The Kindest Cut
Physicians are perfecting procedures that allow major surgeries to take place with only tiny openings in the patient's skin.
by Alicia Di Rado

When French surgeon Antoine Jean Desormeaux was inspired in the mid-1800s to introduce a lighted instrument into the body to see its internal organs, the idea seemed promising, except for a pesky detail: The flame used as a light source tended to burn patients.

Thankfully, we've come a long way.

Today, surgeons are using the latest instruments and surgical techniques to operate on patients endoscopically, passing slender scopes and instruments through small cuts in the skin, instead of working through a large incision that separates skin and muscle. It means patients can undergo surgeries with only a minimum of scarring and a quicker recovery time.

Doctors call it minimally invasive surgery because it seeks to open up a patient as little as necessary. And the term today encompasses a wide spectrum of procedures-from removing painful gallstones to assisting in the treatment of gynecological cancers.

These are a few of the surgeons' tools:

Not to mention steady hands.

 

The Art of the Technique

It is late afternoon in the USC lecture room of Namir Katkhouda, M.D., and laparoscopic surgery fellows Karen Chojnacki, M.D., and Kelly Francis, M.D., are attentively watching their mentor.

"This is known as a fisherman's knot," says Katkhouda, flipping a purple rope around the back of a chair.

"One, two," he says, tucking the end of the rope around itself, then tightening it lightly.

He has them practice for a moment, then hands the pair a set of sutures, or surgical thread, with curved, fishhook-like needles to tie their knots-and tie them carefully.

"There is no place for a rough laparoscopic surgeon," says Katkhouda, professor of surgery, director of the USC Department of Surgery's laparoscopic program, and chief of emergency non-trauma and minimally invasive surgery.

Katkhouda pioneered the use of laparoscopy in operations to treat ulcers, called vagotomies, has written or co-written several books on laparoscopy, teaches other surgeons and has designed instruments used in the procedures.

"Laparoscopy is more than just surgery," he says. "To me, it is an art." In the mid-1980s, as a surgeon at the University of Nice, France, Katkhouda was concentrating on surgery for the treatment of peptic ulcer disease. He heard about an astounding procedure being done in Paris in which a prominent French surgeon was removing patients' gallbladders through their belly buttons-and Katkhouda traveled north to see it for himself.

"When I saw the gallbladder being removed, it seemed like the birth of a child," he remembers. "I was amazed." He doggedly set himself to learn the procedure and practice it, even though he only had gynecological instruments-not the specialized tools of today-available to him. Upon mastering it, he realized the technique had possibilities for other operations as well. By 1990, he published his first work on his successful laparoscopic peptic ulcer procedure, and laparoscopy's potential boomed.

 

Gallstones to GERD

Not that the procedures are easy. Endoscopic surgery requires rethinking the hand-eye relationship and lots of practice. "It's like eating Chinese food with chopsticks while watching yourself in a mirror," Katkhouda says.

Surgeons must manipulate organs-snipping a bile duct or repairing cartilage-without seeing the actual organs directly in front of them, as they would in open surgery. Instead, the endoscope, once inserted into the body, transmits video onto a monitor, and the surgeons manipulate their scalpels and forceps while watching their actions-greatly enlarged-on the screen.

"It's like operating under a magnifying glass," adds Robert Beart, Jr., M.D., the Charles W. and Carolyn Costello Chair in Colorectal Diseases and chief of colorectal surgery. "The detail is great, and it takes a different type of hand-eye coordination than many surgeons are used to."

Holes and probes in the abdomen may sound like science fiction, but compared to open surgery, the advantages are hard to deny. Those benefits are most often seen in laparoscopic gallbladder surgery, which is now the most common operation in the nation, Katkhouda says.

Until the early 1990s, open surgery to remove the gallbladder, a small sac on the side of the liver, required a single, long abdominal incision through the skin and muscle, and a four- to seven-day hospital stay. But the laparoscopic technique means less pain, leaves only four tiny scars, and can often be done on an outpatient basis. Patients can return to work or other physical activities quicker.

Laparoscopy also has become the favored method of performing surgery for gastroesophageal reflux disease, or GERD. At USC, physicians Tom R. DeMeester, M.D., professor and chair of surgery, Cedric G. Bremner, M.D., and Jeffrey H. Peters, M.D., professors of surgery, and their team can rid patients of chronic heartburn and indigestion this way.

Ordinarily, a sphincter in the lower esophagus keeps digestive acids in the stomach, where they belong. But a GERD patient often has a defective sphincter that allows gastric juice to regurgitate, causing irritation.

Using a technique that sounds like a gymnastic feat-the Nissen fundoplication-the surgeons laparoscopically remove part of a stomach muscle and wrap it around the incompetent sphincter in the esophagus, creating a collar that keeps acids down in the stomach. For the patient, daily antacids are no longer necessary, and the surgery is done with only five small incisions followed by a 48-hour hospital stay.

 

Cartilage and Colons

Perhaps endoscopy is most publicly prominent in the world of sports, where professional athletes often undergo arthroscopic surgery after injuries.

When a patient complains of serious joint pain or injuries, USC orthopaedic surgeon C. Thomas Vangsness, Jr., M.D., can insert an arthroscope into the joint to better assess the problem.

Active patients often seek help from Vangsness, co-director of Center for Athletic Medicine at USC University Hospital, for a torn meniscus in their knees, an injury causing pain and inflammation. (The knee has two menisci, crescent-shaped pads of tissue between the tibia and femur that act as shock absorbers.) Surgeons can repair or remove just the damaged part of the meniscus with arthroscopic surgery. This procedure needs only two- to three-millimeter-long incisions through the skin, says Vangsness, which usually means less disturbance to the joint, smoother recovery and no need for an overnight hospital stay.

He also uses the technique to help diagnose and plan treatment for those with articular cartilage damage in their knees and surgeries for the shoulder.

Even spinal surgeries have gotten into the act, as Katkhouda has joined with orthopaedists to offer minimally invasive surgery for chronic back pain. All this is in addition to his laparoscopic abdominal work: removing spleens, excising liver cysts, performing appendectomies, repairing hernias and treating adrenal disease. As with other laparoscopic surgeries, the patient benefit is a reduced hospital stay, less post-operative pain and minimal scarring compared to open surgery techniques.

And in the case of live-donor organ transplant operations, in which a living donor chooses to give up a kidney for someone who desperately needs it, USC surgeons can even remove the donor's kidney laparoscopically-making the generous gift a lot easier on the donor.

Colon resections also can be done through a laparoscopic technique.

"Laparoscopy is our procedure of choice for diverticulitis surgery," explains Beart, who specializes in colon and rectal disorders. USC is one of the few centers in Southern California that offers this option, he says.

Diverticula are small sacs that can poke out from the sides of the large intestine, and diverticulitis results when these diverticula become infected. That causes inflammation, discomfort and abdominal pain. Although doctors usually treat the problem with antibiotics and rest, sometimes patients need surgery. And laparoscopy usually leaves these patients feeling better, quicker. Says Beart: "It is our impression that laparoscopy reduces length of stay in the hospital by 20 to 50 percent." The colon also begins to function normally more quickly after laparoscopic procedures, he says.

Not only that, but patients get to eat sooner. "Our open surgery patients usually are given food on the second day after the operation," Beart says. "For laparoscopy patients, though, we can actually feed them liquids on the day of their surgery."

 

Cautious on cancer

Beart and his colorectal surgery colleagues also are participating in a multi-center, National Cancer Institute (NCI) study testing the effectiveness of laparoscopic resection of the colon due to non-metastatic colon cancer. USC is the only study site in California, and one of the largest study sites in the nation.

Recovery from the open surgery typically involves a seven- to 10-day hospital stay and a six-week period of recuperation and rest. But depending on the portion of colon removed, the laparoscopic surgery patient may experience complete bowel function and be ready to go home as early as three days after surgery.

Laparoscopy can be controversial when it comes to cancer. Some physicians believe laparoscopy, as a stand-alone surgical treatment, is best kept to benign diseases not involving any cancer.

Beart believes that laparoscopic resection of the colon for colon cancer must be rigorously tested and thoroughly proven in trials as beneficial to patients before it is offered openly.

One of the controversies revolves around potential contamination when the tumor is removed laparoscopically, Beart says. "That is why we take special care when doing the procedure," he adds. He and colleagues are monitoring the patients long after surgery to make sure there are no discrepancies in the incidence of cancer recurrence in the patients who get laparascopic surgeries, compared to those getting open surgeries.

"I'm cautiously optimistic," Beart says. "I haven't seen anything in our practice to suggest it's not a superior alternative to traditional surgery."

In addition to the colon study, the NCI has funded Dilip Parekh, M.D., professor of clinical surgery and chief of tumor and endocrine surgery, and his team for a study of the effectiveness of using laparoscopy to minimize open surgeries on pancreatic cancer patients.

Doctors often must perform open surgery on these patients to best diagnose them and see how far the cancer has progressed, before determining the best treatment plan. But Parekh's team is testing the use of a laparoscope, as well as advanced scanning and imaging, to assess the stage of a patient's cancer without open surgery. If the cancer is operable, doctors can then opt for an open surgery to remove the tumor. If it is not operable, doctors can use other palliative laparoscopic techniques to treat a patient-saving the patient from potentially grueling open surgery.

Finally, USC gynecologic oncologists such as Lynda D. Roman, M.D., associate professor, rely heavily on the laparoscope. Although they have long used it to help remove benign masses less invasively, gynecologists now are seeing the tool have an impact on cancer operations. In many patients with advanced cervical cancer, for example, surgeons can remove lymph nodes in the abdomen laparoscopically to check for cancer spread, without the long incision that is otherwise required.

"The healing is quicker, so the patient can start radiation sooner," Roman says. USC surgeons recently started using a new technique in which they "sneak" under the skin in the abdomen to remove these lymph nodes, without disturbing the patient's intestines. "Bowels are less irritated that way, and the patient recovers faster," she explains.

In women with early cervical cancer who want the option of having a baby, doctors can perform a radical trachelectomy-removing the cervix vaginally, taking out lymph nodes laparoscopically-thus preserving the uterus, Roman says.

Endometrial (or uterine) cancer patients who are otherwise healthy also can be treated laparoscopically, she says. Surgeons can remove the ovaries and fallopian tubes laparoscopically to make sure no cancer has spread. They then remove the uterus vaginally and check on the extent and aggressiveness of the cancer within it. If appropriate, they remove lymph nodes in the abdomen laparoscopically. It is all done in one procedure, again with quicker recovery time allowing for earlier radiation treatments if needed.

Colorectal surgeon Beart looks for laparoscopy to become a valuable tool in cancer treatment. He says, "It clearly is the wave of the future."

Katkhouda, who helped usher in the modern era of laparoscopy, says the technique is rich in history-and rich in its potential for the future.

"Laparoscopy is the biggest advance in surgery since antibiotics and anesthesia," he says. "The surgery books are slowly being rewritten, and the 21st Century will no doubt herald a new era of minimally invasive techniques."


For more information about laparoscopic surgery or to learn more about The Doctors of USC, call 1-800-USC-CARE (1-800-872-2273) or visit www.usc.edu/go/usc-care.

 
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