The saber cuts from guzzle to zatch,
But I thinks it's finally found its match.
For all the above are good for killing,
But I've got one that's used, God willing,
Instead of for wounding or taking of life,
It's used to cure the scalpel knife.
Why on earth write a chapter on knives, lasers, and cautery?
Just cause I oughtery!
I can vaguely recall the first time I held a scalpel in my hand and drew it across human skin to make an incision. I was an intern at a prestigious hospital in New York City and was doing my first appendectomy with the guidance of a gray-haired surgeon who couldn't keep his hands out of the wound. I cut his hand! Just a tiny nick but it was enough to make me the laughing stock among my colleagues. That was the last time I did that, but to me it seemed like an inauspicious start to my surgical career. Reminiscing brings back many good and bad moments during my training program; I digress. We're talking about knives, lasers, and cautery.
The first two are methods of cutting. The first of these is timeworn, used since man first made stone tools, and the second is a child of the late twentieth century. Many of my patients inquire whether I can do their surgery with lasers and are somewhat disheartened when I tell them that a laser is just another method for cutting. Laser is an abbreviation of the first letters of Light Amplification by Stimulated Emission of Radiation, and its use in general surgery is actually very limited. It was early on used for cutting and coagulating during certain laparoscopic procedures, but the side effects and complications made it fall into minimal usage. However, in certain procedures, such as hemorrhoidectomy, eye surgery, and certain brain operations, it has become an important tool for the surgeon. Lasers can cut, coagulate, vaporize and selectively destroy tissue. There are several different types of lasers including CO2 carbon dioxide, Nd:YAG - neodymium (yttrium-aluminum-garnet), Ho:YAG holmium, Er:YAG erbium, and the KTP potassiumtitanylphosphate.
Anyway, the word laser sounds good and many surgeons, who advertise, use the word laser in their “ads” because it sounds high-tech, modern, and has a catchy patient-appealing sound to it. “Hey doc, I want my surgery done with lasers.”
I feel like saying, “We'll bring in Dr. McCoy from Star Trek and use ultragammaneutrinolasers for your surgery, sir! Beam me out.”
But to get back to real cutting, scalpels—some completely disposable and the handles of some often reusable—are very fine, ultra-sharp instruments that can become dull cutting through tough tissue and frequently have to be replaced several times during a surgery. They also come in several sizes and types, some broad, some tiny, some with round or pointed tips, and others adapted to certain special operating conditions.
Another modality used in the surgical operation is electrocautery; this can either be monopolar or bipolar. Cautery is used for cutting in place of a scalpel or for cauterizing or sealing off bleeding vessels with heat, a modern adaptation of the Middle Ages technique of using boiling oil or fire to stop bleeding, but they didn't have much for anesthesia! It has become an irreplaceable modality for many surgeons to cut, and then dry, the operative field using this tool, whereas many years ago the surgeon had to tie off each bleeding vessel with a suture, requiring much more time and prolonging the surgical procedure. Another relatively new device is the argon beam coagulator, which uses the gas argon and electrons to seal off bleeding areas, has a very minimal tissue depth penetration and can be used on the surface of vital organs without damaging the organ, as may occur with standard electrocautery.
I am sure, in the years to come, new and even more efficient tools for cutting and stopping bleeding will be discovered and used in surgical operations, but somehow I think the scalpel will still hold sway in the hands and minds of the surgeons.
Chapter 15
LAPAROSCOPY
They say that Isaac Newton was sitting under a tree,
When an apple fell upon his head, and he found gravity.
And likewise, after centuries had passed, to please society,
Someone sat under that very tree and found laparoscopy.
It's just the product of a brilliant and inquiring mind,
That finds a new idea and leaves the old ones far behind.
With laparoscopic surgery we have turned a brand new page,
And ushered in a new and different type of surgical age.
We put a camera in a joint or abdomen to see,
What was causing all that person's symptomatology,
And without making big incisions we can take out many organs,
With such success that we'll be known as surgical J.P. Morgans.
When I first heard about laparoscopic cholecystectomy—taking out the gall bladder using four tiny holes, a camera, and some strange instruments—I said, “It'll never fly. Too risky! Not me!” Now I do two or three every week and rarely do the old type of procedure using a large oblique incision under the right rib margin. My patients are done as outpatients, coming to the hospital and going home the same day, and have minimal pain and almost no incisional scarring. They are usually back to work in a few days and eat normal food. It's the closest thing to the invention of the wheel I have ever seen.
The first laparoscopic cholecystectomy was performed in Germany in 1985 and, though pooh-poohed by surgeons like me for years, by 1993 nearly half a million procedures were done that year alone. Laparoscopy is a method of operating which uses only a few small openings into the abdomen. A special needle is inserted into the abdomen, and carbon dioxide gas is insufflated into the peritoneal cavity inside of the abdomen, allowing an interface between organs and the abdominal wall. Then a ten millimeter camera attached to a television screen is inserted through this port and a general exam of the intra-abdominal contents can be done. Under direct vision, at least three more ports are placed and using special clamps, scissors, and cautery, the gall bladder can be dissected out, the veins, arteries, and bile ducts sealed with staples, and the gall bladder can be dissected out of its location under the liver and brought out through one of the ports. Then most of the CO2 gas is removed. Any remaining CO2 may sometimes get caught temporarily under the diaphragm, and this may cause some patients to have an annoying aching pain in the right shoulder after abdominal laparoscopic procedures. The gas gets absorbed by the body in about six to twelve hours, and the pain goes away. I have known some patients to get very worried about this, and knowing its cause and that it will soon go away is usually all they need to hear!
Abdominal laparoscopy is not without complications, and I will mention a few of the general considerations now and more specific ones under the particular types of surgery later in the book. The trocars that are placed in the abdomen can be very dangerous in untrained and uncareful hands and may result in severe injuries to the intestines and, more seriously, injury to major blood vessels such as the aorta, the vena cava, the iliac arteries or their accompanying veins, or may just cause nonspecific bleeding. These injuries usually require making a large incision in the abdomen and repairing the damage. However, sometimes the damage is not immediately apparent. As an example, a surgeon made a hole in an artery during what should have been a routine laparoscopic appendectomy. Because the blood vessel had a lot of peritoneum and fat around it, the bleeding
