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    Tuesday, April 20, 2004

    Kindest Cuts: My morning paper had an interesting article today on minimally invasive hip replacements (alas, it requires registration, but it's only a one-time registration, and it's free!):

    Owens, 62, of Carrollton, mowed his lawn four days after surgery. And he was back to work as a mechanic in 17 days -- not the three months or more that's typical of traditional hip surgery.

    That's exactly why he sought out the minimally invasive route.

    ``I'm getting ready to retire,'' he said. ``The longer I stay off work, the longer before I retire.''

    Siciliano's reason was much the same, with one added incentive -- he'd been through hip-replacement surgery the traditional way and he knew he didn't want to go through it again. That was two years ago, when his left hip was sliced open, a surgeon cutting through muscle and ligaments to get to his arthritic joint. He spent the next 11 days in the hospital. For two weeks, he couldn't put any weight on his left leg. It took 90 days to get back to work. And the pain -- he couldn't even bend over to tie his shoe for months.

    Three months ago, Palutsis replaced Siciliano's right hip. This time, no muscles were cut. He was walking the afternoon of the surgery. He was out of the hospital within 48 hours. And it took him just 40 days to get back to work as a mechanic, even helping to push cars into the garage.

    ``It's like night and day,'' the 64-year-old Siciliano said of the two surgical approaches. ``It's a world of difference.''

    This kept me puzzled all day long. I know minimally invasive gallbladder surgeries are common, but the gallbladder is like a balloon and can easily be pulled out of a small incision. The appendix can be easily removed that way, too, because it's like a worm. The spleen can be removed with a laparoscope, but first it has to be put in a bag and cut it up into tiny pieces or pureed. But how do they get those pieces of hip hardware through tiny incisions? Turns out they don't:

    “Minimally-invasive” means different things to different surgeons. There is no accepted definition--it can be the same operation done through a slightly smaller incision than the surgeon used to use (say 5 inches rather than 6 or 8 inches), a much shorter incision (an approach calling for a 3 inch incision is popular in some places), or even two 1.5-inch incisions using an x-ray machine to find the bones and put the components in the right place.

    In other words, they just squeeze the hardware in through a smaller space. And they sacrifice their field of view. There's a lecture here with still photos of the procedure, and a skeptical look at its claims (fast forward to 17 min and 4 seconds.) As the speaker points out:

    One might reasonably ask “What could be wrong with a shorter incision--if anything, the results would be the same, but the scar would be more attractive, right?” The answer is, not necessarily. If the shorter incision causes the surgeon difficulty seeing the hip socket or the thigh bone (femur) clearly, or if it impedes his/her ability to work in the tighter surgical field, the result could be badly positioned hip replacement components. That could cause surgical complications like fractures or nerve injuries, hip dislocations (where the ball painfully comes out of the socket after the surgery), and premature wear of the artificial bearing surface.

    As exciting as it might sound, it's a new procedure whose complications and successes have yet to be measured.

    ADDENDUM: Another item of interest is the robotic da Vinci Surgical System which is used for minimally invasive heart surgery. Scroll down to the end of that last link and you can see a video of the daVinci in action. No wonder video game skills are must for surgeons.

    And here's a collection of laparoscopic movies.

    posted by Sydney on 4/20/2004 09:30:00 PM 0 comments


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