Last October, Tom Brassil faced a difficult decision. The 41-year old physical education teacher and baseball coach in Holyoke had been told he needed surgery to repair a torn anterior ligament in his left knee -- an injury he sustained when he was 26 and had now become career-threatening.
"It got to the point where I had no mobility in my knee," Brassil told BusinessWest. "In addition to the pain and onset of arthritis, within a couple of years I wouldn't be able to coach or even move around in my gym classes."
Brassil knew he needed to have the knee repaired with arthroscopic surgery, but remained hesitant. He had learned that other athletes who had undergone the procedure faced several weeks in the hospital after the operation, followed by months, even years of painful post-operative therapy, as well as the necessity to wear a heavy, expensive brace.
In Brassil's case, however, the outcome was very different.
He checked into New England Baptist Hospital in Boston on Oct. 25 and the surgery was performed the same afternoon. Had he lived closer to Boston, he would have been discharged the same day as well.
He did return home the next morning, and was back at work within a week, and finished a mild therapy routine two months later. He doesn't need any additional treatment, nor does he wear a brace. Most important, he has regained full mobility in his leg and is looking forward to the opening of the high school baseball season this month.
The surgical technique used on Brassil was initially developed in the 1970's, but thanks to remarkable advances in computer, fiber-optic and video technologies, what used to be a difficult and expensive procedure has now become commonplace.
It is one of a number of techniques which involves inserting a fiber-optic tube the size of a knitting needle through a small incision, then using a scope to look directly into the target area. A video camera can be mounted to the end of the scope, bringing to the surgeon dynamic pictures of the muscle, tissue or organ where the surgery will be performed.
Such procedures are known collectively as minimally-invasive surgery (MIS), sometimes called minimal-access surgery (MAS), and known as videoendoscopic surgery if utilized with video technology. It has become the surgical procedure of choice for gall bladder operations, as well as for certain types of hernias and gynecological procedures.
When a camera is attached to the scope, the surgeon actually views his work on a video screen, much like a television monitor, mounted in the operating room. "It's kind of like doing surgery by looking at a mirror," says Dr. Herbert DiMeola, vice president of Medical Affairs at Mercy Hospital, "and while it can't be used on all patients, the results in certain situations are remarkable.
"For those patients who are fit subjects for MIS there is a tremendous decrease in the incidence of post-operative pain, infection, and length of post-operative hospital stays," he added.
In the case of gall bladder removals, for example, DiMeola points out that a typical incision would be 4 to 6 inches, which resulted in significant pain and a post-operative hospitalization of four to six days. The incision in a "scoped" operation is usually no longer than one inch. The patient usually reports minimal post-operative discomfort, and most of these procedures are now performed on an out-patient basis.
Focus on Technology
Although the technology for minimally invasive surgery was first developed in Germany, it turns out that one of the few American companies now manufacturing medical scopes is located in Western Mass. The company, Instrument Technology Inc. (ITI) of Westfield, first started delivering sophisticated industrial scopes to the nuclear-power industry, which used the devices for inspection of the interiors of nuclear reactors, minimizing the effects of radiation on nuclear power employees.
In 1990, the company was approached by several medical manufacturers who could not meet the rapid growth in demand for fiber-optic surgical scopes from overseas suppliers.
"Until about 1980," said ITI President Jeffrey Carignan, "our business was overwhelmingly industrial, with about 10 or 15% of our revenues coming from Department of Defense contracts related to work on the F-14 and F-15 fighters." As the nuclear power industry waned in the 1980's and defense contracts dried up, ITI reoriented its business toward medical technology. Today, Carignan estimates that about 50% of the company's annual $7 million revenues comes from medical scopes, a market he believes is just now coming into its own.
Although surgeons in certain specialties are quick to point to the advantages of minimally-invasive procedures, many types of medical procedures will continue to be conducted with traditional methods for the foreseeable future. For example, scopes were tested in cardiac surgeries as an alternative to the major difficulties posed by splitting open the sternum and exposing the entire chest cavity, but most thoracic surgeons have discarded this method in favor of the more traditional reliance on open-access surgery.
"The problem that we encountered in bypass surgery," said Dr. Jose Missri, Chief of Cardiology at St. Francis Hospital in Hartford, "is that surgeons could not use the technique effectively to suture arteries.
"It is sometimes possible to make an incision on the side of the sternum rather than splitting it down the middle," he added, "but in most cases the small size of arteries makes direct visualization of the surgical area a necessity, and scopes do not offer much in the way of an alternative."
Stitch in Time
Where the use of scopes has achieved major medical breakthroughs, however, is in diagnostic procedures on just about every area of the body. Until videoendoscopic technology was commonplace, physicians were often put in the position of having to decide whether to perform major surgery just to render a diagnosis. This was particularly the case in areas like the abdomen, where symptoms are often vague, and could be caused by a wide variety of illnesses.
"What do you do with the patient who complains of abdominal pain?" asks DiMeola. "Do you just wait and watch, or try a variety of medications and hope it goes away? Or do you take the patient into surgery and perform a major operation without really knowing what you are looking for?"
This dilemma has largely been solved through the use of videoendoscopy, which allows the specialist to take a video of virtually the entire digestive tract and look for specific infections or other medical problems without cutting through large amounts of muscle and tissue.
"It's a much better procedure than a scan," said DiMeola, "because you are actually looking directly at the organs themselves, but you haven't forced the patient to undergo anything more difficult than a brief procedure that can be performed on an out-patient basis."
One physician who eagerly embraces the virtues of videoendoscopy diagnosis is Dr. Paul Salva, pediatric pulmonologist at Baystate Medical Center. Salva, who regularly performs videoendoscopic diagnostic examinations on more than 100 children a year, is enthusiastic about the technology because it has made an enormous difference in his ability to diagnose a wide variety of pediatric pulmonary disorders, including asthma, lung malformations, vascular compressions and other bronchial and lung problems.
"Before this technology was available, perhaps upwards of 30% of pulmonary asthma cases were really something else," said Salva, "and children were getting medicines for illnesses they didn't have."
"Not only does the scope allow us to look all the way down through the bronchial passages and into the lungs," he continued, "but we are also able to use it to bring up fluid that collects in the lungs from infections, as well as to perform biopsies on lung and bronchial tissue with relatively minor discomfort for the sick child."
The use of scopes for a wide variety of visualization procedures has probably been a greater value to health and medicine than the introduction of scopes for surgery itself. Because scopes can allow physicians to make more accurate diagnoses, the cost and trauma of acute care can be lessened, and many unnecessary surgical procedures avoided. There is virtually no part of the human body into which a scope cannot be inserted, and the value of being able to see into the body's interior without costly and risky surgery cannot be overestimated.
View to the Future
There are two other areas of medicine in which minimally invasive technology is growing quickly. The first is what is known as "tele-medicine," where a doctor or other specialist watches a monitor and advises another doctor or technician about a surgical procedure being performed at another site. Sensationalized versions of these procedures are the regular staples of such television shows as "911" and "ER." But while open-heart surgery is not usually performed in a helicopter, the development of scope technology is indispensable for remote medical procedures, because a video image is usually more reliable than a description based on what someone sees through the naked eye.
The other medical area to watch is veterinary medicine, an industry which continues to grow at a rapid pace without the aid of federal or state reimbursements. ITI's Carignan sees a lucrative opportunity for his company in this market.
"It used to be that minimally-invasive surgery for animals was restricted only to very unique situations, such as prize-winning racehorses," he said, "but the technology is now spreading to the neighborhood veterinary clinic."
Until recently, many veterinarians were reluctant to perform surgeries, because the surgical wound would not heal once the animal regained consciousness and began moving around. But the small size of a scope incision has changed that scenario dramatically. With a small wound that heals quickly, an animal can move about freely following the procedure, and the pet-owner doesn't have to watch the animal every second to make sure the bandage stays in place.
Most physicians in Western Mass. believe that there will be further technological breakthroughs in minimally-invasive surgery, and it is much too early to say how the field will develop over the next few years. Advances in scope technology reflect developments of other areas, particularly lasers, fiber optics, video and computers. To the extent that such technologies are changing at an ever-increasing pace, there is probably no limit to how medical procedures based on these technologies will also change.
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