Almost two years ago I wrote a post about the improvements in infant surgery since I had my own life-saving pyloric stenosis operation (“PS”) in 1945. If these changes for the better are of any interest to you, the reader, you will find the post via this link.
In this post I want to pass on how one pediatric surgeon regards one of these improvements: the increasing use of minimally invasive or laparoscopic surgery (“MIS”) rather than open surgery (“OS”). Dr George W Holcomb is (or was then) the Surgeon-in-Chief at the Mercy Children’s Hospital in Kansas, Missouri, and his powerpoint presentation gives some telling insights into the medical mind.
Dr Holcomb’s opening definition of innovation in medical science is the “creation of more effective health care technologies, processes, or medicines that are accepted by doctors, payors [sic] and patients.”
He then lists as the three most impactful medical-surgical innovations of the last 60 years
- the heart-lung machine (1953),
- total parenteral nutrition (TPN, 1960s) or feeding a patient totally intravenously when the gut is unable to process food, and
- laparoscopy and thoracoscopy (1988), by which surgeons work inside the abdomen or chest by inserting narrow tubes through which they can see or work with miniaturized instruments.
Holcomb discusses the last these, which he says has almost overnight “revolutionized” the model for much surgery, resulting in less pain, faster recovery, and reduced scarring for the patient.
At first, MIS was used mainly in surgery on adults, as the miniaturized instruments and skills required for infant surgery took some time to be developed. I was fascinated and grateful for the revealing insight Dr Holcomb gave into how MIS was received before 1995. He reports that “organized surgery” (presumably meaning medical schools and professional leaders and associations) at first regarded it as a passing fad.
Interestingly, I have on file several journal articles which still (more recently) question the benefits of MIS. While I am well aware that MIS has some disadvantages, risks, and possible negative consequences, open surgery also has its share of these.
Holcomb reports that support for the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) rose at this time – presumably due to their interest in and support level for MIS. Howver, the numbers of those who attended the meetings and conferences of the American College of Surgeons (ACS, presumably a more time-honoured, august and conservative body) fell, while “device manufacturers flocked to SAGES – and felt welcome”. Ah, when novelty, modernity and commercial interests unite!
The presentation goes on to report that after about 1995, ACS began to realise that MIS was no passing fad, but SAGES nevertheless continued to grow and attract business.
Dr Holcomb then directs his attention to infant surgery, focusing on PS, the most common reason for it. He says that in 1990 pediatric surgeons who began to use MIS were seen as “cowboys” – young and daring but reckless. He also tells us that many “open surgery” pediatric surgeons regarded the size of their incision as a reflection of their skill! He adds with obvious feeling that it was commonly felt that a large scar looks impressive on a baby “but we [surgeons] don’t see these patients as teenagers or adults”. How absolutely true! Nor do many surgeons seem to realize the emotional pain and damage these patients and their parents may suffer as a result of their insensitive treatment and care. Holcomb comments succinctly and with some understatement that these people “have no appreciation for the benefits if MIS”.
The good doctor then continues to discuss MIS.
It is not easy to learn, he says. I have read that it usually takes some 30 or so “tries” to learn the techniques involved in a pyloromyotomy by MIS. At first it also takes longer to do and results in more morbidity (mistakes, complications and unwanted effects and extra care).
Dr Holcomb continues by mapping real progress since about 2000.
- Some general surgeons trained in MIS also specialized in pediatric surgery and started to teach in medical schools.
- Schools began to recruit trainees from recognized MIS pediatric surgery programs.
- Appreciation of the benefits of pediatric and adult MIS developed: reduced pain, shorter hospital stays, faster recovery, and an earlier return to normal routines.
- MIS procedures for many conditions reported reduced operating times, especially due to less time being needed for wound closure.
Also of interest to readers will be Dr Holcomb’s notes on the present situation.
- Most practising MIS surgeons are young, or 2-3 generations removed from the “founding fathers” of pediatric surgery.
- Because there are so few schools teaching pediatric and MIS surgery, “the opinions of a few affect the masses”.
- In pediatric surgery, apart from PS, there is “a wide variety of rare cases” which makes it hard to gather objective and meaningful statistics and treatment data.
Regarding PS however, I have seen a considerable amount of data which tends to underline, or at least show equivalence to, the value of MIS on technical, cost and treatment grounds. And of course this disregards the studies which have established the huge preference for PS surgery by MIS whenever parents of the infant patients were consulted.