Windows to the Body

Minimally invasive surgery techniques have given doctors new views of the body and patients quicker, less painful recoveries.

At 3:30 one Friday afternoon, Dr. Lyle Henry found himself in an operating room at Columbia Hospital. Since he's a general and vascular surgeon, as well as chief of surgery, this was hardly unusual.

This time, though, he wasn't there for someone else's operation. He was the patient.

Henry, co-director of the Milwaukee Institute of Minimally Invasive Surgery, was about to have an up-close-and-personal experience with a procedure - laparoscopic removal of a groin hernia - he has performed on countless others.

Because his doctor was skilled in a surgical technique that relies on small incisions as "keyholes" into the body, he'd be back in the operating room Monday morning - this time as the surgeon.

Since the 1980s, Milwaukee physicians, like Henry, have offered patients, like Henry, minimally invasive surgery, a collection of procedures that has revolutionized medicine by shortening recuperation times.

Its potential application is as varied as the human anatomy, for physicians have demonstrated that they can operate throughout the body without making big incisions.

Instead, they cut slits - sometimes as tiny as one-quarter inch - to create windows through which they work. The results are less trauma and a recovery time that puts patients into normal activity within days.

By all accounts, minimally invasive surgery is a miracle of technology that has given physicians and their patients options in every specialty. Observes Dr. Paul Wetter, chairman of the Miami, Florida-based Society of Laparoendoscopic Surgeons: "Many people predict that in the next decade, any surgery within an enclosed space will have some form of minimally invasive technique. And some day, we'll look back at the classic large incision as something archaic."

Still, it's not for every patient and not for every medical condition. Even the most ardent proponents of minimally invasive procedures believe conventional surgery won't be relegated to the archives anytime soon.

But whether or not medicine reaches that pinnacle, minimally invasive surgery is the future for many Milwaukee physicians who are refining and pioneering its use.

Henry himself has performed more than 2,000 procedures, often collaborating on breakthrough techniques. Other physicians count among their surgical achievements several minimally invasive "firsts."

Milwaukee physicians haven't limited themselves to everyday surgeries, such as the cholecystectomy, that are now the standard of care. Instead, many are refining newer procedures - hernia repairs, appendectomies and esophageal reflux surgeries - that have yet to be fully evaluated. Still others are moving from the commonplace to cutting-edge in removing tumors and repairing spines.

But none of this would be possible without a family of viewing tubes called endoscopes. Chief among them is the laparoscope, the enabling tool that provides a visual pathway into the abdomen, where much of the minimally invasive surgery takes place.

With a video camera hooked to its slender tube, the laparoscope gives physicians a spectacular close-up of the abdominal cavity's terrain, magnifying the smallest crevices. Surgeons can probe the landscape to diagnose problems or perform operations in places once reached only through large incisions. What's more exciting is that the camera provides an entire team a look inside by projecting pictures on a screen.

In some areas, surgeons have become so adept at minimally invasive procedures that they're now the preferred method.
And though most minimally invasive procedures are just different approaches to surgery, it's surgery nonetheless and patients still face the same risks under general anesthesia. And because laparoscopy involves working in such small spaces, there is also increased chance of complications with other organs or blood vessels.

While the technology gives doctors better access and views inside the body, it also interferes with their depth perception and ability to feel. In fact, it involves refining hand-eye coordination to manipulate speciahzed instruments through the scope.

"The biggest problem is that because your field of vision is small, you can cause an injury and not be aware of it," says Henry. "It's not as if you can put your hands in there and move things around. You have to be absolutely sure of the anatomy."

Because education in the field hasn't always been widely available, outcomes have reflected it. Even today, training is a mixed bag and universal credentials are nonexistent.

Luckily for recent graduates, residency and fellowship programs now offer endoscopic education. But physicians who entered medicine before minimally invasive surgery debuted have had to rely on colleagues or continuing medical education.

The good news is that over the past decade, many have acquired vast experience on the job and through specialty medical society courses. The other good news is that as physicians accrue longer records with individual surgeries - and as technology improves - they're finding safer techniques.

In fact, in some areas, surgeons have become so adept at procedures that they're now the preferred method. For instance, the National Institutes of Health (NIH) gives thumbs-up to laparoscopic cholecystectomy as the gallbladder surgery of choice.

"We're definitely seeing fewer complications with procedures that have been around longer," says Wetter. "They're getting safer, even to the point that some have surpassed the original open incision. That's exciting for the future."

Those advances come hand in hand with the great strides made in technology: The endoscopes doctors use today are flexible instniments with sophisticated fiberoptics combined with other state-of-the-art technology.

IT'S THOSE AND OTHER POSSlBILITlES that excite physicians about a surgical field in its infancy. Proponents point to procedures still evolving and others so new only a smattering of doctors are trying them.

For example, Dr. James Stoll, an orthopedic surgeon with the Midwest Spinal Center and a member of the Milwaukee Institute of Minimally Invasive Surgery, is using the laparoscope to perform spinal fusions, in which a surgical team removes and replaces a large segment of the disk with implants designed to unite affected bones.

Calling the spine one of the "unexpected frontiers" of minimally invasive surgery, Stoll predicts that the scope may even have a future in the field of genetic engineering: He believes it will be used to transfer artificial chemical substitutes that one day will stimulate bone growth.

"Five or 10 years down the road," he says, "we're going to completely leave behind the days of taking bone grafts out of patients."

While the potential is exciting, some physicians wonderjust how far they should push the minimally invasive envelope, specifically in treating cancer.

Doctors remain convinced that for most malignancies, the only way to capture every deadly cell is by traditional surgery. "There's something to be said about feeling other organs or lymph nodes to see if they're suspicious. You can't tell by just looking," says Froedtert Memorial's Dr. Newcomer. Particularly in insidious cancers such as ovarian, doctors contend that the scope should be used only for diagnosis or second looks.

But those concerns haven't stopped a few surgeons from charting new laparoscopic frontiers for other cancers. For example, Dr. Henry and his colleagues are using minimally invasive procedures to remove colon tumors.

But while Henry believes the laparoscopic procedure has a future in 75 percent to 80 percent of surgeries and has run studies of his own to evaluate the effectiveness of the method, a current national trial evaluating survival rates for both approaches may prove the final arbiter.

"The real beauty of this is that it's just another tool," says Henry. "And what makes us better surgeons is our ability to use all of the tools."

Henry, who handed his surgery over to Dr. Richard Cattey, the colleague he trained in this minimally invasive technique, admits that the weekend after his Friday procedure was uncomfortable. He, too, took naps and a few pain pills.

But, like others, he was soon up and about, taking walks before returning to a heavy Monday operating schedule. As for the experience he now shares with his patients, Henry muses: "lt would be sort of sad if I did this surgery on everyone else and wouldn't let someone do it on me."