Scalpel, Please!
Imagine that first shaky hand lifting a pointed object and performing the world’s first surgery. Harder to imagine is that first surgery originating in the late Stone Age. We know definitively that surgery existed in 10,000 B.C., in China, where anthropologists have found skulls with signs of trephination – the removal, using a saw, of a circle of bone from the skull – although they have no clue why.
As civilizations evolved, so did surgical techniques and medical experience. Over time, from China through India, into Greece, Egypt, and finally Europe, surgery advanced as knowledge grew.
The basic concept of surgery hasn’t changed at all: The surgeon makes a decision, then an incision, remedies a situation and closes. But everything surrounding it has changed dramatically, especially in the past 100 years.
Not so long ago, the family doctor took care of every medical need, from delivering babies and treating illness, to performing surgeries that ranged from simple tonsillectomies and tumor removal to repairing traumatic injuries. As medicine advanced and technology expanded, medical centers and surgeons took on ever more complex operations. Today, patients are referred to general surgeons as well as a growing list of fellowship-trained specialists.
What is General Surgery?
When students begin medical school, some know exactly what specialty they intend to pursue; others do not.
“I was one of the undecided group,” says Dr. Leo Farbota, a board-certified general surgeon who practices at Advocate Sherman Hospital in Elgin. “For the first couple of years, we attended classes. Then, for the last two years, we rotated through the various medical specialties as medical students. General surgery appealed to me.”
Surprisingly, general surgery is somewhat of a misnomer for what is actually a separate specialty, says Farbota. He does mostly abdominal procedures, but also those involving the thyroid, the breast – including cancer cases – and the vascular system.
“I also create access portals for kidney dialysis,” says Farbota. “In short, I do everything not covered by another specialty. During a normal week, I spend two half-days in my office, seeing pre- and post-operative patients and consulting, plus doing the paperwork. I average about 500 surgeries annually. Plus, I’m on call at Sherman and Saint Joseph hospitals.”
Traumatic injuries are treated no differently than other surgical procedures. Farbota performs emergency operations on patients with abdominal trauma, and consults the appropriate specialists for other medical concerns.
“I take on a second role in these cases,” he adds. “I can act on my own for those elements which fall into the field of general surgery, and call in a specialist or consult with the patient’s primary doctor on the best course of action for those items outside the realm of general surgery.”
Currently, the number of medical students going into general surgery is declining, while the median age for physicians in this specialty is 50-plus years of age. Farbota notes that the American College of General Surgery predicts a shortage in the next eight to 12 years, partially because general surgery is viewed as a less-attractive field.
“A lot of paperwork, plus long hours, are part of the reason fewer are entering this field,” he says. “Declining reimbursement is another. I make a fairly good living, but it’s less than many other careers. For a student contemplating his or her future, this is a major consideration. The education is expensive and takes a significant amount of time. I didn’t go into practice until I was 30.”
General surgeons sometimes specialize within their field, finding it rewarding to focus on one particular type of operation. For example, they may prefer to perform surgeries related to cancers, abdominal problems or traumatic injuries. Dr. Barry Rosen, a general surgeon who practices at Advocate Good Shepherd Hospital in Barrington, has his own specialty.
“Over the past 20 years, my practice has evolved such that breast cancer treatment has become my primary area of expertise,” he says. “However, I continue to perform ‘bread and butter’ operations, such as gallbladder and hernia surgery. If your child is in the ER with acute appendicitis, it would be me or one of my colleagues coming in to treat them.”
Breast cancer treatments in particular have improved dramatically over the past two decades. At the same time, surgical disciplines have benefitted from new discoveries.
“When I was in training, the basic philosophy was ‘bigger is better.’ Now, we try to be as minimally invasive as possible to achieve the best outcome,” Rosen says. “We’ve also learned that breast cancer is really not one disease. Therefore, it’s imperative that treatment is individualized. We treat people, not diseases.”
In cancer care, it’s also important that physicians of many specialties coordinate treatment. “I am honored to work with world-class medical and radiation oncologists at Good Shepherd to provide a truly holistic approach to breast cancer treatment,” says Rosen.
New Methods and Procedures
At Good Shepherd, collaboration is especially apparent in the recent introduction of Intraoperative Radiation Therapy (IORT), which provides directed radiation to the specific site of a cancer. Dr. James Ruffer, a board-certified radiation oncologist at Good Shepherd, works with Rosen on IORT procedures. After Rosen removes the cancerous tumor, he inserts an appliance for irradiating the tumor bed, which is hooked to an X-ray machine. This is where Ruffer steps in.
“After assessing the imaging and evaluating the size of the area, I deliver the radiation directly to the site,” he says. “IORT works for smaller tumor beds in a select group of patients. Not only do they tolerate IORT fairly well, but they avoid the traditional four to six weeks of conventional radiation.”
IORT is a more focused method of radiation treatment. Side effects, such as fluid buildup in the area, are rare. It’s a big improvement from earlier, more invasive, procedures.
“Traditionally, radiation therapy for breast cancer took about seven weeks and used an external beam,” Rosen explains. “About 10 years ago, we began using brachytherapy, which cut radiation time down to five days. This was especially good for elderly patients and those with busy work schedules. While effective, brachytherapy was still invasive and messy – we had to keep a tube in the patient’s breast throughout the course of treatment. IORT sets the bar even higher, allowing us to administer an entire course of breast radiation over 20 to 40 minutes, while the patient is still under anesthesia for her breast cancer surgery. Nationally, there are fewer than 100 hospitals currently offering these services, and only two in the Chicagoland area.
“While the equipment is expensive, the actual cost of treatment is about one-quarter of traditional therapy,” Rosen says. “Therefore, I anticipate that this will become more popular in time, as it has in Europe.”
The IORT procedure, applicable to many types of cancers within the abdominal wall, promises to advance cancer care well into the future. “We have more than 30 years of experience with traditional radiation treatment follow-up on which to base decisions,” Ruffer says. “We need to closely follow these new procedures, in order to ensure our patients, old and new, have the latest and most reliable information on which to base a treatment decision.”
Because there is only a one-year assessment period on which to base the efficacy of IORT, Ruffer is hesitant to declare absolute success. “This is too short a time to establish a survival rate, but we know this works especially well for older patients,” he says.
Meanwhile, Good Shepherd is concentrating on community outreach and patient education. After seeing her husband go through traditional radiation therapy, Good Shepherd patient Elizabeth Hart chose IORT for her lumpectomy.
“It was a one-day operation – I went into the hospital at 10 a.m. and went home around 6 p.m. the same day,” she says. “After-effects were almost nonexistent. I went for a walk the next day for fresh air and exercise, and was back at work a week later. I am so grateful that Good Shepherd made this investment in the technology. I had steeled myself for the worst.”
Good Shepherd physicians are also collaborating to develop new, more sensitive advancements, such as oncoplastic surgery, a new cross-specialty procedure for breast cancer care.
“The basic premise – provided that cancer care isn’t compromised – is that we can incorporate plastic surgical techniques into our cancer care,” says Rosen. “This may be as simple as hiding incisions in natural skin creases, or as elaborate as working side-by-side with a plastic surgeon, combining a cancer removal with a breast lift and augmentation. While this isn’t for everyone, it is important for many to maintain their self-image. Cancer surgery no longer needs to be disfiguring.”
Minimal Invasion
Common throughout surgical advancements, minimally invasive technologies continue to break ground, offering optimal results with less pain, faster recovery and more long-term benefits.
Dr. George Bardouniotis, a board-certified general surgeon practicing at Presence Saint Joseph Hospital in Elgin, was a medical student at Chicago’s Loyola University, when minimally invasive surgery came into the spotlight in the early 1990s. Those laparoscopic techniques have actually evolved over the past several decades.
“The procedure was originally used for diagnostic purposes by gynecologists,” Bardouniotis says. “Now, it’s the preferred option for gallbladder and appendix extractions. Roughly 98 percent of patients have these two organs removed as minimally invasive surgeries. That’s not so much the case for hernias, or other surgeries on the abdominal wall.”
With belly button hernias, for example, it’s often better to do a standard surgery, Bardouniotis says, because making three or four incisions doesn’t make sense, when one is sufficient. Every procedure, however, is selected to meet the patient’s specific needs.
“Just because you can do minimally invasive or robotic procedures doesn’t necessarily mean you should,” he adds. “And the push for general surgeons to use robotics is strong, but that doesn’t mean it’s the right choice for every patient.”
Bardouniotis hasn’t seen much use of robotics in community general surgery, but says it’s an important option in the surgeon’s toolkit. “At Saint Joseph Hospital, minimally invasive surgery is the standard of care for gallbladder and many other cases,” Bardouniotis says. “That will continue to be true for common abdominal surgeries down the road.”
Outpatient surgery is also benefitting from improved technology and methodology. Dr. Alan Loren, a board-certified general surgeon with Advanced Surgical Associates, and chief of surgery at Northwest Community Hospital in Arlington Heights, says outpatient surgeries became much more common in the mid-1980s, shortly after he joined Northwest Community.
“It’s a good, clear case of advancing technology,” he says. “The earliest procedures involved hernia and breast surgery, but quickly advanced to laparoscopic removal of diseased gallbladders and other, more complex procedures.”
Today, Loren performs a fairly equal number of inpatient and outpatient surgeries. He estimates that about 90 percent of his gallbladder extraction patients return home the same day.
Because of practitioners’ extensive training, minimally invasive techniques and equipment, and improved medications and anesthesia, outpatients often go home within hours of their procedure. And they’re likely to experience less pain and nausea and have fewer infections, with faster recovery periods and a quicker return to their everyday lives.
According to Loren, when colon surgery is performed using minimally invasive techniques, the average hospital stay is two days, with complete recovery in 10 to 14 days. Even with major surgeries such as a colon resection, patients today remain in the hospital an average of five days, instead of the traditional seven to 10, often with complete recovery in four to six weeks.
“Even the basic concept of minimally invasive surgery has changed since I began my practice,” says Loren. “Until the early 1990s, laparoscopy was largely a diagnostic procedure that enabled us to look into the abdomen to evaluate a potential problem. Today, because of the tremendous advancements in technology, minimally invasive surgery is often performed not only as a diagnostic procedure, but also as a therapeutic procedure. We now do the entire operation using small incisions.”
Patients aren’t the only ones to benefit from these improvements. Outpatient surgeries reduce the caseload for hospital staff, allowing them to focus on sicker patients. They also lower overall health care costs and decrease insurance payouts.
However, Loren hopes that a new balance between traditional and minimally invasive surgeries may emerge, as health care providers consider the high cost of purchasing and maintaining robotic equipment and advanced technologies, as well as training for their use.
“The fact is that insurance companies don’t want to pay more money for robotically performed operations, even while patients continue to demand procedures that offer less pain, smaller scars and faster recovery times,” Loren says. “We’re still trying to figure out how this will play out in the future of declining reimbursements from the payers.”
From a simple beginning more than 12,000 years ago to robotically controlled procedures, surgery has evolved considerably from one civilization to the next. Today’s patients not only fear surgery less, but, in many cases, accept it as routine. While the future of surgery is predictable in some areas, and less so in others, there’s little doubt that advancements in technology and methodology will continue to advance our health care system.