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Recent Advances in Laparoscopic Surgery 

Incision Concision

click to enlarge Dr. Darren Rohan, the chief of thoracic surgery, and co-chair of the department of general surgery for HealthAlliance of the Hudson Valley, performs a thoracoscopic lobectomy with the assistance of surgical technician Rob Wilson while watching on the operating room’s flat-screen high-definition monitor. - DON DEMPSEY, WHITE LIGHT LLC
  • Don Dempsey, White Light LLC
  • Dr. Darren Rohan, the chief of thoracic surgery, and co-chair of the department of general surgery for HealthAlliance of the Hudson Valley, performs a thoracoscopic lobectomy with the assistance of surgical technician Rob Wilson while watching on the operating room’s flat-screen high-definition monitor.

For Katherine Corrigan, the SILS (single-incision laparoscopic surgery) she underwent at Vassar Brothers Hospital felt a little bit like magic or divine intervention. “The first thing I did, of course, was look to see what my belly looked like,” she says. “There was a tiny incision about an inch long. They don’t even need to put on a dressing—they used that NuSkin stuff. There was absolutely no pain at the time and very little afterward. I went home four days later and took the Percocet they gave me for one day, then realized I didn’t need it and switched to Ibuprofen.”

A month later, Corrigan is back to doing her yoga and walking a mile and a half every day—after being relieved of a three-centimeter-long polyp in her intestine, her appendix, and 18 lymph nodes. “I know people who had similar procedures done in the traditional way—opened up from stem to stern—and their recovery took months,” she says. “I’m in awe. Part of me wonders, ‘How’d they do that?’ But I don’t really need to know."

Corrigan’s surgeon, Dr. James Nitzkorski, is equally thrilled to be able to offer the single-incision technique at Vassar Brothers. “The SILS technique has been in use for gall bladder surgery for a while but using it for a colon resection isn’t too common yet,” he says. “In traditional laparoscopy you have three or four ports in use—one for the camera and the others for instruments. With SILS, one slightly larger incision, about 20 to 22 millimeters, can be used for multiple instruments.” (By comparison, a typical incision for an “open” surgery would be 20 or more centimeters.)

“It’s ideal for cancer surgeries, where a specimen has to be retrieved through the incision in any case. It’s vastly better cosmetically. And of course there’s much less pain. Less pain means less pain medication, which is a crucial factor in recovery from any type of gastrointestinal procedure, since narcotic pain relief medication impairs normal intestinal function.”

Leaps in Laparoscopy

Laparoscopy—surgery performed through small incisions using a type of telescope to guide the surgeon’s actions—may sound ultramodern, but the concept goes back over 100 years. The technique was first used on dogs in 1902, and on humans in 1910. It has been undergoing refinement ever since, especially in Europe. But after the advent of the computer microchip television camera in the 1980s, the procedure really gained ground—surgeons, understandably, liking the improved visibility. Prior to 1990, the only type of surgeries routinely practiced with laparoscopic techniques were minor gynecological procedures.

“Every surgeon currently trained is trained in laparoscopy,” says Dr. Darren Rohan of Mid-Hudson Surgical Specialists. “There is a lot of technology that goes into it. In Poughkeepsie [at St. Francis] we just got the daVinci surgical robot, and that takes it to whole new levels. It gives you extra movement and three-dimensional visualization. The daVinci system takes the movements of your wrist and transfers them to the instruments that are inside the patient. Before daVinci, laparoscopy was sort of like operating with chopsticks. With daVinci, it’s like having a miniaturized version of your hand inside the patient. You have the same or more freedom you do with your own hand. It won’t be long before every hospital has one. It will be the new normal, just as laparoscopy itself has become the norm.”

In traditional laparoscopy, tubes (trocars) are inserted through small incisions, or ports. The abdomen is inflated with carbon dioxide to improve both visibility and room to work, and the surgeon views the patient’s interior on a monitor. DaVinci surgery takes this a step further—the surgeon sits six feet away from the operating table, controlling the instruments from a console with equipment that has been described as resembling video game controllers.

A Routine Route

Although such concepts may sound like science fiction to those of us whose concept of “surgery” was formulated during the MASH era by scenes of Hawkeye Pierce up to his elbows in gore, the surgeons interviewed spoke of it casually as an everyday occurrence—and for them, of course, it is. Considerable training is undertaken during a surgeon’s residency period. Explains Rohan: “First you watch experienced surgeons do it. Then you practice on animals. (Veterinary laparoscopy has a long and honorable history.) You practice on cadavers. And when you finally work on an actual patient, you have mentors right there supervising.”

Rohan works on chests and bellies, treating conditions of the gall bladder, colon, and appendix as well as repairing hiatal hernias and lung resections. At Benedictine Hospital’s orthopedic center, Dr. Stephen Maurer applies minimally invasive techniques—called arthroscopy in this context—on shoulders, knees, ankles, and elbows. He too finds it a boon. “I can repair tears in tendons, ligaments, the meniscus, the rotator cuff—all using just a few little holes. The technique’s been around for years now,” he says. “You used to have to look through an eyepiece; now we use a monitor. It’s become routine—I do it every day—and it means a patient can recover from, say, a simple knee surgery in just a few weeks. It used to be that we would have to detach the muscles to get to the joint. Now we just insert the cannula [similar to a trochar] right through the muscle.”

click to enlarge Dr. James Nitzkorski practices out of the Health Quest Medical Practice surgery office located in the new Aronzon Ambulatory Surgery Center at Vassar Brothers Medical Center in Poughkeepsie. The Aronzon Center is a 25,000-square-foot, same-day surgery facility that offers four state-of-the-art operating rooms, a special procedure room, and a spacious post-anesthesia care unit. - DON DEMPSEY, WHITE LIGHT LLC
  • Don Dempsey, White Light LLC
  • Dr. James Nitzkorski practices out of the Health Quest Medical Practice surgery office located in the new Aronzon Ambulatory Surgery Center at Vassar Brothers Medical Center in Poughkeepsie. The Aronzon Center is a 25,000-square-foot, same-day surgery facility that offers four state-of-the-art operating rooms, a special procedure room, and a spacious post-anesthesia care unit.

Completely Scarless
Minimally invasive surgery, with its long and honorable history and exciting new possibilities, may never be the solution to every single problem. Not everyone is a candidate—people who have had a lot of prior abdominal surgery, for example, or who have chronic breathing problems may be unable to tolerate the introduction of the needed carbon dioxide.

And some conditions may simply require the old-fashioned type of incision. But it’s part of the surgeon’s art to know which those are. “Most colon problems are just perfect for SILS, and I think I’ll probably use it for a liver surgery next,” says Nitzkorski. “But the most important thing I can do is give every patient a perfect cancer surgery. I will not compromise, ever, for the sake of technique or comfort. When laparoscopy is possible, we take great care to ensure that you get the same resulting procedure whether the technique is open or closed.
“The techniques themselves are not new—after gynecology, they were applied to gall bladder surgery for years and the introduction as a cancer surgery technique was very cautious and gradual. We know how to do this.”
In fact, they know how to do more. Beyond SILS and daVinci, Nitzkorski is excited to report that his partner, Dr. John Choi, recently performed the Hudson Valley’s first ever trans-anal microsurgery, or TEM—a microsurgical technique that allows avoiding an incision entirely by working through the anus to remove tumors or polyps. “It’s completely scarless,” says Nitzkorski of TEM. “And it can save a patient from a big incision and colostomy bag.”

“Now that this has been done at Vassar Brothers,” says Nitzkorski, “there is literally no procedure you can find at a major teaching hospital that we don’t have available right here in the Hudson Valley.”

Screen Ahead, then Steam Ahead

One point that all of the surgeons emphasize: Take care of yourself. Get those screening procedures, especially if you’d like to be one of the fortunate patients who can be healed with minimally invasive techniques. “The vast majority of colon cancer cases show no symptoms until it’s very late in the game,” says Nitzkorski. “A colonoscopy is the only way they can ever be detected at the stage when these techniques have the best prognosis.”

His grateful patient Corrigan agrees. “If I’d gotten screened at 50, this would have been a tiny polyp,” she observes ruefully. “But if I did have to experience this, I can’t say enough about how wonderful the technique is—and the surgeon himself. I’m into a lot of alternative modalities. Some were helpful—meditation, yoga breathing. I brought my Reiki person with me and Dr. Nitzkorski was fine with that. Some of the Chinese herbs I normally take could have interfered with clotting, and I had to stop taking those a couple of weeks ahead. But between my toolbox of anti-anxiety techniques and Dr. Nitzkorski’s confidence and warmth, I felt like I floated into that operating room—and that was before they gave me the good stuff. How do they do this stuff? I don’t need to know. I just know here it is barely a month later and I’m fine.”

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