Laparoscopy's future: Imagination is only barrier
Laparoscopy's future: Imagination is only barrier
(Editor's note: In the two decades since Same-Day Surgery began publication, the field has experienced a revolutionary change, from the advent of endoscopic and laparoscopic technology to the growth of managed care. Michele Cohen Marill, editor of SDS, asked Marietta, GA, surgeon J. Barry McKernan, MD, PhD, FACS, to assess the past 20 years of progress as well as look forward.
McKernan was the first surgeon to perform a laparoscopic cholecystectomy in the United States in 1987. He is also co-director of the endoscopic training program for Advanced Endoscopic Surgical Techniques at Emory University in Atlanta and a clinical professor of surgery at the Medical College of Georgia in Augusta.)
Question: Laparoscopy has clearly transformed the field of same-day surgery. Could you reflect on the impact of laparoscopy since you performed the first lap choly?
Answer: In some respects the [shift to] lap choly [from open procedures] went faster than I thought. Now, I would say 90% of the gallbladders worldwide are probably done laparoscopically; however, other procedures have not followed with such haste.
There are two or three reasons for that. Surgeons have a real reluctance to change. Surgeons are probably some of the most conservative people in the world. That's not bad in most situations. In gallbladder, there wasn't a choice. You either changed, or nobody was going to let you take out their gallbladder.
The other [more advanced laparoscopic] procedures require the use of two hands, [which is more difficult]. The surgeon can use only one hand to remove a gallbladder. When you get to advanced procedures, one has to have the use of both hands, and you really have to be a little more facile than you do with open surgery. The other difficult area is suturing, which also requires two hands. Even when you use both hands, it takes an awful lot of practice to learn how to tie sutures looking at a video screen.
But I would say the biggest aspect is the public. They're not educated in many respects as to what is possible laparoscopically. In seven years, I think I've done seven open cases. That's it.
Another reason is many physicians are not able to do flexible endoscopy. In flexible endoscopy, for example, if you're going to operate on the stomach or even the colon . . . you use the laparoscope to look at the outside of the bowel and the flexible endoscope to look at the inside. You've got to marry these two technologies to do advanced procedures.
The sad thing, in my opinion, is rather than have the view that we're going to make this work, many surgeons, when they first encounter this and find it to be difficult, find reasons not to do it. And many patients are poorly informed [about their medical options].
Question: The laparoscopic approach has sometimes been criticized as being more costly, taking more OR time, causing higher rates of complications, and even leading to unnecessary surgeries. Are any of those criticisms fair? Has laparoscopy gotten a bum rap?
Answer: The irony to me is this: I would like to take all these people back to 1920 and 1900 when open surgery began. Were there not complications? Orthopedics has already been through this change. I would ask how many of your readers would let a doctor open their knee.
[Laparoscopic technique] may take longer to learn, but over the long haul, it's going to be a much cheaper way to go -- just like in orthopedics. The downtime for having your knee scoped, even for an athlete getting back on the field, is phenomenal. It's the same thing with laparoscopy.
I wonder if there won't be two types of surgeons in 10 years: those that do pure endoscopy and never do it in the hospital, who truly abandon the hospitals, and those who do major oncology or trauma and are hospital-based.
Do you need the traditional hospital of the past, [with so many procedures requiring only an overnight stay]? I would dare say in 10 years, many of the procedures may even be done in the [doctor's] office. I remember 15 years ago when I was a resident, the board was full of cystoscopies. They were all done in the OR. They're never done in the OR anymore. They're done in the doctor's office. I think appendectomies can be done in the office. I think hernias could be done in the office or a really efficient surgery center.
Question: Where is laparoscopy headed? What other procedures are evolving with a minimally invasive approach?
Answer: If you think about orthopedics, they do carpal tunnel. They're scoping fingers, joints. You don't have to insufflate necessarily with CO2 gas. There are other methods to do endoscopy that don't even use gas. There are ways around insufflation.
The only barrier is our imagination. Stanford [University in Palo Alto, CA] is doing coronary artery bypass [laparoscopically]. It only makes sense. With endoscopy . . . you see better than you ever did open. And it's on a screen for everyone [in the OR] to know what's going on. In open surgery, the only person who knows is the assistant scrub nurse, and often she can't see what's going on either. Now the whole room knows, and there can be some anticipation in the room.
Question: Some surgeons express concern that younger surgeons will be trained and skilled in the laparoscopic approach but won't have any experience doing it open.
Answer: I think it's always a concern that you should know . . . it all. [For example, there are] a number of operations you should do for hernia. You must know it all. You can't pick one because you never know when you're going to be in a case where you can't [do the procedure you intended].
But that's certainly not a reason not to go forward. . . . I would say there's a concern, but the structures are the same. It's up to us to know how to use the old system.
I think we're blessed that we can do both. But reality is, there are already orthopedists who hardly do anything open. They've already been through this [change]. And you certainly don't see any problems in orthopedics. The truth is, the technology is going to get so good, the day will come when you don't have to open.
Question: How has managed care impacted laparoscopic surgery?
Answer: For gallbladders, [managed care companies] have demanded they be done laparoscopically. I've had some managed care companies pull me [into] their market [from outside] and have me do laparoscopic nissen fundoplications because our complication rate is so low, and we just have an overnight stay.
But it still doesn't train everybody else. The overall impact, in my opinion, of managed care is to look at the bottom line instead of the comfort to the patient. If they save $10 on an open versus laparoscopic procedure, they're going to choose the open procedure. They're strictly looking at the bottom line of their business, not return to work and all the other issues that are important.
Question: What changes do you envision in laparoscopic technology, and what impact will they have?
Answer: Your imagination is the key to this. To me, surgery has always been so far behind, for example, going to the moon. If you just leave the innovators in surgery alone, changes are going to happen, and they're going to happen in a major way. I think over the next 25 years, you're going to see procedures becoming increasingly less invasive.
Technology is destiny, in my opinion. The only negative thing I see is HMOs and things like this who are only looking at the bottom line today. That really stifles any sort of creative thinking. *
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