Imagine having endometriosis excision surgery and needing no downtime.

That’s the reality for Dr. Mona Orady’s patients. The San Francisco-based OB-GYN specializes in mini-laparoscopy. Instead of using instruments with a circumference of 5 to 12 millimeters, she uses 2 to 3-millimeter tools to excise endo. For many women who undergo traditional laparoscopic excision surgery or robotic excision surgery, recovery can vary from days to weeks to months, depending on the extent of the procedure. “In terms of recovery, it’s a game-changer because it means there’s no restriction to physical activity post-op,” says Orady, 39. “Most people are back to work in a day or two. Most patients have no visible scars. It’s not much bigger than putting a needle through the abdominal wall.” Her technique is so popular she says her patients fly in from around the world to have surgery with her.

Above, Orady (right) operates on a patient with her mini-laparoscopy technique.

She recently treated a Cirque du Soleil performer who needed to get a large ovarian cyst removed a mere ten days before opening night of a show. Her scars looked like tiny freckles. “We did mini-laparoscopic surgery on this acrobat,” Orady says. “With the incisions, only two to three millimeters, [she] didn’t require any downtime; so that’s what we did.”

Working with thinner instruments, however, is no easy feat. “Because my instruments are smaller, the surgery does take a little bit longer, and it requires more skill, but the patient recovers in an hour. You have to be more steady and gentler. It’s like painting with a feather, but to me, it’s completely worth it.”

Orady is used to bucking trends. She was nicknamed “Doogie Howser” by her peers after entering medical school at the tender age of 18. Back then they doubted whether or not a covered Muslim woman would go far in the medical field. Today, she spends much of her time traveling the world to teach other surgeons the techniques and benefits of mini/micro-laparoscopy. She recently taught a three-day course at a military hospital in Honolulu to help female soldiers with endometriosis who needed surgery but couldn’t afford to have six weeks of downtime for recovery.

“Women are suffering,” says Orady. “Twenty percent of women have a menstrual disorder. All women are going to have a problem with their period during their lifetime at some point, and it’s usually more than one problem. Yet, nobody focuses on that.” Orady believes that early diagnosis and early treatment of endometriosis is key. Her youngest patient for minimally invasive surgery was just 16.

“For younger patients who don’t even know if they have endometriosis, you put a two or three-millimeter camera in their belly button, and you can know the answer right away and treat it right then and try to get rid of it right at the beginning before anything becomes really bad later on. When people are younger, in their twenties, they typically just have the endo, and then in their thirties, the adenomyosis comes on, and fibroids start showing up after that. By the time someone is in their mid-thirties, usually, they have the triple whammy, which is all three. You have to treat each of these individually.”

Modern medicine aside, Orady finds simply listening to her patients allows for a more accurate diagnosis. “I have been a patient and know the feeling of not being listened to. The tragedy is just women thinking ‘Oh well this is my life’ and thinking suffering on your period is normal or that it’s just part of being a woman. It’s not right. And it’s definitely not normal.”

Source: Endometriosis Foundation of America

DOT MED Healthcare Business News

By Dr. Raymond Lanzafame and Dr. Richard Satava

It is surprising to see how the understanding of certain aspects of energy medicine are not stressed during traditional medical training, given their importance in daily operations and in the surgery of the future. In fact, our identity as surgeons will eventually end up depending on it. You may think you know enough about surgical energy — but ignorance about the topic and its importance is common.

The importance of learning about surgical energy and its future is the reason we are highlighting these technologies in a exciting session being presented at MIS Week in September.

Critical to Understand
As most of us know, surgical energy and energy devices are essential in the modern OR, yet the vast majority of surgeons do not understand the basic principles, applications, and patterns of complications. When Pennsylvania Congressman John Murtha died in 2010, which likely involved an electrosurgical injury, it led to a renewed interest in both research and education in the safe use of surgical energy-based devices. If we can get the surgeon to recognize the patterns of the complications, they can begin to modify how they use energy-based instruments in the OR and avoid the very real risk of surgical energy-based device−related complications.

Surgeons currently are not required to train on specific energy-based devices or to document their knowledge of safety issues related to their use. There are approximately 40,000 burns by electrosurgical devices every year.2 During laparoscopy, 70% of these burns may go undetected. Safety aside, understanding the different surgical energies and the nuances of the devices used to deliver them is critical not only to current operations, but to a surgeon’s future in medicine. The use of molecular energy to operate is not far off.

It is important that we are well versed, as opposed to just generalized, in the mechanisms of the different types and areas of energy medicine application and research in order to understand the future. Our goal is to cover what is most important to know:

• How energy causes effects in cells and tissue, as well as learning the basic function of an electrosurgical generator is important to know. Understanding the applications of electricity requires a basic understanding of the effects of temperature on the cells and tissue.
• Understanding that electro-surgery is about the control of current density, allows the surgeon to increase safety and versatility.
• Surgeons are not specifically trained on the mechanisms by which monopolar instruments produce their clinical effects nor do they know their optimal use. Knowledge gaps remain common, and injuries are not rare.
• Knowing the differences between monopolar and bipolar instruments, and the basics of their application is key information that is necessary for the surgeon to understand how to develop and refine one’s surgical skills.
• Bipolar devices contain both the “poles” in the tip of the instrument, which focuses the energy delivered and reduces the energy required. This allows for electronic monitoring of tissue, with each manufacturer having a slightly different monitoring system.
• There are key advantages of the use of advanced bipolar energy, and how these devices and their effects are monitored is also important.
• Every surgeon must recognize the critical importance of ultrasound in the current and future practice of surgery. The majority of surgeons don’t have a minimum understanding of these technologies.
• Surgery by molecular energy is in our future, and knowing what is being studied and what surgeons can expect to be available for their use is crucial.

Being able to ask questions in a live setting can help us learn the latest and the future applications.

A New Kind of Surgery and Surgical Understanding
There is a science and an art to understanding electrosurgery. This involves the control of current density, that is defined as the amount of current per unit area of the electrode in contact with or near the tissue, and this is what allows the surgeon a more safe and versatile surgery.

There is much more basic education to cover, which will be accomplished during the session, but it is also vital to talk more about the future of energy medicine. This aspect of medicine should be incorporated within the curriculum of medical schools world wide, just as minimally invasive surgery was finally included in the 1990’s .

Molecular Energy
Scientists have long known that many forms of energy such as light and ultrasound can penetrate through tissues just as x-rays do (but without harmful radiation). By choosing the precise frequency and power of directed energy, it is possible to use it to make a diagnosis or to perform a surgery. This can be done seemingly instantaneously with a single instrument, at either the tissue, cellular or molecular level.

Directed Energy for Diagnosis or Therapy (DEDAT), as we now know it, was based on a concept conceived originally by Richard Feynman, who gave a famous talk on the topic in 1959 at Cal Tech to the American Physical Society. He inspired us to look to molecular energy to heal patients. Because patients are continually demanding progress, we believe that as strategies for using energy result in leading edge technologies, non-invasive surgery will eventually become a reality providing many powerful options in our tool belt as surgeons. During the MIS week session on energy, experts will be discussing how to present energy technology to scientists and surgeons in a way that summarizes its importance to the future of medicine.

How does it work? Nanotechnology involves the control of nano-materials and nano-devices, depending on the tools and methods for manipulation at the nanoscale. There is incredible potential in the manipulation of each molecular species, though at this stage it is still very difficult. But it is not far away. We are already making progress in the research of molecular energy and brain tumors, in optical research, and other areas.

As an example of some of the newer imaging research, broadband Coherent Anti-Stokes Raman Scattering (CARS) micro-spectroscopy is beginning to make an impact after more than a decade of instrument and method development. CARS can rapidly generate high-resolution images with high quality abilities. Raman spectroscopy is a laser-based technique that can be used to nondestructively differentiate molecules based on the inelastic scattering of light. While most of the existing instruments are prototypes being used in research projects, it appears that the relevant technologies are maturing at a rate that will allow commercially available instruments in the foreseeable future, making these remarkable imaging modalities widely available to clinicians.

There are advances in the surgical management of brain tumors, that are achieving more optimal surgical results. However, there is much more work to be done in order to identify and destroy tumors. Certainly, as the science matures, it will become an important component for identifying residual tumor and improving the surgical management of brain tumors.

There are other advances in various specialties, and we are now at a tipping point where we realize that energy medicine will be making great strides in the future. We want to be aware of it and learn all we can in order to be prepared for what we can count on—exciting developments in energy medicine.

About the Authors: Both Raymond Lanzafame, M.D., M.B.A. and Richard Satava, M.D. are board members of the Society of Laparoendoscopic Surgeons (SLS). Their discussion on energy medicine will occur at MIS Week in San Francisco, on September 7th, 2017.

Michael Kavic, MD, a hernia surgeon and editor-in-chief of the Journal of the Society of Laparoscopic Surgeons, is calling on practicing surgeons, surgical educators and medical device manufacturers to re-evaluate their approach to inguinal hernia repair, recommending less reliance on synthetic mesh repair as the go-to method for repairing inguinal hernias.

In a presentation at Minimally Invasive Surgery Week, Dr. Kavic called the incidence of chronic pain after mesh hernia repair a “potential time bomb for the surgical community and medical device suppliers.

“The surgical community, as well as the industry that garners huge profits from the use of synthetic materials, must address this troubling issue,” said Dr. Kavic, professor emeritus of surgery at Northeast Ohio Medical University and a leader in the field of hernia surgery. “The evidence is mounting that mesh, which was generally thought—and promoted—to be inert, now appears not to be so.”

An extended version of his speech was published in the July-September edition of the Journal of the Society of Laparoendoscopic Surgeons (20[3]. pii: e2016.00081).

However, other surgeons disagree with Dr. Kavic’s arguments, saying he both amplifies the extent of chronic pain after hernia repair and simplifies the causes.

“The number of people with chronic debilitating pain is around [4%] to 6% so I don’t think this qualifies as an epidemic,” said Guy Voeller, MD, a professor of surgery at the University of Tennessee Health Science Center, in Memphis. “While it may not be an epidemic, it is certainly an important issue and I agree with Dr. Kavic in that respect. I think we were always focused on recurrence rates prior to mesh introduction. I don’t think that we really looked at pain. It doesn’t mean it didn’t occur prior to mesh introduction and it doesn’t mean that mesh-based repairs are the cause.”

Synthetic mesh repair became the standard of care because it solved the problem of high recurrence rates. But an unintended and unforeseen consequence of mesh repair is chronic postoperative pain, Dr. Kavic pointed out.

In 2001, Dutch researchers who surveyed adults who underwent inguinal herniorrhaphy reported that more than 25% of patients experienced pain in their groin one year after surgery and 11% reported pain that was interfering with work or leisure activity (Ann Surg 2001;233:1-7). Ten years later, a German study reported a 16.5% incidence of chronic pain six months after mesh repair (Ann Surg 2011;254:163-168). Nevertheless, a wide range of pain incidence, from 0% to 45%, has been reported in studies, with a broad range of definitions, making it difficult to know the true incidence of chronic pain.

Approximately 800,000 inguinal hernia repairs are performed each year in the United States. Since 2000, repairs not using mesh have represented less than 10% of groin hernia repair techniques.

If one in 10 patients experience debilitating pain after a mesh hernia repair, millions of patients could be affected worldwide, Dr. Kavic noted in an interview following his presentation.

“I don’t think this is a matter of Chicken Little saying the sky is falling. The science is pretty good to show there’s a problem with chronic pain and the reason for the chronic pain is the mesh itself and the behavior of it. This could be far-reaching in its consequences.”

Dr. Kavic noted that the cause of chronic pain is not well understood, but he cited research led by Robert Bendavid, MD, a surgeon and senior consultant at Canada’s Shouldice Clinic, in Toronto, where hernia surgeons do not use mesh. Dr. Bendavid has linked chronic pain to nerve ingrowth into the mesh. He and his colleagues reported that the degree of mesh innervation was significantly higher in patients who required mesh removal for pain than in patients who had mesh excised for recurrence (Hernia 2016;20:357-365). The finding was based on an analysis of 33 hernia meshes: 17 were excised because of severe pain, two for combined pain and recurrence, and 14 sampled during revision for recurrence without pain.

Dr. Bendavid and his co-authors noted that neither triple neurectomy nor careful nerve preservation—often recommended for the prevention of chronic pain—eliminated pain after hernia repair. “Perhaps because we have forgotten that nerves, in response to some evolutionary mechanism, tend to regenerate, undergo changes imposed by prosthetic elements and architecture, mimicking entrapment and compartment syndromes,” they wrote.

Mesh shrinkage, loss of pliancy and increasing rigidity may also be contributing factors, Dr. Bendavid’s group reported in an earlier study (Int J Clin Med 2014;5:799-810).

But these arguments oversimplify the cause of chronic pain, according to other hernia surgeons. Dr. Voeller points out that randomized studies in Europe have directly compared Shouldice repair with a Lichtenstein repair, and found less pain (Langenbecks Arch Surg 2004;389:361-365). He cited a number of studies that indicate mesh repairs are associated with less chronic pain than nonmesh repair, including a randomized clinical trial with a 10-year follow-up that showed mesh repair was equal to nonmesh repair with regard to long-term persistent pain and discomfort interfering with daily activity (Surgery 2007;142:695-698). The EU Hernia trialists (Hernia 2002;6:130-136) and a Cochrane review (Cochrane Database Syst Rev 2002;4:CD002197) also reported lower rates of persisting pain after mesh repair.

“If you look at the clinical data, laparoscopic repairs, when they are done properly, definitely had less chronic pain, and it’s a mesh-based repair,” Dr. Voeller said.

He said the study from the Shouldice Clinic that looked at nerve fibers in explanted mesh was too small to conclude nerve ingrowth causes chronic pain. “You can’t make that jump.” He added, “You’ll never be able to have chronic pain as a never event with hernia repair. There are too many variables, including the surgeon’s ability, patient characteristics and techniques of repair.”

Shirin Towfigh, MD, a surgeon at Cedars-Sinai Medical Center, in Los Angeles, and the Beverly Hills Hernia Center, in California, believes Dr. Bendavid’s research “partially” explains the epidemic of chronic pain after hernia repair. She attributes long-term pain to the presence of mesh, as well as poor surgical technique and misunderstanding of anatomy.

“All efforts by industry were to maximize ease of repair, basically making it idiot-proof. The marketing was focused on fast surgery, small incisions, etc.,” she said. “The result was little attention to the delicate anatomy of the groin and lack of adequate training on all of these new [meshes] that were sprouting. I personally feel this is the main reason for the increase in mesh-related chronic pain,” she said.

Patients with chronic pain generally have meshomas, nerve injury, nerve entrapment, erosion or obstruction of the spermatic cord, Dr. Towfigh said.

William Hope, MD, president of Americas Hernia Society and a hernia surgeon at New Hanover Regional Medical Center, in Wilmington, N.C., believes the cause and the solution to chronic pain lies somewhere between the positions of Drs. Kavic and Voeller.

“To me, mesh and technique may contribute to chronic pain, but I do not think the problem is that simple and is likely multifactorial that we don’t completely understand yet,” Dr. Hope said.

It’s hard to know what the incidence of chronic pain was prior to mesh repair, as historically surgeons did a poor job of assessing patients’ long-time pain, he said. “We are recognizing it more. Chronic pain is a problem. I’m not sure ‘massive’ is the right word but it is a ‘difficult’ problem.”

He agrees with recently updated inguinal hernia guidelines published by the European Hernia Society that state the use of mesh has significantly decreased hernia recurrence rates and “at present is likely the best option we have available.”

But he feels surgeons rely too much on mesh as a go-to technique. “I think education is important and one of the main problems, at least in the U.S., is there are very few surgeons and training programs that are performing nonmesh/tissue repairs, so younger surgeons are not learning these techniques or the anatomy.”

Dr. Kavic asked surgical educators to change their approach to teaching hernia repair, calling for more emphasis on anatomic knowledge and physiologic function of the groin. Trainees should be required to perform a minimum number of pure tissue hernia repairs, as well as mesh repairs, he said.

He said all surgeons who offer hernia repair need to be able to complete the operation both open and laparoscopically, with and without mesh. They need to stay updated on the latest findings on mesh outcomes and mesh materials, he said. “They need to understand the risks and talk to their patients about the risks.” He also said, “Surgeons need to get involved with their institutions and their device companies. It comes down to all of us.”

Source: General Surgery News

NEW YORK – The next big advance in gynecologic minimally invasive surgery could be the wider adoption of minilaparoscopy using newer, frictionless instruments.

Minilaparoscopy is commonly used in cholecystectomy, but is making inroads in gynecology. Minilaparoscopy performed with the newer, smaller instruments is especially well suited for fertility procedures and endometriosis surgery, according to Dr. Gustavo Carvalho, a pioneer in minilaparoscopy. Gynecologists are using minilaparoscopy successfully in hysterectomy as well, but the mini-instruments are not strong enough to survive many hysterectomies, he added.

“Traditional laparoscopy is suited for brutal procedures, such as hysterectomy, but minilap is better for delicate procedures requiring precise, tiny instruments,” Dr. Carvalho said at the meeting.

Despite the promise of utilizing the newer instruments, many surgeons have misconceptions about them.

“This is partly related to instruments used in older procedures called minilap. But after they try it with these newer instruments and learn how to do it, they actually prefer it for many procedures,” Dr. Carvalho, an associate professor of general surgery at Pernambuco University, Recife, Brazil, said in an interview.

Dr. Carvalho debunked the following “myths” about minilaparoscopy:

1. Single-port laparoscopy is cosmetically superior to minilaparoscopy. That’s not the case, Dr. Carvalho said. The few published papers on this subject compared single-port laparoscopy with older, high-friction instruments for minilaparoscopy, he said.

2. Minilaparoscopy should not be performed on obese patients. That’s false, Dr. Carvalho said. “Using newer instruments, we can move around better and see better for delicate operations in obese patients, but surgeons need special training,” he said.

3. Patients don’t want minilaparoscopy. The only published paper looking at patient preference did not offer patients minilaparoscopy with the newer instruments, Dr. Carvalho said. He and his colleagues plans to publish a paper based on research showing that 47% of patients prefer minilaparoscopy, compared with 27% who preferred single-port procedures. “There is a role for single-port procedures,” he added.

4. Minilaparoscopy hurts more than single-port laparoscopy. “No one can prove that minilap hurts less, but it is obvious and intuitive that smaller trocars and instruments cause less pain,” Dr. Carvalho said. “Surgeons want randomized trials, but they won’t be done because this is obvious.”

5. Surgeons lose dexterity and precision with minilaparoscopy. In new research that will be published in the Journal of the Society Laparoendoscopic Surgeons, Dr. Caravalho and his colleagues demonstrate that newer minilaparoscopy instruments are better than larger instruments for delicate tasks. In this study, 22 medical students and 22 surgical residents were given one gross task and three delicate tasks to perform randomly with a 3-mm frictionless trocar, a 3-mm high-friction trocar, and a 5-mm trocar. The larger instruments were significantly better for the gross task, while the smaller instruments were significantly better for the delicate tasks, Dr. Carvalho said. “This study shows the utility of precise, delicate instruments for delicate procedures,” he said.

Dr. Caravalho reported that he is an unpaid consultant for Karl Storz on the development of minilaparoscopic low-friction trocars.

Source: Ob.Gyn. News

At Minimally Invasive Surgery Week

NEW YORK – Displaying a low-tech, low-cost white board in the operating room during the “time out” before surgery can significantly improve memory retention among members of the surgical team, a new study suggests.

“We found that providing a white board that you can buy at any office supply store gives a visual stimulus on top of the verbal stimulus [that] improves retention of important information,” Dr. Aryan Meknat, the study author, said at the annual Minimally Invasive Surgery Week.

During the study, surgical teams were randomly divided into two groups: in the first group, 30 team members were given information verbally during the surgical pause; while a second group of 29 team members was provided with verbal information that was read from the white board. The white board was displayed in the operating room throughout the surgical procedure for the second group.A surgical pause or “time out” performed before any operative procedure is a major component of the Joint Commission’s Universal Protocol to prevent wrong site, wrong procedure, and wrong person surgery. Retention of information presented during the surgical pause is essential, at the beginning of the case and for the duration of the procedure, he said.

After the conclusion of the procedure, the white board was removed and both groups were given a short written questionnaire. Each team was tested only once in order to keep the study blinded. Also, participants had no prior knowledge that they would be tested after the procedure.

Study participants were asked to recall several facts about the patient, including the patient’s first and last name, age, sex, weight, site of IV placement, allergies, medications, relation of accompanying guardian, and the signature on the consent form.

Team members in the first study group answered a total of 300 questions, and 200 questions (66.7%) were correctly answered. Participants in the second group – which used the white board – answered 290 questions, and 239 (82.4%) were correctly answered. The white board group had a 23.6% overall increase in correctly answered questions. The difference between retention in the two groups was statistically significant (P less than .05) in every category tested.

“These findings apply to operating rooms everywhere, especially in cases where there may be long delays before starting the procedure, changes in anesthesia midcase, situations where two procedures are scheduled in one patient, or in intraoperative emergency situations. We need to be sure that the surgical team retains information, as well as [listens] to verbal instructions,” said Dr. Meknat of MobiSurg, a mobile surgical unit based in Laguna Hills, Calif.

Dr. Meknat reported having no financial disclosures.

Source: Ob Gyn News