Is the newest, smallest, and fastest always best? How surgical innovations come about.

Frederick Ilgenfritz, MD
Bitterroot General & Vascular Surgery

Kids growing up are always trying to find something to brag a bit about. "My dog's bigger than yours." "My brother can beat up your brother." "I have pretty hair because its: curly, long, short straight"…you fill in the blank. This seems to be built into the nature of children somehow. You can imagine Abraham Lincoln bragging about how many books he read by candle light. Another drive is to do something that hasn't been done before. Climb the tallest mountain, swim the ocean, go over the falls in a barrel. And finally people seem to have the need to take good things to an extreme. For example: eat the entire container of ice cream, or build an enormous house, or wear the smallest bikini.

It seems that when we get to older, we don't necessarily outgrow this tendency. I saw this in medical school where the bragging was about how little sleep we got, or which journals we had read to be ready for the professor's quizzing. Among the senior residents and surgeons, it came down to who could do the fastest operation with the smallest incision. Or who could suggest the most obscure diagnosis and confuse everyone else.

There are surgeons who have made their reputation by attempting to do just about every possible difficult thing you can imagine. One example is the removal of a pituitary tumor (located in the brain, behind and between the eyes) by making a hole through your nose, and sinuses, into the brain, and scooping it out. It turns out that this works pretty well. Imagine being the first guy to think of it and try it! Another advance is the removal of the gallbladder or appendix through a set of small incisions and a long skinny camera. These laparoscopic operations have become the most common and best way to do these operations. Instead of a large incision and a several day stay in the hospital, people now are going home the same day. Once these initial operations were successful, surgeons then tried to do every other difficult operation they could think of through the same technique. This included aortic aneurysms, kidney removal, partial and complete removal of the pancreas, and many more. Some of these have also become the preferred way to do the operation, others remain somewhat of a curiosity…..yah you can do it, but why would you want to?

The most recent addition to this striving to do something that other people haven't done or can't do is NOTES surgery. NOTES stands for Natural Orifice Transluminal Endoscopic Surgery. You can see why they just call it NOTES. It is the next logical step on the scale of "my incisions are smaller than yours" In this case there are no external, visible incisions after the operation is completed. The primary uses so far are for cholecystectomy and appendectomy. That is, removal of the gallbladder and appendix respectively. As discussed above the laparoscopic surgery revolution made it possible to remove these organs with very small scars and quicker recoveries. If small scars are good, wouldn't no scar be better? Possibly this would be helpful for the one wearing the smallest bikini?
So some clever surgeons decided to try to take out the gallbladder through the throat and stomach. They would place a scope down the throat and then make a hole in the wall of the stomach and then perform the surgery using some specialized instruments that would work at the end of the scope. Once the gallbladder was removed from its attachments it was pulled up out through the throat and then the hole in the stomach wall was closed. This has been done many times now, but many surgeons feel that the risk of complications is higher, and the advantage of no visible incision is not worth the risks. It turns out that to reach the appendix from the stomach is difficult so the same surgeons figured out that they could come from the lower abdomen with a small opening in the side wall of the vagina and take the appendix out of women from that location. This has also not really become popular; again it is difficult to justify the risk versus the benefit.

The same motivation that led to playground boasting, and ocean swimming seems to lead some doctors to try new techniques or an innovative way to do old operations. Some may see it as a way of gaining recognition and acclaim. For others it is a better way to serve their patient's needs. Out of these bold efforts have come better ways to do some operations. These techniques have moved into the mainstream of medical/surgical care.

Newest, fastest, smallest are not always better, but the drive to innovate does bring us advances and improvements. The challenge for the practicing surgeon is to sort through what is being done and pick the real innovations from the unnecessary or dangerous ones. And then bring the newest, fastest, smallest along with safest and most reasonable to their patients.

Questions or comments can be addressed to Frederick M. Ilgenfritz, MD, FACS, c/o Bitterroot General & Vascular Surgery, 1150 Westwood Drive, Suite C, Hamilton, MT 59840 or visit www.bgvs.us.

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