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Healthy Monday: Surgery through the belly button limits scars

POSTED: August 15, 2008 5:01 a.m.
TOM REED /The Times

Nydia Gonzalez, director of surgical services at Northeast Georgia Medical Center, holds a model that shows how the instruments are inserted in the navel for minimally invasive surgery.

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Imagine surgery with no incisions. It would be like something Dr. McCoy used to do on "Star Trek."

We’re not there yet, but local surgeons are inching ever closer. This summer, several Gainesville doctors began performing a new technique known as single port access.

Like nearly all surgeries these days, this technique is laparoscopic, meaning that instead of cutting a wide slash through the patient’s abdomen, the doctor inserts instruments through tiny incisions and uses a miniature video camera called a laparoscope to look inside.

But until now, laparoscopy involved three or four incisions. With single port access, there’s just one, right through the belly button. There’s virtually no scar, which comes in handy if you’re planning to wear a bikini.

The technique is being used by some surgeons at Northeast Georgia Medical Center for gallbladder and appendix removal.

"Patients like it because of the cosmetic improvement," said Dr. Casey Graybeal, a Gainesville surgeon. "They also seem to have less discomfort. If you keep the incision down lower on the abdomen, there’s less pain during breathing."

In a typical laparoscopic gallbladder operation, the main incision is in the right upper abdomen, just below the ribs. Most patients have four incisions: one for the laparoscope, the others for instruments to retract organs and to detach and remove the gallbladder.

With single port, all of that equipment goes through one incision.

"It’s a more challenging way of doing this for the surgeon," said Graybeal. "But I think patients are going to start demanding it."

Other Gainesville physicians who are performing the technique include Dr. Ronald Lewis, who is one of Graybeal’s colleagues at Northeast Georgia Surgical Associates, and Dr. Charles D. Procter Jr. at Surgical Specialists of Georgia.

Procter said there is "a tremendous amount of interest" in the procedure, noting that a recent seminar was attended by about 50 Gainesville and metro Atlanta surgeons.

"I think this is the way all laparoscopic surgery is going to go," he said. "We’re used to having the instruments a little more spread out, but once you start doing it, it’s not all that difficult. There’s going to be a learning curve, but I do think it is here to stay."

Gallbladder removal, or cholecystectomy, seems a natural way to introduce the single port technique because it is the most widely performed operation in the United States, with about 1 million procedures done each year.

"We’re always looking for better ways it can be done," said Procter, who has even practiced doing the single port technique with robotic equipment, using a pig as a "patient."

Procter said aside from cosmetic concerns, the size and location of the incision does matter.

"It’s the incision that causes most of the post-operative pain," he said.

He describes single-port surgery as "the same operation on the inside, different operation on the outside."

Laparoscopic cholecystectomy was pioneered by Atlanta surgeons in the early 1990s. Back then, Procter said, doing it through a single incision would not have been possible. The surgical instruments were much larger than those in use today. Procter marvels at the rapid development of new medical technology.

"The procedures I do now are so different even from the ones I did in my last year of residency," he said.

Procter has been offering his patients a choice between traditional laparoscopy and single-port access. He’s observed that the women seem more enthusiastic about the new option.

"Most of the male patients don’t seem to care," he said.

Winder resident Stephanie Survis had her gallbladder removed by Graybeal in June. During her pre-op visit, she said, "He told me about the new way of doing it, and I said that was fine with me."

Survis said she wasn’t really worried about having a scar.

"But as little incision as possible would be great for me, because it would heal faster," she said.

A couple days after the operation, Survis felt well enough to resume her normal activities.

"I had no discomfort at all around the actual incision," she said.

Graybeal said the single-port technique is not appropriate for everyone. Patients who may need a more traditional procedure include those who are morbidly obese, have cirrhosis of the liver or whose gallbladder is severely infected.

"The goal is not to just have one incision. The goal is to remove a gallbladder safely," he said. "If I need to make additional incisions, I will."

Graybeal and other local doctors are also exploring a technique called Natural Orifice Transluminal Endoscopic Surgery. NOTES, or so-called "invisible incision" surgery, is performed through an existing opening in the body, such as the mouth, vagina or anus.

But Procter said this approach actually can make a procedure more complicated. For example, it is possible to remove a gallbladder by going through the vagina, but you have to cut through some internal organs in order to do it.

"Right now, I think single port is safer than NOTES," he said.



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