Home' Technology Review : July August 2008 Contents ESSAY 79
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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? Some-
times a little detail here or there is more voodoo than com-
mon sense, but we keep up the tradition because that's what
we were taught. Perhaps we don't question the standard pro-
cedures 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 oint-
ment 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.
In my mind, however, it's not so clear whether the mini-
mally invasive approach is a plus for smaller, less involved
spine cases. Take a typical lumbar microdiscectomy, in which
a small window of bone is drilled into the spine in order to
extract a fragment of disc pressing on a nerve. This is the most
common operation that neurosurgeons perform.
The senior surgeon who taught me the traditional approach
to this surgery showed me how to do the operation through
an incision measuring about an inch. He was so proud of
his small incisions that he would take a picture of the large
fragment of extracted disc held up next to a ruler, which was
placed in line with the incision. He would give this photo to
the patient after surgery. This was quite e ective for word-of-
mouth marketing. ("Wait, you need disc surgery? Go to my guy.
Take a look at this!") I became quite comfortable and e cient
with this technique, and I found that most patients did not
have significant postoperative pain at the incision site.
As minimally invasive spine surgery became popular, as
patients started to ask for it, and as instrumentation compa-
nies pushed their tools for both the big and small cases, I felt
obligated to try it. What I found, though, was that the juice wasn't
worth the squeeze. All of a sudden, what had been a relatively
pared-down operation required more instrument trays in the
room, a nurse familiar with the new tools, a large specialized
retractor that had to be bolted to the bed, an unwieldy fluo-
roscopic "C-arm" machine that seemed to get in the way, and
(because the new technique involved fluoroscopy) a heavy lead
apron that I had to wear for at least the first part of the surgery.
Spine surgeons have started to realize that a minimally
invasive discectomy actually seems to increase the likelihood
of one particular complication: leakage of cerebrospinal fluid.
That's because the surgeon must use a rigid and narrow retrac-
tor, which makes it di cult to achieve unfettered access to all
the necessary anatomy, especially when the surgeon is still
on the steep part of the learning curve. As for the prospect of
reducing postoperative pain, an original selling point of the
new approach, I have not been impressed. I will admit that the
new tools enable surgeons to operate through an incision that
is slightly smaller than my usual inch. Is anyone excited?
For all my griping, I am inspired by the general direction of
innovation in surgery. I can't help believing that the answer to
the fiddle factor is better technology, not less technology: after
all, the innovative leaps in other fields leave medicine far behind.
The most high-tech equipment available to the brain surgeon
pales in comparison with the technology onboard a fifth-
generation fighter jet, or in a modern nuclear power plant.
If we can catch up a bit, it will be fascinating to see what's in
store for neurosurgeons of future generations. But we should
be careful what we wish for. Just as technological advances
in nuclear plants and fighter jets try to maximize safety and
e cacy by minimizing (or even eliminating) the human ele-
ment, we should realize that the ultimate advances in surgery
will take aim at perhaps the most fickle tool in the operating
room: the surgeon.
KATRINA S. FIRLIK IS A NEUROSURGEON IN GREENWICH, CT, AND THE AUTHOR
OF ANOTHER DAY IN THE FRONTAL LOBE: A BRAIN SURGEON EXPOSES LIFE ON
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