Has minimally invasive laparoscopy gotten stale in your ORs? Could some of your surgeons use a nudge to make sure they keep striving for new, less-invasive tools and techniques that let them produce better outcomes and faster recoveries?
It can seem that way, says Alexander Rosemurgy, MD, director of the Southeastern Center for Digestive Disorders at Florida Hospital Tampa. "People who are still doing conventional laparoscopy are doing the same thing today they did in 1990," he says. "That was 25 years ago. That would have been like doing the same thing in 1990 that they did in 1965. That's a huge time warp."
Complacency aside, time didn't stand still between 1965 and 1990, and it hasn't stood still since. We asked a panel of experts to talk about the following 10 important innovations that are making a difference in 2015 advances that weren't necessarily on the radar 2, 3 or 5 years ago, let alone a quarter century past.
1 Laparo-endoscopic single-site (LESS) surgery
The innovative single-port, through-the-navel approach known as LESS surgery is a clean break from that 1990 time warp, says Dr. Rosemurgy. It requires some training, but "going from open to laparoscopy in 1990 was a much bigger step than going from laparoscopy to single-incision laparoscopy today."
And the benefits? They couldn't be more obvious if they bit you, he argues. "The navel is itself a scar," he points out. "So what we're essentially doing is putting a scar in an already existing scar. That way the surgery becomes scar-less. People have some expectation that there should be some benefit beyond the obvious. But the fact that the difference is so obvious is what points out the importance of this."
Still, says Dr. Rosemurgy, a dismayingly large number of surgeons seem not to want to embrace progress. "Some doctors find it difficult to do," he says, "but they've not taken the time to learn it. It didn't happen right away for them, so they're not going to learn it."
Are there other issues? "Some say it's more expensive, but I don't think that's true," he says. Certain instruments like multi-trocar single ports and deflectable-tip laparoscopes are needed, "but everything else is pretty much standard stuff. You might need a bent grasper, one that actually comes bent," he adds. "That's helpful for doing cholecystectomies. But it's reusable. You have to use a grasper anyway, so why not use a bent one?"
And the LESS technique is appropriate for just about any laparoscopic abdominal operation, says Dr. Rosemurgy, "from colon surgery, to adrenal surgery, to anti-reflux surgery, to cholecystectomies just about anything."
Patients are receptive from the get-go, he adds, "but they don't really get a sense of it until it's over. Then they say, 'Wow, this is great.'"
2 Microlaparoscopic surgery
Microlaparoscopy (also called minilaparoscopy) also represents a step up from standard lap, says Aurora Pryor, MD, vice chair for clinical affairs and chief of bariatric, foregut and advanced GI surgery at the Stony Brook University School of Medicine in New York. With tools that range in thickness from about 2.7 mm to about 3.5 mm (or roughly one-ninth of an inch), "you get smaller incisions, less pain and less hernia risk," says Dr. Pryor. "And it's better cosmetically."
It also represents a shorter, easier step up from conventional laps than single-site surgery. "It's the same setup as you're used to with standard laparoscopy," says Dr. Pryor, "so you don't have to modify your technique tremendously, as opposed to the single-incision approach. Many people feel it's an easy adoption from laparoscopy."
There are challenges, such as infusing extremely thin instruments with adequate strength, but manufacturers seem to be overcoming the strength issue with newer materials and different configurations.
"I don't use it for patients who are already going to be a difficult surgery, because it adds an additional level of complexity," says Dr. Pryor. "But with a generally straightforward case, you have more room to add another level of complexity and still make it a very reasonable procedure. And if you need to convert to standard lap, just add some standard size trocars. It doesn't have a major impact on the case."
3 Indocyanine green (ICG)
Indocyanine green is an injectable fluorescent dye that binds tightly to plasma proteins, providing a kind of internal road map that lasts a few minutes before it's removed by the liver. It's marketed as ICG-Pulsion (Dynamic Diagnostics) and IC-Green (Akorn). When combined with improving visualization technology, ICG gives surgeons a great view in real time, says Dmitry Oleynikov, MD, FACS, a professor of surgery and director of minimally invasive and robotic surgery at the Center for Advanced Surgical Technology at the Nebraska Medical Center in Omaha. "It gives you the anatomy behind the anatomy. It augments reality."
And by making it easier to detect major blood flow and other structures, it reduces the likelihood of dangerous mistakes, like nicking or cutting the bile duct during cholecystectomies. "It lets you see the things you want to avoid cutting," says David Renton, MD, FACS, MPH, assistant professor of surgery at Ohio State University's Center for Minimally Invasive Surgery in Columbus. "If it can reduce the rate of common bile duct injuries by even 1% which can cut 5 years off someone's life it's dirt cheap compared to what it saves."
"It's useful for all kinds of procedures," adds Dr. Oleynikov. "Any procedure where you want to know how good the blood flow is colon surgery, plastic surgery or intestinal surgery, for example."
4 Narrow band imaging
Narrow band imaging, developed by Olympus, is another visualization tool that can lead to better outcomes. The technology filters light waves in such a way that peak light absorption of hemoglobin occurs in endoscopic procedures.
By helping surgeons see through some of the superficial epithelium or other superficial tissues, it allows you to see things you couldn't see before, says Dr. Rosemurgy. "Barrett's esophagus jumps out at you. Some pre-malignant neoplastic change might jump out, as well. It can make it possible to visualize endometriosis or to see the blood vessels on the ureter, so you don't cut it."
5 Pneumoperitoneum management
Regional blocks help address somatic pain during abdominal laparoscopic procedures, but visceral pain can still be an issue, says Bruce Ramshaw, MD, co-director of Advanced Hernia Solutions and chief medical officer of Surgical Momentum in Atlanta, Ga., and Daytona Beach, Fla.
To help reduce shoulder pain and the pain associated with abdominal distention, Dr. Ramshaw has had success with a low-pressure pneumoperitoneum system (AirSeal by Surgiquest). The technology provides continuous smoke evacuation and valve-free access to the abdominal cavity as well as a stable pneumoperitoneum.
6 Hemodynamics monitoring
An innovation that helps preclude the need for potentially problematic pulmonary artery catheters and central venous lines, hemodynamics monitoring enables the same information monitoring with a non-invasive arterial line or, in many cases, a device that resembles a pulse oximeter and which fits on the patient's finger.
7 New robotics
The recently released DaVinci XI system, designed for more general surgical applications and greater versatility, represents an intriguing prospect, say several members of our panel.
Among other things, it acknowledges the proponents of the LESS approach with a single-site configuration that can be used in cholecystectomy, benign hysterectomy and salpingo-oophorectomy procedures.
8 Intragastric balloon system
Also attracting attention is the recently FDA-approved Orbera intragastric balloon weight-loss system, which is placed into the stomach through the mouths of patients under mild sedation and then filled with saline, so it takes up space and helps patients feel less hungry. One key will be whether patients maintain weight loss, since it must be removed after 6 months.
9 Reflux management
A new means for treating gastroesophageal reflux disease (GERD) also shows promise. The Linx prosthetic device, approved last year by the FDA, is a flexible band of interlinked titanium beads that's laparoscopically implanted around the lower esophagus just above the stomach. The beads have magnetic cores, which tighten the band and resist gastric pressure. But swallowing temporarily breaks the magnetic bond and allows food and liquid to pass into the stomach.
10 Expedited recovery after surgery (ERAS)
Designed to move patients through the system faster, less expensively and with better quality care, ERAS is a set of specialized protocols that align with the kinds of surgeries patients are undergoing. It covers everything from patient education and counseling, to fluid management, to monitoring devices, says Dr. Rosemurgy. "We want to expedite recovery and minimize complications. The goal is to have less impairment of patients, less of an insult with the operation. And we have better long-term clinical outcomes. We know, for example, that if a patient gets a blood transfusion, it affects their chance of survival. Or if there's an infection, no matter what kind, it's going to negatively impact the chance of survival associated with any kind of cancer."
The ERAS approach also saves money by decreasing length of stay and readmissions, says Dr. Rosemurgy, and can reveal other potential money-saving efficiencies. "We reduced our infection rate by 75% and saved the hospital about $400,000 a year by getting rid of nasal swab cultures," he says. "Instead of testing individual patients, we just went with the assumption that everyone has MRSA and treated them accordingly."