July/August 2008

A Messy Art

Continued from page 7

By Katrina S. Firlik

Craving Simplicity
I once spoke with a freelance writer who was observing his first operation in preparation for a piece on brain surgery. In the crowded operating room, he watched a nurse as she struggled to push a surgical microscope into position, trying her best to move the heavy and unwieldy base amid the tangle of cords and tubes draped across the floor. I asked what he thought of the operation so far, expecting him to say something about the wonder of the human brain. Instead, he said that he had worked on a ship once, and that a ship's deck would never see such a tangle of ropes.

A young surgeon relishes such tangly cases--tough, complex, time-consuming, high-tech. While the operation is in progress, the room might be crammed with people--two surgeons plus a surgical assistant, two or three nurses, one anesthesiologist, one or two neuromonitoring technicians (who usually sit quietly in a corner), a "cell-saver" technician (to run the machine that cleans and recirculates lost blood), one or two industry reps who stand back and field questions from staff about their equipment, and perhaps a radiology technician if fluoroscopy is being performed. The size of the crowd can be almost comical. More and more trays of surgical instruments are brought in as the surgeon encounters tricky conditions or unusual anatomy.

I've found, though, that as surgeons get older, they appreciate the simpler cases more and more. Some of the happiest senior surgeons I know have reduced their practices to just a few nice cases--the ones that require the least support staff, the least technology, and the least clutter in the operating room. The other day, while I was doing a quick carpal-tunnel operation using only a few simple instruments, I had two thoughts. The first was that this procedure is one of my favorites. The second was that I must be getting old.

When I was a resident, one of my attending surgeons was revered for his minimalist style and slick surgical skills. His description of his method was something like this: "I like to pare down an operation to its essentials. I cut out one small, unnecessary step at a time. If I detect any problems, then I add a step back in." This may sound scary, until you realize that fiddling with extra steps can cause problems. Extra steps--extra instruments and maneuvers--can mean more time under anesthesia and a greater chance of infection.

Why do these extra steps exist in the first place? Sometimes a little detail here or there is more voodoo than common sense, but we keep up the tradition because that's what we were taught. Perhaps we don't question the standard procedures enough. Do we really need to leave a drain behind? Do we really need to close that layer in a careful, watertight fashion? Does it actually help to inject a numbing medication into the muscle before closing? Is smearing antibiotic ointment over a clean incision really necessary?

On the other hand, sometimes technological innovation adds details to an operation that may not benefit from them. Don't get me wrong: I am more enthusiast than Luddite. But sometimes what I observe is a new technology searching for a need instead of filling one. In that case, beware.

For example, a common buzzword in surgery is "minimally invasive." An entire industry's worth of scopes, retractors, and instruments have been developed so that practically any operation can be done in a way that meets that description. In general, I welcome the trend. Who would choose to have an open gallbladder operation instead of leaving the hospital with just a few small stab marks?

In the case of gallbladder surgery, the benefit of minimally invasive laparoscopic techniques over open surgery became so obvious over time that a randomized, controlled trial--another buzzword in medicine--was never even undertaken. And within neurosurgery, the minimally invasive approach to certain major spine fusions is a godsend to the patient. The advantages over traditional, open surgery are numerous: a much smaller incision, less surgical trauma to the muscles, less pain, fewer narcotics, and a shorter recovery.