A new generation of minimal-access operations
Nine-year-old Ryan was the first patient at Packard Children's Hospital to have his spleen removed through a single incision in his belly button.
When Thomas Krummel, MD, was in medical school 25 years ago, a senior surgeon told him, "Son, big hole, big surgeon. Give yourself some room."
At that time, his colleagues defined themselves by making large incisions, said Krummel, now the Susan B. Ford surgeon-in-chief at Lucile Packard Children's Hospital and Stanford Hospital & Clinics. "The problem was they ignored one important participant in surgery: the patient."
Now, thanks to minimal-access techniques pioneered at Packard Children's and Stanford Hospital & Clinics, surgeons at the two hospitals avoid many of the big incisions that were once an inevitable feature of surgery. Teams are building their repertoires beyond basic laparoscopy to robotic surgery and single-incision operations with small, hidden scars.
"These advances are far in the future at many other hospitals," said Craig Albanese, MD, the division chief of pediatric general surgery at Packard Children's.
Building skills
For example, 9-year-old Packard patient Ryan recently became the first person to have his spleen removed through a single incision in his belly button. His mother, Elaine, guessed he might receive a laparoscopic procedure but was surprised to learn that the surgeons could use his belly button. "I thought, 'Wow, that seems even better since there are no scars at all,' " she said.
The surgical team now performs scarless appendectomies and gall bladder surgery.
Another Packard patient has only a few tiny marks in his armpit from his recent thyroid lobectomy, an operation that typically leaves a prominent scar across the front of the neck. His surgeons burrowed under his skin from armpit to neck, carefully avoiding the nerves near the thyroid gland that control the vocal cords.
"We had been gradually building our skills by taking out smaller masses in the neck," said surgeon Marilyn Butler, MD, a clinical associate professor of pediatric surgery. "Now we're able to do more complex operations."
Psychological benefits
Packard surgeons aren't just developing new procedures-they're also investigating the psychological benefits of reduced scarring in children. "There is evidence to suggest visible scars are related to poor socialization in children," said Packard pediatric surgeon Sanjeev Dutta, MD, who performed Ryan's scarless operation.
The Packard team is running the first-ever study of the psychological cost of big scars. "Essentially, we're expanding the surgeon's definition of health to include mental well-being," said Claudia Mueller, MD, PhD, who is leading the study with Dutta.
There is no question that patients of all ages value minimal-access operations for more than just small scars. "For instance, abdominal surgeries commonly performed in adults-such as hernia repair, appendectomy and gallstone removal-used to put patients out of work for four to six weeks," said Krummel. "Now patients' discomfort and healing are dramatically improved. They can go back to work in two to three days. I tell my patients, 'It'll hurt less, you'll get out of the hospital quicker, and you'll be up and around much sooner.'"
Small steps
The challenge for surgical innovators is to find ways to maneuver through tiny incisions without losing the safe, reliable results of conventional operations.
"We take innovation baby steps," said Dutta. "Any surgical step that seems a little unusual, we discuss as a group ahead of time."
The team tries new procedures in phases, first attempting successive small changes during open-incision surgeries. Finally, with patient consent, they attempt a new minimal-access technique in its entirety, knowing they can revert to an open-incision procedure if necessary, he said.
"Every single surgery requires an active process of decision making," added Krummel.
Technology and training
Innovation also depends heavily on surgical technology. The laparoscopic instruments pioneered at Packard Children's for infants are just 3 millimeters in diameter and 20 centimeters long-thinner and shorter than a ballpoint pen. After years of struggling against manufacturers reluctant to develop such tools for the tiny pediatric surgical market, Dutta and his colleagues recently founded MISTRAL, a nonprofit research collaboration between Stanford University and SRI International to develop improved pediatric surgical tools.
His work is now benefiting adult patients, too. "Our research has had a trickle-up effect on adult devices," Dutta said.
Stanford and Packard surgeons are also adept at using the DaVinci surgery robot, a computer-assisted device that improves dexterity of minimally invasive tools and provides three-dimensional views of the body's interior. Surgical residents in the School of Medicine are able to build their minimal-access skills at the school's Goodman Simulation Center, a suite equipped with top-notch technological equipment. One simulator allows surgeons-in-training to manipulate laparoscopic tools at an arcade game-style console, getting the feel of cutting, pulling and stitching tissue before they operate on real patients.
Promoting innovation
The environment at Packard Children's and Stanford Hospital & Clinics is ideal for fostering all types of innovation in minimal-access surgery, Krummel said. "We attract people who think there's a better way to do things," he said. "You can't dissociate Stanford from that sort of Silicon Valley spirit."
And surgical innovation got a big push from the opening of Packard Children's Ford Family Surgery Center in December. Its seven new operating rooms boast the best surgical technology available.
"Innovation begets innovation," said Albanese. "We can think more broadly, generate new ideas and figure out how to make things better for our patients. We're all very excited."