Jan. 24, 2002?In a University Hospital operating room, Dr. Robert Glasgow watches approvingly as the resident surgeon across the table performs the difficult procedure.
“Oh, doctor!” he said with satisfaction. “Great dissection. The best I’ve ever seen. You’re the man!”
Except for a minor instrument malfunction, the surgery continues without any glitches. When it is over, Glasgow immediately picks up the phone next to the operating table and calls the waiting relatives in the hospital.
“I’m really pleased with how it went. He lost about a tablespoon of blood,” Glasgow says on the phone.
Surgery is serious business and a life-altering event for many who go under the knife. Anesthesia takes the patient delicately close to a state of death, large incisions expose the usually protected interior, and the chances for complications make surgeries an often traumatic experience.
New technology and techniques have made laparoscopy a more popular option today. A type of minimal invasive surgery, laparoscopy is used in many procedures to reduce the trauma of surgery. Using high-tech equipment, such as fiber optic cameras and blades that cut with sound waves, surgeons can get the same end results as traditional surgery but get by with much smaller incisions and blood loss.
The decreased trauma from the surgery also means less pain, smaller scars and faster recovery. Procedures that used to require several days of hospital stay now may need only an overnight visit.
The surgery being performed today by Glasgow and his resident is called Nissen fundoplication. The patient suffers chronic acid reflux because the valve separating his stomach and esophagus (the tube connecting the stomach to the throat) is not working properly. In the past, fundoplication would usually mean a five-night stay in the hospital, but this patient may go home tomorrow, a Friday, and return to work next Monday.
“The equipment in general is more expensive” than those used in conventional surgeries, Glasgow says. “[But] in most of the procedures studied, there’s a cost saving to the hospital and health system because of the shorter hospital stay.”
Because of the promising future of laparoscopy, the U School of Medicine recruited Glasgow last year to expand the use of the technique at U Hospital. Glasgow received his training at the University of California at San Francisco and went on to serve a fellowship at Oregon’s Legacy Health System’s hospitals. In Portland, he worked with Dr. Lee Swanstrom, “a world leader” in minimal invasive surgery, Glasgow says.
“I’ve always been interested in gastrointestinal,” Glasgow recalls. “It became apparent to me in San Francisco that the future of that [is in laparoscopy]. Gastrointestinal is an ideal area to apply minimal invasive [techniques]? I was recruited here? to bring more complicated and less practiced procedures, and bring the U to the forefront.”
And that often involves teaching the procedures to others. At today’s surgery, resident surgeon Dr. Jared Speakman and a medical student are assisting Glasgow. The surgeons make four 5 millimeter and one 10 millimeter incisions on the patient’s abdomen and fit trocars into each of these small openings. Trocars are devices that act as portals into the body cavity. They allow the instruments?camera, graspers, suction, scissors and anything else the surgeons may need for the operation?to slide into and out from the body cavity more easily.
The trocars also serve another purpose. The abdomen is inflated with carbon dioxide gas to create room for the procedure, and the trocars help maintain the gas pressure within the body cavity. Carbon dioxide is usually the gas used because it does not support combustion and is easily absorbed into the body without too much side effect.
The surgeons rely on two video monitors standing on either side of the operating table to see inside the body. The view is like going into a small wet cave with a flashlight.
“The challenge is making 3-D [decisions] with 2-D cues,” Glasgow explains.
To minimize trauma further, the surgeons use Harmonic scalpels to dissect tissues inside the body. The high frequency sound waves from the scalpel seal the blood vessels as they cut.
Little graspers and scissors at the end of foot-long rods are inserted through the trocars to manipulate the organs and tissues, and also used to do suturing.
“The suturing is very hard to teach and to learn,” Glasgow says as he watches the monitor. Speakman, the resident, is controlling the graspers that are pushing the needle through a part of the stomach, and then he deftly maneuvers the suture into knots. “Jared [Speakman] is making it look easy, but it’s really not. Getting the instrument in the right place is a feat by itself.”
The lack of depth from the monitors and tactile cues from not using their hands directly make laparoscopy a delicate craft. This is only Speakman’s third laparosopic surgery, but residents practice in the animal labs for hours before operating on patients.
Using laparoscopy for routine gastrointestinal procedures, like the fundoplication just performed, is increasingly commonplace. Glasgow says laparoscopy wasn’t available for fundoplication 10 years ago; but now, 90 percent of fundoplications use laparoscopy. Glasgow would like to expand the application of laparoscopy to areas not used before, such as removing liver cancer. The intrepid surgeon is hard pressed to think of the limitations. “You’re talking to a guy who would try to do anything,” he says.