STORY BYDuke University 's recently published study on the benefits of minimally-invasive, or laparoscopic appendectomy over the traditional open surgery made national headlines.
But the results came as no surprise to Craig P. Fischer, M.D., M.P.A., and assistant professor of surgery at the University of Texas Medical School at Houston. In 2002 he had already reported on the "current state of laparoscopy" in the journal Seminars in Laparoscopic Surgery.
In this minimally-invasive procedure, surgeons insert a laparoscope into the abdomen and perform the operation with small incisions, facilitating improved patient satisfaction.
The chief benefit to laparoscopic surgery appears to be that patients tend to recover much quicker. The incision is much smaller and doesn't involve the cutting of muscle.
More importantly, laparoscopic surgery mitigates the main drawback to the traditional open surgery: infection. In open appendectomy, the appendix often exudes some purulent bacteria into and around the incision during its extraction. Through the laparoscope, the appendix is placed in a "sterile bag and is removed through a sterile wound," Fischer says.
Fischer learned in his research that patients are often back at work within 48 hours, and simple acetaminophen often suffices for pain. But in open surgery, infection-based delays of up to two weeks were not uncommon.
The Duke study confirmed this impressive reduction in healing time on a large scale-they tested over 40,000 patients. Now it appears likely that laparoscopic surgery will become the wave of the future in appendectomies.
But, the benefits of minimally invasive appendectomies have been known since the late 1980s. Why are they only becoming the focus of widespread attention today?
Fischer says that surgeons have tended to take an "if-it-ain't-broke-don't-fix-it" approach toward the humble appendectomy, especially since the open surgery is relatively easy to perform. "Medical students cut their teeth on the traditional procedure," he says. Despite the possibility of infection, it was hard to argue with the success of the tried-and-true surgery.
And laparoscopic surgery is more expensive. "It involves lots of disposable equipment," Fischer says. Each disposable device costs $300-$500, making the bill for a typical surgery run between $1,500--$2,000.
But a cost-benefit analysis shows that, in societal terms, the decreased downtime on the part of patients more than covers the extra costs of the procedure. They are back to work sooner, and their employers do not have to hire temporary replacements.
There are other benefits to the minimally invasive appendectomy as well, especially for women of child-bearing age. "There are multiple reasons why someone might have right-lower abdominal pain," Fischer says, but "because of the risk of infection of the ovaries or tubes," the woman's appendix is automatically removed when such pains occur, "even though we know that in 20 percent of the cases we are removing a healthy appendix."
This problem is avoided in minimally invasive surgery because "we can actually look at the appendix" before taking it out.
There are a few cases in which open surgery will probably continue to make sense. Children tolerate the traditional procedure better than adults do, so there's little need to make the expensive change. And when patients present with sepsis and generalized peritonitis, traditional open surgery may be preferable.
Otherwise, it seems likely that laparoscopic surgery is the future of appendectomy, or perhaps of other procedures as well. Advances in robotics will change surgery drastically, Fischer says. "In 20 years, we'll have developed robotic procedures that actually allow the surgeon the sensation of touch. The 'X-Box generation' of surgeons in the future will likely perform most abdominal surgery with robotic assistance in the not- too-distant future."
UPDATED: 1-21-2004
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Dr. Craig Fisher is an assistant professor of surgery at the UT Medical School.
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