Minimizing pain, accelerating healing

After a recent successful intervention at Yale-New Haven Hospital to restore blood flow through a failing hemodialysis graft, a patient shook the hand of Assistant Professor of Surgery and Diagnostic Radiology James Wong, M.D., and declared, “Dr. Wong, you are the best!”

This scene would be unremarkable except for the fact that the man congratulating Wong was still lying on the table where the procedure had been performed. Because Wong had used a balloon angioplasty catheter instead of a surgical incision to open up the graft, the patient remained awake during the procedure and went home immediately afterward.

Balloon angioplasty is just one example of a growing number of procedures that can now be performed with “minimally invasive” techniques, which for patients means little or no pain, extremely small wounds, little scarring, no hospitalization, shorter recovery periods and fewer complications, says Robert Udelsman, M.D., M.B.A., chair of the Department of Surgery and Lampman Memorial Professor of Surgery and Oncology.

Today, Udelsman says, many patients are informed consumers who seek out surgeons trained in minimally invasive surgery. The School of Medicine has retooled its educational programs to train students in these techniques, which generally adds an additional year of training to a resident’s preparation for a surgical specialty.

Udelsman is one of the world’s foremost practitioners of minimally invasive parathyroidectomy, a procedure to treat cancer or overactivity of the parathyroid glands in which the pea-sized glands are removed from the neck through very small incisions. Udelsman is able to speak to patients during the procedure to ensure that the surgery does no damage to the nearby larynx, and patients can generally return home shortly after the operation.

Vascular surgeons like Wong who typically operate on elderly patients have been eager to adopt minimally invasive methods because these patients are especially vulnerable to pneumonia and other complications following complex vascular surgery. Some of his patients who might have been too frail to undergo traditional surgery have done very well with the newer techniques, Wong says.

But the very young are also benefiting from the new approaches, especially endoscopic surgery, says Milissa A. McKee, M.D., M.P.H., assistant professor of surgery and pediatrics and director of pediatric trauma services at Yale-New Haven Children’s Hospital. McKee says that Yale offers more minimally invasive surgical options specifically for children than any other institution in Connecticut. In her practice, McKee often uses endoscopes, devices that can be inserted through tiny incisions and include a camera, a lamp and a channel for surgical instruments. A surgeon operating on an adult might use a 10-millimeter endoscope, McKee says, but she typically works with a 4-millimeter version, about half the diameter of a pencil, to perform major operations, including the repair of defects of the lungs and intestines in newborns.

In some cases, McKee has used endoscopic techniques to treat hereditary conditions in children whose parents had been treated with traditional “open” surgery. She says that children treated with the new techniques are back to school and their normal routines sooner, their parents miss less time at work and hospitalization costs are cut substantially. “The difference is dramatic,” McKee says. “This is definitely the future of children’s health care.”

Studies have shown that kidney donations increased after surgeons developed minimally invasive techniques for harvesting kidneys from live donors. Robert L. Bell, M.D., assistant professor of surgery, has observed a similar phenomenon since the advent of laparoscopic gastric bypass procedure to treat extreme obesity (a laparoscope is a thin endoscope specially designed to be inserted through the abdominal wall).

Bell, one of three surgeons at Yale meeting the growing demand for the gastric bypass procedure, now does almost all of these operations laparoscopically, and he says there are numerous advantages to minimally invasive techniques.

Patients now opt for the surgery much sooner (heading off many of the health problems that accompany prolonged obesity), recovery time is measured in days rather than weeks and complications are minimized, says Bell.

When patients come in for check-ups two weeks after surgery, Bell says that he can tell them, “Go to the gym today and lift as much as you want.”