A surgeon's learning curve
Dr. A.K VENKATACHALAM discusses the pros and cons of minimally invasive orthopaedic surgery.
AS a final year medical student, about 22 years ago, I was taught that "Big surgeons make big incisions". Surgeons in training were also taught that incisions heal from side to side and not along their length.
All branches of surgery, including orthopaedic surgery, have evolved since then. Earlier, and sometimes even now, exposure of the joints of the knee, hip and shoulder and the spine need large incisions to visualise the pathology and put in prostheses and carry out reconstructive procedures. Therefore, conditioned by surgical training, many orthopaedic surgeons in the eagerness to visualise the joints properly are not really bothered about the length of their incisions.
Big incisions mean more inflammation and more pain. To expose the diseased or damaged joint, muscle origins have to be divided or elevated. Post-operative physiotherapy has to be accommodative to let muscles heal. So patients take longer to recover, involving longer hospital stays and delays in returning to work.
Minimally invasive surgery has already found its place in arthroscopic knee and shoulder surgery. Now it is finding a place in joint replacements of the hip and the knee. At the recently concluded annual conference of the American Academy of Orthopaedic Surgeons, papers were presented on the results of about 250 hip replacements done through two small incisions each about one or two inches long. The patients return home the same day or within 2-3 days. Knee replacements are also possible through incisions about 6-8 cm long. With the help of the operative microscope, spinal surgeons can decompress the spine or remove a disc through incisions about an inch long.
The introduction of arthroscopy in orthopaedic surgery has provided a new tool to surgeons to inspect the joints through tiny keyhole incisions. Arthroscopy of the knee is the commonest operation done in the U.K. A precise history of the patient's symptoms and diligent clinical examination can clinch the diagnosis. Investigative tools like the CT/MRI, ultrasound, computer-assisted surgery have enables surgeons to zero in on the abnormal areas and confirm or supplement the diagnosis. A confirmative or staging arthroscopy may help matters further when dealing with large joints of the knee and shoulder.
Several technological advances in biomedical engineering contribute to the ability of the surgeon to perform minimally invasive surgery. These are the image intensifier, operating microscope, arthroscopy, laser, radio frequency, power equipment, and computer-assisted surgery. Surgical instruments have also been modified to suit this kind of surgery. Implants that carry suture material embedded in them called suture anchors are available to treat the majority of painful shoulder conditions. These suture anchors decrease the exposure and operative time needed to perform technically difficult operations, stabilisation of an unstable shoulder, rotator cuff repair and SLAP lesions. Radio frequency devices make it possible to shrink connective tissue through small incisions.
But all these technical gadgets can only complement a skilled surgeon's abilities and are not substitutes for clinical judgment or training. Although it is possible to use smaller incisions, it depends on the extent of damage. A large rotator cuff tear in the shoulder may well need an open operation instead of arthroscopic repair. Inherent to this process is the surgeon's learning curve.
Patients should also not be swayed by advertisements like "have your back surgery today, sunbathe on the beach tomorrow" or "run a mile next week after a mini-hip replacement".
Newer advances in surgery require surgeons to acquire newer skills and climb the learning curve in order to deliver quality treatment. A reinvented thought process, astute mind, surgical skills, technological advances in investigative and interventional modalities have made it possible to reap the advantages of minimally invasive orthopaedic surgery.
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