“Is it Only Heartburn?

From 1988 to 1993 I was a general surgery resident at Keesler Air Force Base in Biloxi Mississippi. Surgical residency is that period of time after medical school where you learn to be a surgeon. You start doing operations under the guidance of experienced surgeons and only after this period of time are you permitted to function independently as a surgeon. When I began my surgical residency there was essentially no such thing as laparoscopic general surgery (surgery using small incisions and a scope placed inside the abdomen). The idea of looking into the belly with a scope, and scattered reports of cases of this had been around for many years. The gynecologists used laparoscopy commonly for many minor procedures, but when I entered surgical training the text book that we used, which was over a thousand pages long, had only two paragraphs devoted to laparoscopic general surgery.

About this time, surgeons began removing the gallbladder using the laparoscope. In my residency program we started performing this procedure in my third year of training. By the time I finished my five years of training, an examination of my case log showed that in the first two years all gallbladder removals where done open and the last two years virtually all gallbladder removals were done laparoscopically. A friend who graduated from the same program as I three years later graduated with virtually NO experience with open gallbladder removal. So in the span of a few years there was a complete shift in the way we performed one of the most common general surgery operations.

In 1992 I began performing laparoscopic colon removals. The early experience with colon removal was equally encouraging as it was with gallbladder removal and since that time it has been the predominate technique I use for colon removal. Unlike gallbladder removal where laparoscopic removal very quickly became the standard, the adoption of laparoscopic colon removal has been VERY slow. A recent review estimates that nationwide only 10 to 30 percent of colon removals are done laparoscopically. The following is a list of “reasons” that have been thrown around usually be people resisting this change:

1. “Laparoscopic surgery may not be as good a cancer operations“- FALSE – I’m sad to say that I contributed to this misconception in a small way. I reported the first case in the literature of a patient with recurrent cancer at a trocar site after laparoscopic colon removal. This issues has very vigorously been resolved. There are multiple multi-center randomized controlled trials both in Europe (“c.o.l.o.r. trial”) and in the US (“c.o.s.t. trial”) with thousands of patients that show that laparoscopic surgery is as effective as open for cancer cure.
2. “Laparoscopic colon removal is a lot more difficult to learn” – TRUE – The difficulty lies in needing to operate in multiple different quadrants of the abdomen, having to handle much larger blood vessels than with gallbladder removal, needing to be able to sew inside the body. It is estimated that the “learning curve”, the number of cases it takes before the surgeons facility with the procedure approaches the average, is 50 to 100 cases. For surgeons in low volume colon practices this can take such a prolonged period of time that they never make the needed strides to feel proficient.
3. “Open surgery patients leave the hospital after 4 or 5 days anyway so the trouble of doing this procedure is not worth it” – FALSE – I guess a lot of this depends on which end of the knife you are on. When I first moved to Melbourne I did a study looking at the early recovery results of my laparoscopic colon removals vs the rest in the community which were primarily done open. This study showed that the average length of hospital stay for the open group was 11.3 days. The length of stay for the laparoscopic group was 2.6 days. The open colon removal group was also 6 x more likely to need intravenous narcotic pain medications. Clearly this is a marked improvement in overall short term recovery.
4. “Its more expensive” – PROBABLY NO LONGER TRUE – Have you looked at what a week in the hospital costs lately. As time has gone on this cost gap has decreased and in some cases reversed.
5. Unlike with gallbladder surgery where there is often little urgency to the timing of operations, colon surgery often must be done on a more expedited basis. Patients are therefore referred to a surgeon by a primary of GI doctor and may not be aware that by seeing a different surgeon they could have the surgery laparoscopically.

In most cases colon removal (colectomy) can be done with minimally invasive techniques (laparoscopy). Only in very few situations is open colon surgery required. Make an appointment with a surgeon who specializes in minimally invasive techniques to see if you are a candidate.