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Health Matters: Advances in modern surgery

Conway McLean, DPM, Journal columnist

Surgery has come a long way over the last century, as have all fields of medicine. Numerous examples can be found in the headlines, from giving one particular individual someone else’s face (and I am not making that up!) to transplanting numerous organs. Our ability to perform many different procedures, with reliable results, has improved by leaps and bounds.

We’re now able to open up clogged arteries with the use of new endovascular procedures, literally meaning “inside of blood vessels”. The clogging material is approached from inside the vessel, negating the need to ‘open up’ the area with a long incision. These techniques to improve blood flow involve the passage of thin wires through a small opening in the skin, then inside a blood vessel, until the area of clogging is reached. Lasers or blades then chew up the unwanted material. Even robots are being used to assist surgeons when performing complex procedures, adding precision while allowing these to be carried out through smaller openings.

This concept, of using smaller incisions, has gone from being bold and experimental, to becoming the standard of care. It is generally known as “Minimally Invasive Surgery” or MIS. We can now correct all manner of damage and deformity through tiny openings. And the benefits are considerable. Maybe the most significant is the reduction of post-operative pain. Although a difficult lesson, the prolonged administration of opioid analgesics for pain after an operation is fraught with complications, and comes at considerable cost to society.

Much of the pain after any surgery is the result of cutting through the skin and soft tissues to reach the target tissue, be it a bone or an internal organ. Often, the pain produced is not because of the work that is the goal of the operation, but the trauma created in getting there. And make no mistake about it: surgery is trauma, no matter the procedure. When the degree of trauma is minimized, reduced pain afterward results.

One of the biggest hazards to surgery, and well-recognized by the public, is the development of a post-operative infection. When an opening is created into a human body, our best defense, human skin, is violated. The bigger the opening, the greater the opportunity for bacteria to find there way into the body. As you may have surmised, the longer the incision, the larger the risk of infection. Thus, minimal incision surgeries have a lower rate of getting one of these because the openings are so small.

Depending on the location of the incision, the aesthetic effects of some procedures can be emotionally scarring because of physical scarring. Areas of high visibility, or those that are pressured during the course of our day, both can be problematic if a painful or larger scar develops after an operation. With MIS procedures, the wound is extremely small, so scarring is rare.

Less trauma also means less swelling. Post-operative edema can be a disabling, difficult finding after many procedures, especially those performed on the lower extremity, the foot, ankle and leg. This lasting collection of fluid produced by an operation is going to be worse the more skin, tissues, and vessels that are cut. As has been previously noted, smaller incisions means less damage and, consequently, less swelling problems. This is quite advantageous when it comes to foot surgery. Why there? People want to fit back into a shoe, often difficult when swelling doesn’t resolve after foot surgery.

A common problem occurring on the foot (that far too many live with), is the simple corn, which is a painful callused bump on a toe. These are the long term result of pressure to the skin, either because of a bump of bone on a toe or a digit that has become bent (aka hammertoe). Typically, one incision, roughly the width of a pencil lead, allows for removal of the spur in the former case. In the latter, cutting a wedge of bone allows straightening of the appendage. The goal is eliminating the skin pressure. Without it, the skin heals and pain resolves, all with little to no post-op discomfort or downtime.

When any of the more common foot conditions is present, like bunions and hammertoes, exploration and evaluation of the condition isn’t required. These are well studied deformities. In a bunion, the big toe gradually angles over towards the smaller toes. Simultaneously, a bony bump develops on the inside of the foot at the base of the big toe. Correction of this commonplace malformation has a reputation of being extraordinarily painful afterwards. When performed with minimally invasive techniques, most have noticeably reduced pain after surgery.

Technology provides an essential ability in our efforts to perform minimally invasive bone surgery. A device called fluoroscopy allows the surgeon to see bone “real time”, a movie camera which can only show bony tissue. In essence, this device gives the operating doctor x-ray vision, like some kind of super-hero.

As science and medicine advance, as new methods are developed, many operations have become significantly less painful and the results more reliable. Procedures once thought intimidating, to be avoided at all costs, have become routine through the application of minimally invasive surgical techniques. Numerous examples can be found, from hip replacement to toe straightening. Rewarding tasks like renewing blood flow to a non-healing foot wound or repairing a joint ligament arthroscopically, through two small incisions around a painful joint.

Minimally invasive techniques are able to straighten all manner of deformity, all through tiny openings. Although several medical specialties receive training in foot surgery during their schooling and residency, too few get experience with minimally invasive techniques. And yet, this is the direction of surgery in general: why cause more trauma than necessary? If you have a foot problem, it is possible your path to relief includes an operation performed through tiny openings. The future is now!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.

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