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Belly button video games: patient demand leads to high-tech procedures for common operations.

NEW SURGICAL PROcedures are leading to shorter stays in the hospital for patients and more training for physicians, who are forced to use modern techniques if they want to compete in the medical market.

The use of laparoscopic surgery, in which surgeons work with video monitors and much smaller incisions, actually started in Europe in the late '70s. But some of the advanced procedures being done today caught on slowly in the United States -- until the news spread.

"It's mostly patient-driven," says Dr. John B. Cone, chief of the division of general surgery at UAMS Medical Center. "The medical profession was slow to adopt it because it's difficult."

Surgeons are being asked to use skills required for playing video games to do surgery they have been trained for years to do with their hands.

"It requires an adjustment in the manner of operating," says Cone, adding that some surgeons initially thought the procedure was dangerous because they have less control. "You can't feel tissues. You're operating by remote control."

Thinking that the technique would not catch on, surgeons might never have adopted the high-tech method if patients had not demanded it.

About three years ago, patients diagnosed with inoperable gallbladders heard about a new high-tech procedure referred to as "Nintendo" or "Star Wars" surgery. The actual name of the procedure is laparoscopic cholecystectomy, referred to as "lap chole" for short.

Gallbladder surgery traditionally required a very large abdominal incision that left a scar; extended pain resulting from cuts into the abdominal muscles; a hospital stay of three to five days; and up to six weeks away from the job for the patient.

Technology has changed all that.

Lap chole requires two half-inch and two quarter-inch incisions, Cone says, and one of those is through the navel, from which the gallbladder is actually removed. Video and cutting instruments are inserted after the abdominal area is expanded using carbon dioxide.

Rather than exposing the surgical area, it is monitored on a video monitor through a laparoscope and the procedures are carried out by using the instruments rather than direct hand contact.

"The first one I did took four hours," Cone says of lap chole. "Now I can do a straightforward one in 45 minutes or so, but that's still twice as long as the regular way. For the new generation of surgeons who are being trained in the beginning, it may not be any slower for them."

As the technique became popular over the past three years, Cone says, surgeons who had not converted to high-tech lap chole found themselves losing patients to those who were using it.

"Keeping patients happy is a part of it," Cone says. "We're doing it to make them feel better. It doesn't really make much difference to us. It just hides the scar, putting the scar in the belly button."

About 10 percent to 15 percent of gall bladder removal surgeries still have to be done the "old-fashioned" way because of complications that can't be forecast, Cone says. Patients are warned before surgery that the method might have to be changed once the procedure begins.

Because the technique is relatively new, surgeons still don't know all the possible complications. This should change, however, because 600,000 gall bladders are removed annually in the United States.

Cone says early indications are that it's safer.

"Purely looking at the complication rate, it's lower with the scope," he says of a 1 percent trouble rate. "But complications you have are more serious. You injure bile duct that you wouldn't injure doing the old way. Nobody has been able to totally eliminate problems, but we know it's less painful with less hospital stay."

Gynecological and orthopedic surgeons also implement laparoscopic techniques, and a growing number of procedures are in the experimental stages.

Simple appendectomies, colon resections and hernia operations, as well as diagnostic procedures that have replaced traditional exploratory surgery, are being done with the laparoscope. Ulcer surgery, kidney removal and lung biopsies are still relatively new laparoscopic procedures that are not readily available to most people, Cone says.

Kathy Giglia, an assistant administrator at Doctors Hospital, says a new surgeon who has been practicing and teaching advanced laparoscopic surgery will be joining the staff in August. He is involved in experimental techniques, she says.

Although gynecological use of the laparoscope has been in place for several years, Giglia says one of the biggest changes has been in its use for hysterectomies during the past year and a half. Like gallbladder surgery, hysterectomies have traditionally meant longer stays in the hospital and extended time off work.

With the medical advancements, Giglia says, hospitals have had to make a major shift in what they do for patients.

"People aren't in the hospital long enough to get information" on pre-operative and post-operative care, she says. "It's a real challenge when we don't have our hands on them for any more time than we do."

Doctors Hospital has an outpatient processing area that's separate from the normal admissions office as a result of the growing number of quick surgeries. Giglia says 58 percent of the surgical procedures at Doctors are being done on an outpatient basis, compared with 43 percent last year.

"The kinds of cases we're doing on an outpatient basis now, we never would have thought about doing," Giglia says. "Now that they've gotten the time down, they go home in the late evening or early the next morning."

Patients don't necessarily see a large decrease in expense with the high-tech surgery. Giglia says the majority of the cost comes from surgery itself, which requires more costly equipment, and not the hospital stay.

"But patients can come in, have a good experience that's not as painful and can return to work more quickly," she says.

Carolyn Lindsey of St. Vincent's Infirmary Medical Center says laparoscopy will continue to have a significant impact on reducing length of stay in the hospital.

"We're able to identify those patients who would be appropriate candidates for laparoscopic procedures," she says. "However, the demands will be greater on the hospital because those patients who are not candidates, by virtue of other associated illnesses, will usually require more resources.

"One futurist predicts that eventually we'll have small, acute care hospitals that will be the equivalent of today's intensive care units, and the remainder of the patients will be treated in other settings."

Cone agrees that medical technology and procedures are improving every day.

"But I still think that proving you can do it doesn't mean you should," he adds.

AT A GLANCE

* Use of laparoscopic surgery, in which surgeons work with video monitors and much smaller incisions, actually started in Europe in the late '70s.

* Surgeons might never have adopted the high-tech method of "lap chole" if patients had not demanded it.

* About 10 percent to 15 percent of gallbladder removal surgeries still have to be done the "old-fashioned" way because of complications that can't be forecast.

* 600,000 gallbladders are removed annually in the U.S.

* The complication rate of lap chole surgery is only 1 percent.

* 58 percent of the surgical procedures at Doctors Hospital are being done on an outpatient basis, compared with 43 percent last year.

* Traditional gallbladder removal is one of the safest and most effective of the abdominal surgery procedures.

* Lasers are frequently used to dissect the gallbladder.
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Title Annotation:Health Care Update
Author:Hankins, Jeff
Publication:Arkansas Business
Date:Jul 26, 1993
Words:1227
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