With decades of experience using minimally invasive surgical techniques to correct spinal issues Juan Bartolomei, MD, assistant professor for neurosurgery, explains the evolution of the practice and how Yale has made it an integral part of surgical residency while remaining on the cutting-edge of clinical practice.
“I attended Yale School of Medicine and completed my residency at Yale New Haven Hospital in the late 1990s / early 2000s. At that time spine surgery meant having to make large incisions, often cutting through muscle,” Bartolomei said. “As a result, patients would face a lengthy recovery.”
The benefits these techniques provide are one reason they are part of surgical residency programs. Yale remains a leader in this area, making the technique an important part of surgical training.
“Everybody here is trained to perform these procedures as part of residency,” Bartolomei said. “Our residents are trained to perform these procedures, and they’re also trained to develop the clinical judgment to decide when it’s appropriate to use the techniques. That, in turn, benefits our patients because they are able to go home sooner with a much shorter recovery period. Our goal is always to get the patient home and enjoying their life as quickly as possible.”
Bartolomei said it’s incredibly fulfilling to see the first-year residents grow more comfortable with the procedures as they advance through the program adding, “It’s amazing to see them, in their first year, get exposed to it, then by years five, six, and seven they’re performing these procedures with a lot of independence.”
Minimally invasive endoscopic techniques make surgeries dramatically safer and more tolerable. Instead of a large incision that cuts through the muscle at the treatment site, the surgeon makes one or more very small incisions and inserts slender instruments and a tiny camera between the muscle fibers to help visualize progress on a monitor. That’s why the technique is sometimes referred to as muscle-sparing. The result, in some cases, is the patient goes home with only bandages to cover the wounds.
The access to advanced technologies is something that sets the Yale residency training apart and lays the foundation for further advancements.
“The minimally invasive, muscle-sparing techniques developed over the last 20 years are now being significantly enhanced by technologies like computerized navigational systems and robotics which our residents have access to,” Bartolomei explained. “For example, these advancements are actively used in today’s scoliosis surgeries. Typically, these surgeries require long incisions and treatments across multiple spine segments. Now, with the precision provided by the navigational systems and robotics, we can insert screws in the bone and attach rods to restore normal spine curvature with significantly less trauma to the muscle. This is just one example of Yale’s ongoing commitment to refining surgical methods and applying these innovative techniques to a broader range of procedures.”
Not content to only apply current minimally invasive techniques to more complex surgeries, Yale is pushing the envelope when it comes to developing newer techniques and applying newer technologies to these procedures.
“One of our surgeons, Jacky Yeung, MD, assistant professor for neurosurgery, is innovating with a new concept called ultra minimally invasive surgery which is performed through incisions even smaller than 18 millimeters,” Bartolomei said. “Dr. Yeung really is a pioneer in our state when it comes to this type of surgery, which is very exciting.”
Yeung was recently highlighted for his work to correct a spinal issue in a pregnant woman. He was able to remove a herniated disc from the patient using only a small incision and a camera while the patient was under local anesthesia and awake the entire time. Because the procedure was performed using very small incisions, avoiding the muscle, risk to the unborn baby, then in the second trimester, was greatly reduced. The surgery was a success, providing instant pain relief for the patient who was discharged the same day. She later delivered a healthy baby boy.
According to Bartolomei, emerging technologies like augmented reality can also play a role in the advancement of these techniques. “Similar to how the computer navigation systems provide a higher level of precision, augmented reality can take that even further because it allows us to see the anatomy much better,” he said. “With augmented reality you can see exactly where the blood vessels are, not only on the side you are working on, but on the other side as well. As a surgeon, you know you’re getting close to those blood vessels, but the augmented reality shows you exactly where they are.”
Yale, like other major academic healthcare institutions, tends to receive patients requiring more complex surgeries. However, Bartolomei said he still sees patients for less complicated procedures which are opportunities to work on the minimally invasive techniques.
“I just performed a minimally invasive procedure a few weeks ago,” he said. “It was a large disc herniation we had to remove to take pressure off the sciatic nerve. It took about an hour to perform the surgery, and the patient went home the same day, extremely happy. They were off pain medications two days later. That really shows how impactful this type of work can be.”