MINIMALLY INVASIVE SUGERY WAVE OF THE PRESENT

Modern medicine has made many advances benefitting our health and wellbeing. Our understanding of disease has progressed tremendously, more so in some fields than others. An examination of life expectancy is evidence of these advances. Prior to the development of antibiotics, before we knew about bacteria and hygiene, many infections were deadly. These days, more people succumb to the chronic diseases of lifestyle as opposed to trauma or infection, as was the case just a few decades ago.

The improvements made in operative interventions, aka surgery, has similarly been significant. In cardiac surgery, we can ‘unhook’ the heart from the circulatory system to correct a variety of issues. In orthopedics as well, we routinely replace damaged joints and can even lengthen legs. Many cancers once considered deadly can now be treated effectively with remarkable improvements in mortality rate. Endoscopes, long skinny tubes with cameras at the end, have allowed us to peer inside of blood vessels without opening them.

These endoscopes are an example of the most important trend in surgical care: minimally invasive surgery, often referred to as MIS. As the name implies, the basic principle is to perform whatever needs to be done inside the body through the smallest opening possible. MIS techniques have proven beneficial in various ways, especially post-operative pain.

These methods have demonstrated that much of the pain following a surgical procedure is due to the soft tissue injury necessitated in accessing the organ or structure the procedure is directed at. Before MIS, getting to internal organs required a large incision on the abdomen and obvious pain typically resulted. With a smaller incision, fewer nerves are cut, less bleeding occurs, and healing is expedited.

Post-operative infections have been of great concern since the advent of surgery. Before we knew about bacteria, many operations were deadly. They remain a significant concern with an important factor being the amount of tissue exposed. Skin is able to keep ‘germs’ out quite well if healthy and intact. But the larger the opening in the body, the greater the risk of exposure to disease-causing pathogens.

Surgery is traumatic: don’t let anyone tell you otherwise. The more traumatized the tissues resulting from some surgery, the more post-operative pain and the slower the recovery. And minimally invasive techniques result in less tissue injury. These incisions are generally quite small, especially in the case of many foot procedures. Less nerves are cut, fewer vessels sliced.

The cosmetic benefits present an even more obvious picture. These openings are small enough that, once completely healed, there is no obvious indication of any skin injury. Observers will express disbelief that surgery was ever performed. But the positives of less scarring are more consequential when it comes to joint surgery.

A bunionectomy, an extremely common elective surgery, utilizes a long incision when done with an open technique. This cut goes into the capsule which covers the joint.  Scarring of the fibrous material composing this structure is inevitable and functions to limit the available motion of the joint, even after healing is completed. In contrast, MIS does not damage the capsule and motion rarely ends up restricted.

Surprisingly, minimally invasive techniques have been around for centuries, built on a history of invention and evolving technology. The first example would likely be in 1806 when a physician used mirrors in a metal tube to perform a urological procedure. A significant advance occurred in the late 1800’s with the use of a modified light bulb which provided improved illumination. Rigid tubes (the ‘scope’ in endoscope) were the order of the day until the 1950’s when fiber optic technology led to the next breakthrough.

Essential to many forms of minimally invasive surgery is the use of fluoroscopy. Because the opening is small, visualization of the structure being altered isn’t possible….at least not directly. Fluoroscopy provides real time viewing of bone, as it’s being cut, all seen directly on the monitor. This vital piece of equipment gives the surgeon the proverbial “x-ray spectacles” allowing a precise view of the structure.

Laparoscopy is an example of minimally invasive surgery, whereby the interior of the abdomen is examined and treatment provided, all without a long opening. As the equipment has improved, so have the options for use expanded, from diagnosis to intervention. Laparoscopic surgeries are commonplace, used for exploratory, diagnostic and therapeutic procedures.

Podiatry was an early adopter of minimally invasive procedures, although the complication rate was high since fluoroscopic technology wasn’t in regular use. With time, the benefits of MIS  have become well-recognized in foot surgery and consequently a significant trend. Many foot procedures not deemed possible through small incisions are now everyday occurrences.

A chronic callus on a toe, a loose ligament in a knee, a clogged artery in the leg, these and so many more are all problems well treated utilizing the principles of minimally invasive surgery. All these operations can be performed without a long incision and the associated damage to multiple nerves and arteries, fascia and lymph vessels. Not all procedures can be performed with MIS methods, but when they can be, it just makes sense. And the list is growing all the time.