicine and maybe even to the precepts of e-patients. Isn't it all about evidence and information? And yes, you'll tell me statistics don't apply to the individual (as you know best of all), but what is a guy like Paul supposed to use when making these decisions? Should every hospital have a da Vinci around just in case a surgeon feels he needs to use it in a minority of cases?
So when you say "heaven knows when/if outcomes data will exist to show any benefit, but....", does everybody should buy it and then find out later after they've spent the $$ whether it works? Broaden this to other clinical situations and you have - what we have now, a "medical arms race" as Paul terms it with little or no evidence of better outcomes.

No offense intended, of course. Just trying to apply your logic to a hospital and a nation trying to make difficult quality/cost decisions for more than one patient.


e-Patient Dave said...


I'm all for public airings-out - that's much more social. And no offense taken.

Believe me, when I wrote my "who cares if there's evidence" paragraphs (not quite that, but you know what I mean) I was keenly aware of what I was saying.

Personally, I'd dispute the idea that this is contrary to the idea of e-patients. Empowered, engaged, educated? IMO, if I'm informed and well aware of risks and alternatives, how would it be anti-"e" to say "I want my chosen wizard to have what he wants"?

I'm open to discussion on this.

Paul will have to answer what he'd say. I don't know whether his "uncle" post came after discussion with my doc or someone else.

How DO we get data on outcomes without carving a few people? (Honest question - do they run clinical trials?)

I'd think you can't measure 5- and 10-year results without waiting that long.


And now for a bit of self-awareness that I don't know how to take - this all makes me notice that I think my surgeon's different, better than everyone else. PROBABLY not provable :), and it probably puts me in a big bucket with many patients who think highly of their "savers."


p.s. Why does my word verification thingie say "weedism"? Does it know something?

Anonymous said...

OK, let’s continue the discussion. (Sorry for the long comment.)

“How would it be anti-e to say ‘I want my chosen wizard to have what he wants.’”
Well, what if he is an orthopedist who wants the gazillion $$ hip implant instead of the half-gazillion because he happens to like the rep from that company? Or he believes, alone in his department, that a certain brand of suture is better than others and demands it for only his operations? Trust me, these exact things are going on today. Does an informed e-patient demand that his doctor be similarly informed by real data?

As for clinical trials, yes they run them for devices as well as drugs. However, necessarily they involve a very small population, and the bar for approval is low (“safe and effective”) and highly political. (see the current kerfuffle over the FDA’s re-review of the Menaflex knee implant, HIGHLY educational).
And there is a large bandwagon effect among doctors; get on the bandwagon for the latest and greatest. Usually there is a huge pendulum swing towards adoption of something new, eventually followed by research showing it isn’t as great as they thought, or it’s only good for a certain subgroup, or in rare cases it kills people. Then and only then is there rational discussion at conferences and forums on the appropriate uses. Coronary stents are an absolute poster child for this phenomenon.

I am saying that the “system” for adoption of new technology, which is supposed to be a strength of American medicine, is broken. I favor mandatory post-marketing clinical trials – e.g. if a hospital wants to buy and use a da Vinci system, or put a new cancer drug on its formulary, it must agree to participate in a national clinical trial and submit its data so we can find out sooner rather than later if it is really safe, effective and cost-effective. NIH could collect/analyze the data, or whomever.

And as for your surgeon being savior, well, he is - but, see above. You know what I mean.


MPI said...

This is the exact proceedure my mother had. She had it on a Monday and sent her home on Wednesday.

She died a few days later. This has been an absolutely devastating year for my family. There is so much I want to share but cannot at this point. There is s much I would like to say but I can't at this time.
I find it hard to believe that the doctor's are able to give a percentage of risk if only a few people have ever had this done.

e-Patient Dave said...

Nonlocal, I just had occasion (post-weeks-of-overflow) to absorb your post about the other-than-scientific things that influence people's choice of tools. Thanks for the info.