Health Matters: Many benefits to small incision surgery

Conway McLean, DPM, Journal columnist

Modern medicine is in a constant state of change, owing largely to innumerable studies and the subsequent accumulation of knowledge. New techniques are discovered, and new medicines developed, the result of research performed over the years (as well as practical experience, of course). Perhaps these advances are most notably apparent in the area of surgical techniques.

The progress we have made in many facets of operative intervention is remarkable, from our abilities to fix and alter bone tissue, to the implantation of prosthetic joints. But clearly some of the greatest advances are in regards to minimally invasive surgical techniques, in which surgeons use specialized instrumentation to perform some task internally with less damage externally. As the name implies, the openings performed for this general style of surgery involves dramatically smaller incisions. This is a great benefit to the patient since the larger incision, the more trauma produced.

Many Americans are familiar with the negative consequences associated with the trauma which ensues in open procedures. In this method of operative intervention, an opening is made in the skin envelope which allows direct visualization of the structure being altered, be it a broken bone or a diseased appendix. With minimally invasive surgery (MIS), newer technologies allow precise information about the deeper structures being treated, but without direct exposure.

The concept of surgery through small incisions has been made possible primarily because of the development of these new devices and technologies. For example, we are able to clean out clogged arteries by inserting long, skinny tubes into blood vessels, inserted through a small opening. These have tools at the end of the tube, removing the clogs from inside the vessel, a far more efficient and far less traumatic approach.

The difference in complications from scarring and inflammation with these endovascular techniques is dramatic (although open arterial “bypass” procedures are still performed). These days, we are more likely to attempt, at least initially, one of these endovascular methods because of the markedly easier recovery and fewer complications.

One of the most common concerns with any surgery is the development of a postoperative infection. Despite the sterile environment created for surgery in this country, postoperative infections continue to occur. But this contagion is more likely when there is greater trauma, as well as greater exposure of the tissues beneath the skin, as with an open procedure. With MIS techniques, the skin incisions are dramatically smaller, exposing less tissue. This would help to explain the reduced incidence of infection developing after these surgeries.

Any type of surgery entails the occurrence of trauma, in which there is damage to tissues. Any tissue that has been cut with a scalpel will heal with some scar tissue; the new tissues will never be as strong as the original. How much scarring is dependent on a multitude of factors. But scar tissue formation will be stimulated in the presence of increased inflammation, and many believe this is a critical part of the failure of many surgical procedures. With minimally invasive techniques, the amount of scar tissue generated produced by the body during healing is dramatically less, and this will reliably result in less stiffness and pain after an operation.

Many of us have heard horror stories about the surgical correction of a bunion deformity, a condition in which the big toe angles over towards the lesser toes and a bony prominence develops on the inner side of the foot. Various open surgeries have been utilized over the years to correct these common deformities, but those who have had bunions repaired with traditional open surgeries too often have found the experience both debilitating and extremely painful.

This is generally not the experience when small incision techniques are used. But other benefits have been documented in the literature. Because there is dramatically less damage done to the joint structures, there is minimal stiffness of the joint, a very common problem with open techniques. As mentioned, significantly less swelling is experienced, another important benefit.

Important in many bony procedures is the use of some type of fixation, securing the two pieces of the bone which have been cut. A multitude of new technologies have been developed to allow the application of screws and wires to secure the altered bones through small incisions, again entailing less pain, stiffness, and scarring.

The aforementioned bunion surgery is made possible because of bone screws inserted through small openings, as well as the use of fluoroscopy, a device allowing real time imaging of a bone. As promised by the old comic book ads for X-ray spectacles, fluoroscopy allows us to see a bone in real time. When performing any bone work, we can see the change produced, even though the bone is still inside the foot. Direct visualization of the structure is no longer necessary.

Procedures once deemed impossible to perform with these advanced techniques are becoming commonplace. Many operations on our internal organs can be performed with endoscopy, in which a specialized “telescopic microscope” is inserted into the belly, allowing visualization of the target tissue.

Operations performed on various structures and areas of the body are all trending towards minimally invasive techniques, although many physicians have not received training in these methods. Yet the benefits are real and include a faster return to activity, less pain following the procedure, with reduced scar tissue and inflammation. Should you or a loved one require some type of operation, find out if it can be performed minimally invasively. But only if you like the idea of less pain and an easier recovery.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.


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