Surgery still can be scary for a patient, but with the major advancements that have happened over the past half-century, operations are now safer than ever before.
Going “under the knife” isn’t like it used to be. There’s no record of the first time a human cut through flesh in an effort to repair the body, but we know surgery has a very long history. Today it has advanced to a highly specialized state that wasn’t imaginable even 50 years ago.
It’s true that surgery can be scary for a patient, but it’s also true that doctors are addressing issues and saving lives every day.
Minimally invasive procedures using laparoscopy and arthroscopy have been in use since the mid-1980s, but it’s robotics in general, and the da Vinci robotic surgical system in particular, that have revolutionized the field of surgery in the past decade.
“We do an average of 80 da Vinci surgeries monthly,” says Dr. Robert Rao, a board-certified general surgeon who serves as chief of surgery at Northwest Community Hospital in Arlington Heights. “Northwest Community Healthcare owns three da Vinci robotic systems which are in constant use.”
The scope of uses for the da Vinci keeps widening.
“With the da Vinci, we basically transitioned from performing solely urological procedures to including gynecological and now general surgeries,” Rao says. “We do pretty much exactly what we used to do with open incisions and our hands, except we now use the da Vinci as a tool for doing what we already are trained to do – but with smaller, less-traumatic incisions.”
In the past five to six years, da Vinci robotic surgeries have been used successfully in procedures involving the kidneys, prostate, urological and gynecological organs. Benefits of robotic surgery include a decrease in pain, blood loss, infection, length of hospital stay, recovery time and medication use.
“In addition, we now regularly use the da Vinci for colon cancer resections, rectal prolapse, transanal procedures, hernia repair and gall bladder procedures,” Rao says. “Instead of incisions that may be several inches long, we’re now down to four little holes. Much of what we used to do laparoscopically we now do with the da Vinci.”
A colon resection, for example, once required an incision of 6 to 10 inches – large enough for the surgeon’s hands to work deep inside the patient.
Now, the surgeon is seated at the da Vinci controls, facing away from the patient. The robotic surgical system enables much more flexibility than laparoscopic or arthroscopic instruments.
“The da Vinci moves exactly the same way our hands do,” Rao says. “It is far more sensitive and there is no hesitation in the way it responds to our every move. We can turn our ‘hands’ and twist our ‘wrists’ just as if our real hands were inside the patient.”
Rao says nearly all da Vinci surgeries are done on an outpatient basis.
“We did a da Vinci procedure on a man who weighed 385 pounds, and he did stay in the hospital for two days, but with just four tiny holes to show for his surgery,” Rao adds.
The da Vinci constantly is being upgraded. At one time, it took 30 minutes to set up and dock a da Vinci. Now, it takes a matter of minutes.
“The newest upgrade uses one small incision instead of four, into which the camera and all other needed internal mechanisms can be inserted, cutting the opening to just a small one-inch incision,” Rao says.
Although Rao envisions many more uses for the da Vinci, he points out that operations on spongy tissue, such as that in the liver, are not standard with this technology. “It’s too soft and pliable for us to stop any bleeding,” he says. “Even so, I won’t say that the day won’t come when we can work with any type of human tissue.”
Weight Loss Surgery
One of the most frequently performed operations is bariatic surgery, a procedure designed to help a patient lose weight.
“Most patients learn about bariatric surgery from searching sites on the internet,” says Dr. John Cheregi, a board-certified general surgeon who specializes in bariatric surgery at Centegra Health System in McHenry County. “Basically, there are four major procedures aimed at helping patients lose weight. We encourage patients to consider weight-loss surgery to prevent major damage to their organ systems.”
About 300 bariatric procedures are performed at Centegra every year, including gastric bypass, vertical sleeve gastrectomy, and adjustable gastric banding, more commonly called lap band. Most are done using laparoscopic and endoscopic methods.
Recently, gastric balloon has been introduced as another bariatric technique, although Cheregi says this is designed as a temporary treatment rather than a long-term solution.
“Gastric bypass is still the gold standard for bariatric treatments,” Cheregi says. “We offer the surgeries and treatments we believe are best for our patients. One procedure that some providers perform is the biliopancreatic diversion, which we don’t offer at Centegra because of the higher risks of malnutrition and other unhealthy side effects that can develop in the future.”
Cheregi’s patients often come to him with their minds made up about what type of gastric surgery they prefer. Before making any decisions, he addresses important questions.
“Insurance will pay for bariatric surgery but its coverage is based on the patient’s body mass index (BMI),” Cheregi says. “It’s a simple matrix. You find your height and weight on a chart, and it calculates your BMI. A patient with a BMI of 40 or higher with no adverse health conditions is eligible. A patient with a BMI of 35 or higher who also has diabetes, high blood pressure, high cholesterol or another health concern is also eligible for insurance coverage. Age or gender are not factors.”
Other concerns that can impact a patient’s eligibility for bariatric surgery may include the patient’s general health, dietary habits and the amount of weight he or she needs to lose. Cheregi has performed bariatric surgeries on patients as young as 17 and older than 80.
“When it comes to older patients, we have to make a judgment on whether doing bariatric surgery is going to be of sufficient enough benefit to warrant the procedure,” Cheregi says.
Most patients prefer a laparoscopic approach to surgery, which typically results in a faster, more comfortable recovery.
“Many patients are fearful when it comes to an invasive gastric bypass surgery,” Cheregi says. “They insist they will only consider the lap band because it is less invasive. One downside of lap band, though, is that if the patient already suffers from acid reflux, the lap band method may make it worse. Some patients wait to make up their minds about which method they prefer until the last appointment before surgery.”
Lap band or sleeve gastrectomy may be a better choice for patients who have been operated on for cancer or other major health threats, Cheregi says, because scar tissue may have built up enough to make a second surgery less desirable.
Recovery time depends on the form of bariatric surgery conducted. Cheregi finds that lap band procedures, which involve laparoscopic techniques, are almost always conducted on an outpatient basis, so that 99 percent of patients go home the same day or the next day.
“They heal faster, but I still recommend that they take at least 30 days to recover before returning to work, lifting anything heavy or engaging in strenuous exercise,” Cheregi says.
He believes bariatric surgery is a proven life saver. Patients often can reduce or eliminate medications they have taken for years, including insulin for diabetes. Studies report that it also lowers blood pressure and cholesterol levels in most patients, and it can reduce or eliminate obstructive sleep apnea.
“The main goal is not just to help patients lose weight but also to offer them a healthier, more productive lifestyle,” Cheregi adds.
Follow-up is vital with bariatric patients.
“Patients have visits with our bariatric registered dietitians, bariatric nurses, insurance specialists, and a program psychologist for education and support pre-operatively,” Cheregi says. “Some appointments are done individually and some in a group class.”
During the hospital stay, patients receive a visit from registered dietitians connected with the bariatric program.
“After the procedure, we also provide continued support from our wellness coaches,” Cheregi says. “Each patient receives a full-year membership to our two Centegra Health Bridge Fitness centers and personal training visits, at no cost. Lastly, support groups are available monthly and are open to the community. To access the support groups, the patient does not need to have had his or her surgery at Centegra.”
Repairing Torn Tendons
Our bodies are made up of muscle and bone, but without tendons not much of it would work. Tendons are the “rubber bands” that not only hold muscle, bone and joints together, but also make joints move as they should, with flexibility.
“We have tendons all over our bodies, from the neck and shoulders to the elbows, wrists, fingers, hips, knees, ankles and toes,” says Dr. Michael Kogan, an orthopedic surgeon at Presence Saint Joseph Hospital in Elgin. “Tendons connect them all together, and when something happens to one, it often takes surgery to repair these tough bands when they break, rupture or tear.”
Tendons can be damaged for any number of reasons. The Achilles tendon, which stretches from the heel bone to the calf muscles and allows people to flex their feet or point their toes, is commonly injured, says Kogan.
The tendon can tear partially or rupture completely if too much force is applied. Overuse or quickly accelerating the level of physical activity can also impact this tendon.
Wearing high heels can increase stress on the Achilles, but so can flat feet or fallen arches. Injury is common in athletics.
“You are more likely to tear an Achilles tendon when you start moving suddenly,” Kogan says. “What happens is that you stretch the tendon at the same time the muscles contract. These opposing motions are called ‘eccentric’ contractions. Surgery to repair or reattach the Achilles, or any tendon for that matter, is followed by slow, careful rehab to promote complete healing.”
These eccentric contractions can happen to just about every tendon in the body, including the biceps muscle, which bends the elbow and rotates the forearm, to the rotator cuff, where tendons attach four muscles from the shoulder blade to the upper arm bone.
One of the worst kinds of tendon tears occurs in the quadriceps tendon, which pulls four muscles together between the pelvic area down the front of the thigh to the kneecap, Kogan says. More frequently, tears of the hamstring, located on the back of the thigh, occur at the pelvic area of that tendon.
“When the quadriceps tendon is ruptured or torn, a person literally cannot walk and requires surgery,” Kogan says. “For hamstring injuries, surgery is not normally used. Instead, the injury is given a lot of time and careful stretch rehab to heal.”
Modern surgical technologies, including arthroscopies, have been of tremendous assistance in helping tendons to recover from whatever injury has occurred. Kogan almost always uses arthroscopic procedures, except when repairing rotator cuffs.
“With that particular injury, I prefer to use arthroscopy as well as a mini open approach and do the surgery traditionally, so I can clearly see exactly how the tendon is being reattached to the shoulder joint,” he says.
The key to successful tendon healing starts with getting the patient up and moving as early as possible, Kogan says. If the tendon is immobilized for too long, scar tissue can build up and the injured area becomes stiff and painful.
“We get them started on rehab and physical therapy as soon as possible,” Kogan says. “When a bone breaks, it can take around six weeks to heal. Depending on where the tendon is and how severely it was damaged, it can take from two to three months to heal completely.
“Patients can help themselves to avoid tendon injuries by warming up their muscles adequately before starting any exercise or sports activity and keeping the tendons stretched properly,” Kogan adds. “It’s impossible to avoid sudden moves, awkward twists and other movements that cause tendon trauma, of course. Post-activity treatment can help reduce the pain and stiffness when unavoidable accidents occur or the tendons are overworked.”
Kogan recommends an appropriate heating and stretching session before activity, followed by a cool-down to reduce inflammation. Icing down swollen areas also can help to alleviate pain and minimize the risk of injury during the next activity.