Minimally invasive surgery often best for patients

Washington -- It's difficult to find an area of health care where primary care physicians don't need at least a basic knowledge of the latest treatments and techniques, and that includes surgery. As minimally invasive approaches continue to soar in popularity, patients are very likely to ask about advantages and disadvantages, or they may need to be apprised of the benefits of these new techniques.

As a matter of fact, so many patients ask about alternatives to traditional surgery, especially bariatric surgery, that the American Academy of Family Physicians decided to offer guidance. A monograph: "Guiding the Patient Through Minimally Invasive Surgery," was released in April.

The advances driving this interest are obvious.

Surgeries performed through half-inch incisions using tools the size of a fingernail and smaller are becoming the norm, particularly for some operations. In 2001, for instance, nearly 75% of cholecystectomies were performed using laparoscopy, and last year, the laparoscopic method for performing bariatric surgery was more common than was open surgery, said Philip Schauer, MD, director of Cleveland Clinic's bariatric surgery program.

Techniques are emerging so quickly that open-chest cardiac surgery could become a treatment of the past, predicted Stephen Colvin, MD, chair of cardiothoracic surgery at New York University Medical Center. Dr. Colvin spoke at an AMA media briefing on cardiovascular disease in April.

"Knowing the risks and benefits enables us to counsel patients to make the best decisions for them and for their general health. We're in a great spot to be able to advise," said Barbara Apgar, MD, professor of family medicine at the University of Michigan, who served on the panel that drafted the AAFP monograph. "If we're informed, we can direct our patients to the people who will get the job done."

In some ways, the term "minimally invasive surgery" seems almost an oxymoron, Dr. Schauer said. But although many operations are still considered major undertakings, the amount of surgery necessary to get the job done has decreased. It used to be that just getting to the site of the problem sometimes caused more trauma to the body than correcting the actual health issue, he added.

This concept is now particularly true for abdominal procedures, where, instead of an incision that stretches from just below the breast bone to the navel or even lower, a few small incisions allow a surgeon to perform appendectomies, hernia repairs and even colectomies.

These techniques offer significant advantages to nearly all patients: shorter hospital stays, less pain and scarring and earlier return to daily activities. "I can't say there are drawbacks. It's a system that offers significant advantages," Dr. Apgar said.

But not all patients are good candidates. Those who have had a lot of surgery and have thick scar tissue as a result may have better outcomes with open surgery, said Anita Courcoulas, MD, chief of the section on minimally invasive bariatric and general surgery at the University of Pittsburgh School of Medicine. "When you work in a minimally invasive way, you need some freedom to move."

It is a different approach to surgery, Dr. Schauer said. "It takes some time for a surgeon to become comfortable. However, with this wonderful technology, excellent cameras, optics and lighting, we can actually see much better than what we would see with traditional surgery."

Experience counts

Primary care physicians play a major role in referring patients to surgeons in their region who have expertise in these approaches, Dr. Courcoulas said.

"Like any other specialty, experience, experience, experience is important," Dr. Schauer said.

"I think primary care physicians are so in tune with their communities and since they refer on a regular basis, they would be able to steer the patient in the right direction," Dr. Apgar said.

Recent findings support this notion as well as underscoring the positives associated with this minimally invasive approach.

A study found that morbidity and mortality levels were very low when bariatric surgery was performed in academic centers on patients with body mass index of 35 to 70. Plus, the authors noted, such surgery has shifted from open to laparoscopic, with gastric bypass being the primary procedure. Their study appeared in the May 15 Archives of Surgery.

Although bariatric surgery has a higher level of difficulty than some others, it is still becoming increasingly popular. "I think physicians are most interested in talking to patients about bariatric surgery," Dr. Apgar said. The benefits of surgery for obese patients are striking and can include improved lipid profiles and reduced risk of cardiovascular disease and type 2 diabetes.

While minimally invasive approaches carry obvious pluses, patients could harbor some misperceptions, Dr. Schauer said. Patients don't always grasp that all surgery is serious and that a hospital stay of a few days might be necessary. Also, the possibility of complications still exists.

Primary care physicians could find that they have a counseling role to play after surgery, according to the AAFP monograph. Following bariatric surgery, patients might require advice on diet as well as with psychological issues. "Some patients have trouble adjusting," Dr. Apgar said. "They may not have thoroughly considered all of the problems such as having to eat smaller meals."

Also, "If there is a wound problem, the family physician can direct them back to the surgeon," she said.

The monograph examines five laparoscopic surgical procedures: cholecystectomy, appendectomy, bariatric surgery, surgery for endometriosis and diagnostic laparoscopy. Because of its increased popularity, bariatric surgery will be explored in a monograph in the works, Dr. Apgar said.