UCSD professor and surgeon Dr. Richard Bodor says improvements in equipment are lessening both side effects and the possibility for mistakes.

While the medical community’s lifesaving advances get the most attention, technological advances are doing a remarkable job of minimizing invasive surgeries, which lead to a reduction in postoperative scarring. Once the primary treatment is over, hospitals also are providing cosmetic surgery and after-care counseling to assist patients in resuming their lives.

In the case of surgeries, procedures are so improved that patients feel less pain, are discharged earlier, recover faster and see less scarring than a decade ago. What used to require a large open incision is being done with tiny incisions and microscopic equipment. The smaller incisions have helped reduce weeks of recovery time in many cases to just days.

Improvements in technology and techniques are allowing the medical profession not only to treat symptoms, but to give patients the opportunity to resume a normal life quicker with fewer physical and mental limitations. Advances include laser surgery and laparoscopic procedures that can repair and remove organs through the tiniest incisions. Even dressings are much improved, reducing infections and more quickly sealing wounds.

“The equipment gets better and the side effects get less,” says Dr. Richard Bodor, chief of plastic surgery at Veterans Affairs Medical Center and assistant professor in the department of plastic surgery at UCSD.

Laser advances make mistakes in some operations nearly impossible. Examples include lasers that will operate only on an area of skin marked with a blue dye and won’t “zap” an area unless the equipment is being correctly moved. “Therefore, you’re less likely to overburn an area or treat an area unnecessarily,” says Bodor. “It won’t accidentally reflect up into somebody’s eyeballs. Many operators don’t even wear protective goggles anymore.”

Laser waves also can now be oriented to treat certain skin pigments. “Like aging spots; it will only get the darker spots, not the lighter ones. These techniques make patients have less skin damage, less injury, less risks.”

Tiny Scopes; Big Picture

Gallbladder removal is one example of how far treatment has come. Traditionally, the gallbladder would be removed through a five- to eight-inch long abdominal incision. Fiberoptic technology has transformed this surgery into what is known as a laparoscopic cholecystectomy. A laparoscope — a small, thin tube with a scope on the tip of it used to see the inside of the body — is used to remove the gallbladder. Several small cuts are made rather than one large incision. The doctor views the gallbladder on a television screen while performing the surgery using tools inserted in three other small cuts. The gallbladder is removed through one of the incisions. This technique may be used in other procedures that require organ removal or internal surgery.

Available to women are laparoscopic hysterectomies. Patients feel less pain, have significantly smaller incisions, encounter fewer complications and can resume their normal lives much sooner than with traditional abdominal hysterectomy. Those benefits, plus the ability to go home the same day for most women, have led to nearly 60 percent of Kaiser Permanente’s elective hysterectomy patients opting for this procedure. Patient education prior to surgery, a supportive home or family team, and careful preparation by the hospital team are key factors in successful same-day procedures.

“Our foremost consideration is benefit to the patient, in terms of an effective, safe and minimally invasive surgery,” says Dr. Silverio Chavez, chief of OB/GYN at Kaiser Permanente, San Diego. “We find our LH procedure patients experience significantly more positive results than TAH patients, particularly in reduced loss of blood, less need for pain medications, reduced length of stay in the hospital and a much quicker return to normal activity.” Complication rates are substantially lower and most patients are sent home needing only a few medications.

Clement Hoffman and John S. Kennedy, obstetrics and gynecology surgeons with Kaiser Permanente in San Diego, are pioneers of the LH procedure. The pair lead the local medical community in the surgery, performing more than 250 of the operations per year. They also have helped position Kaiser as a leader in endoscopic education. “Members of the OB/GYN department here at Kaiser Permanente in San Diego have made a major commitment to widen their skills beyond traditional training to master these new procedures,” explains Dr. Hoffman, “thanks to the great support we’ve received from our leadership.”

Sharp Coronado Hospital reports it is the only hospital in San Diego that offers endoscopic cyclophotocoagulation for glaucoma. The procedure uses a diode laser and fiberoptic light to reduce pressure from inside the eye. It can reduce or eliminate the dependence on expensive medications. Glaucoma is a leading cause of blindness, affecting an estimated 6 million Americans.

At Sharp’s Grossmont Hospital surgeons use a new, minimally invasive procedure for hip replacements. People suffering with arthritis, hip pain and stiffness are candidates for what is known as an “anterior approach.” The procedure allows the surgeon to reach the hip joint from the front of the hip. This way, the hip can be replaced without detachment of muscle or tendon from the pelvis or femur, a procedure made possible by a specialized table. All this results in a smaller incision, less muscle trauma, reduced pain and a speedier recovery.

Sharp Grossmont began the anterior procedure in December and the results have been positive. “We’re seeing remarkable outcomes and satisfaction from patients,” says Dr. Peter Hanson, the orthopedic surgeon who performed the first surgery at the hospital. “One of my patients took me fishing on her boat in less than two weeks. When we can help patients get back on their feet and to their regular routine as quickly as possible, it’s a good thing.”

Open, Shut Them, Give A Little Healing

It wasn’t long ago that open surgery — cutting into the body to make repairs — was the only option to surgeons. Dr. Dan I. Giurgiu, Scripps Mercy staff surgeon, went to medical school in the 1980s and was taught only open procedures.

“The concepts weren’t there,” Giurgiu says. “We couldn’t have imagined having done the types of surgeries we’re doing now because we didn’t have the tools. Technology wasn’t applied to what we were trying to do. It’s been a mini-revolution in the approach to how people get their surgery done. It was routine for people to be in the hospital for four or five days to recover. Today we send people home the same day.”

Giurgiu’s clinical interests include conditions requiring advanced laparoscopic procedures. He specializes in the surgical management of gastroesophageal reflux disease and laparoscopic colon surgery, as well as laparoscopic removal of solid organs, such as spleen and adrenal glands. He performs both standard and laparoscopic surgery for hernias, biliary tract disease and tumors of the digestive tract. He also has extensive experience with sentinel lymph node biopsy for diseases of the breast.

Are these new procedures better?

Giurgiu says it depends on who you are and how you look at it. “It is a huge benefit to the patient,” he says. “In general, the patient has to endure far less pain and recuperation. The flip side is that these procedures are highly more technically demanding for the surgeon. They require skills that traditional surgical education does not impart.”

A push is on today to ensure that more hospital interns — doctors-in-training — can take advantage of advanced surgical education training programs. The skills required are more adaptable to the video game-playing generation. Giurgiu also says doing it this way is more fun. (Ironically, surgeons are not paid as much for the more advanced procedures because they take less time and get the patient out of the hospital faster.)

While he would be fine with never performing another open surgery, Giurgiu says there still are instances in which these new procedures will not work.

New Wound Treatments

Wound treatment also has advanced. To promote healing in acute and chronic wounds hospitals are turning to negative pressure therapy. The treatment involves the application of negative pressure (suction) to the wound bed. The concept is to turn an open wound into a controlled, closed wound while removing the excess fluid from the wound bed. Using suction and a drainage tube with a nonadherent, porous wound dressing, the wound drains and heals without constant need for dressing changes and less concern for infection.

Even anesthesia is better with fewer patients waking up with what is best described as a hangover. It all boils down to a reduction in recovery time. “They all want to be getting back to work quicker,” UCSD’s Bodor says of his patients.

Making Patients Look Good

“We are seeing great improvements in technology,” Bodor says. “Always increasing our surgical effectiveness while decreasing our risks and side effects. Improved prosthetics have helped patients immensely, such as when we are unable to successfully replant an amputated digit or limb.” Technology has even allowed implantable devices to motorize artificial limbs with better coordination, and less cosmetic deformity and less energy being wasted. In the case of partial facial and eye loss due to cancer, “there is beautiful latex with glass that you can’t even tell,” Bodor says. “You know something is wrong because the guy isn’t moving his eye, but it isn’t evident that when he pulls his glasses away, coming with it will be a third of his face.”

Improved tissue engineering has optimized bone replacements to reduce the need for bone graft harvesting, bringing better bone gap healing. Implanted hardware that used to require surgical removal, now often is absorbable, eliminating the need for a second surgery. Evolving skin substitutes and tissue fillers (that started with improving contour in reconstructive problems), now have demonstrated success in cosmetic procedures as well.

Cutting Is Deeper Than The Knife

Dr. Erminia Guarneri, director of Scripps Center for Integrative Medicine, which helps patients cope with life after surgery.

“It’s not enough to surgically fix a problem, cure the illness or cut out the cancer,” says Dr. Jon Greif, an attending surgeon in the department of general surgery at Kaiser Permanente. “We have to go further, and give the patient our very best skills, compassion and resources so they can return to a sense of wholeness and well-being.” That takes both state-of-the-art technology and a comprehensive health plan offering support services, pre- and post-surgical counseling, patient education services and connection to community resources.

At Kaiser, patients receive comprehensive, personalized care that ranges from prevention and wellness to chronic condition treatment, hospitalization and education for long-term lifestyle changes that improve and maintain health.

Scripps Center for Integrative Medicine helps patients find underlying issues and helps them cope with life after surgery. “Even if they have had a simple procedure,” says center director Dr. Erminia Guarneri, “the procedure fixes only one segment. Surgery is easy, but now many patients go home with a new diagnosis (of a problem).”

Guarneri sees many patients recovering from heart surgery. Although the problem that landed the patient in the hospital may be fixed, there are lifestyle changes that must be made to ensure the patient does not immediately return to the operating table. Someone is doing fine one day, they develop chest discomfort, and they receive a stent,” Guarneri says. “This is not a big procedure, but all of a sudden they have found out they have coronary artery disease. ‘Now I have a new diagnosis I didn’t have before. Now I have to face all the underlying causes of heart disease. What am I eating? Is my cholesterol up? How am I living my life?’ All the mind, body, spirit things that go into heart disease.”

At Scripps, patients like that may be referred to a cardiac rehab program, where they are taught how to exercise again or perhaps referred to a more intensive, integrative program where they begin to change their life. They meet with a nutritionist to learn how to eat. If their issue is stress, get them to yoga and stress reduction classes. “Get to the underlying cause or the process is going to continue,” Guarneri says.

The Scripps Center also can help prepare patients mentally before surgery to decrease anxiety and pain. “There is no such thing emotionally as a small surgery,” Guarneri says. “It is very rare to go to the hospital and shake it off. It can be a traumatic experience. People may even come out depressed.” The Scripps Center offers these programs to everyone.

Sharp HealthCare provides many counseling options including the Joint Endeavor Program, which tracks each patient from a pre-hospital screening through surgery and the hospital stay and for years after discharge. Results of this multiple-year study are compared across Sharp hospitals and with national benchmarks to continuously improve services so patients achieve the best possible results.

From curing disease to replacing body parts, minimally invasive surgeries are curing people and lessening the disruption of recovery, while other hospital services are doing their part to minimize the mental changes and help patients change their life to avoid further complications.