Through advances in technology, UAB surgeons are performing minimally invasive surgeries in a wide variety of areas
By Tom Weede
In one of the biggest trends in medicine today, things are getting smaller—much smaller. Through techniques collectively known as minimally invasive surgery, physicians are using shorter incisions and miniaturized instruments to transform the ways in which patients are healed. And at UAB, doctors are performing thousands of these operations every year.
“Minimally invasive surgery means that you accomplish the traditional operation with minimal invasion of the body,” says UAB laparoscopic surgeon Ronald H. Clements, M.D., who also serves as director of the Alabama Institute for Minimally Invasive Surgery at UAB. “You achieve the same things on the inside, without having the large-scale incision.”
The benefits include reduced scarring, less postoperative pain, decreased risk of infection, less blood loss and a faster return to normal activities. “Also, the hospital stay is usually much shorter,” Dr. Clements says. Video magnification used in minimally invasive operations also gives surgeons a better view of the operating site, allowing precise movements that protect surrounding structures while removing or repairing organs.
As with traditional open operations, minimally invasive surgeries usually require general anesthesia. “It’s still a major operation,” Dr. Clements says. “On the inside, all of the risks of the procedure are basically the same as they would be had you done an open procedure.”
Driven by Technology
With advances in fiber optics and miniaturization of video equipment, minimally invasive operations became more prevalent in the late 1980s and early 1990s, and have continued to progress. Also, developments in robotics, as well as techniques such as electrocautery and ultrasonic technology to seal blood vessels during procedures, have been driving forces. Voice-recognition technology has been another factor—in specially designed operating rooms at UAB, surgeons are performing operations using voice-controlled equipment. Wearing a device that looks like a wireless microphone, they can control much of the equipment hands free.
Minimally invasive procedures, Dr. Clements says, “have continued to grow at an exponential pace every year.” Today, operations can involve the abdomen, pelvis, chest, spine, knee, hip, heart, brain and other body parts. “Minimally invasive techniques can be applied to so many different types of procedures,” Dr. Clements notes.
Laparoscopy, for example, is a type of minimally invasive surgery in which the surgeon makes a small incision and inflates the abdomen with carbon dioxide to expand the body cavity. Other small holes are used to insert a tiny video camera attached to a long rod (called a laparoscope), as well as to insert long and thin surgical tools. While an assistant handles the camera, the surgeon performs the operation as he or she watches a TV monitor. “You can see everything inside the patient on a 20-inch flat-panel monitor much like a computer screen,” says Dr. Clements, who specializes in laparoscopic surgery and performs hundreds of minimally invasive operations per year.
Using laparoscopy, surgeons are able to target the stomach, intestines, pancreas, spleen, kidneys, appendix, uterus, adrenal gland, prostate and colon. Procedures that can be done laparoscopically include gastric bypass for morbid obesity and operations to alleviate hernias, endometriosis and gastroesophageal reflux disease (GERD). “Now, almost every operation that used to require an open procedure has been done laparoscopically,” Dr. Clements says. “Doctors can remove the gallbladder using a laparoscope in more than 90 percent of patients, according to the Society of Laparoendoscopic Surgeons.
Head and neck surgeon Glenn Peters, M.D., is performing thyroidectomies laparoscopically at UAB—the only facility in Birmingham to offer the procedure. This same-day surgery, for select patients with small nodules, hyperthyroidism, Grave’s disease and other thyroid disorders, leaves a smaller scar and has a shorter recovery time than traditional surgery.
Expanding the Minimally Invasive Horizon
Surgeons also are using minimally invasive techniques in heart surgery. In the case of coronary artery bypass surgery, the surgeon does not have to split the breastbone as with a traditional open bypass operation, and instead gains access to the heart through a six- to 10-centimeter “keyhole” incision and removal of a small portion of the rib. Surgery also may be performed without having to stop the heart and place the patient on a heart-lung machine.
The typical recovery time is two to four weeks, compared to the six to eight weeks required after traditional heart surgery. (Only patients requiring one or two coronary artery bypasses are good candidates for the minimally invasive technique.) Aortic and mitral valve replacement and repair is also possible using a minimally invasive procedure in some cases.
Special devices have been developed for minimally invasive approaches, and are available at UAB. The da Vinci Prostatectomy is a procedure employed in cases of prostate cancer. Using a robotic apparatus and looking at a magnified three-dimensional image, the surgeon sits at a console in the operating room, 10 to 15 feet away from the patient. His hand movements are converted into precise movements of small surgical instruments in the patient. “The surgeon actually doesn’t touch the instruments,” Dr. Clements explains. “This same device has been used before—just to prove that it could be done—in an operation where a surgeon was in New York City and the patient was in Paris.”
Another device, the gamma knife, was first developed in Sweden 30 years ago and has become more advanced with improvements in software and technology. With this tool, UAB doctors can irradiate smaller targets in the brain, such as a tumor, with a high degree of precision. The instrument uses multiple low-dose radiation beams—each originates from a different place so that normal tissue along the route to the tumor receives harmless doses of radiation. The beams then converge on the target, delivering intense amounts of radiation at the precise spot needed. As the number of targets increases, the device is less able to spare normal tissues, and isn’t appropriate for large targets.
“It’s pretty similar to external radiation for any cancer, but it’s very refined,” Dr. Clements says. “There is minimal destruction of tissue around the tumor, which is obviously very important when you’re talking about the brain. You don’t want to destroy any normal tissue.” Gamma Knife surgery is performed at the new UAB Highlands facility in the Southside Medical Center District.
With the rapid advances in minimally invasive surgery in recent years, what does the future hold? As new surgical instruments are developed and cameras and video systems are improved, the possibilities will continue to expand. Says Dr. Clements: “I think every operation is going to have some element of minimally invasive surgery in it.”