Plantation, Florida, USA
|Abdominal section performed on a woman at Vienna, 10 November 1549. Credit: Wellcome Collection. CC BY 4.0|
Nothing grabs our attention more than being flattened by a diagnosis of significant illness. Mine arrived just a few weeks ago.
For decades I had harbored a large hiatal hernia. I had no symptoms, even though my upper stomach had pushed through the diaphragm to occupy much of my left chest cavity. In my mind it was nothing more than a common and generally inconsequential anatomic curiosity. While I knew these hernias could occasionally progress and twist in a volvulus or have their blood supply cut off in an incarceration, I had never heard of such serious complications happening to patients in our large group practice.
Then one evening I suffered an episode of colicky left chest and upper abdominal pain, dry heaves, and intense sweating – which thankfully resolved after a few hours. Naturally my internal medicine brain took me to thoughts of inferior cardiac ischemia, but I revised that self-diagnosis when Wagnerian blasts of peristalsis also began emanating from my chest. In a visit with my surgeon the next day, normal EKG and cardiac enzymes in hand, he agreed the hiatal hernia finally had declared its resolve to cause me significant bodily harm. It was time to proceed with surgical repair before a scarier or even fatal episode came along.
Now a surgical patient, I found myself reflecting on the course of my long career in medical oncology, grateful on a daily basis for the support of some truly stellar surgical colleagues along the way. With admiration and a touch of envy, I regularly applauded their ability to solve serious problems with a single surgical intervention, while my lot was to plod at a glacial pace through the labyrinth of my patients’ chronic medical diseases. This is not to say my chosen specialty was unrewarding or unfulfilling; but sometimes I longed for a surgeon’s power to promptly cure or at least simplify the pressing needs of my cancer patients, complete with the drama and ceremony of the operating room’s inner sanctum. In fact, if I were to be totally honest I would have to admit to mild regrets that I had not become a surgeon in the first place.
While most have heard the hackneyed and sometimes flippant remark, “A chance to cut is a chance to cure,” I must say I have generally endorsed that way of thinking. I never felt surgery should be avoided at all costs; I have never been reluctant to send my patients to a thoughtful surgeon. Recalling the proclamation of one of my medical school surgery professors, “A surgeon is an internist who knows how to cut, too,” I have known surgical colleagues for whom that aphorism was very close to the truth.
Unnerved by my current plight, I began jumping to conclusions based on an internist’s poor understanding of surgical nuance. I knew small hiatal hernias were commonly repaired laparoscopically. However, since 80% of my stomach now resided in my chest and in surgical parlance had been placed in the “giant” category, I naturally figured the repair would be a bigger job than a laparoscope could handle. I conjured up visions of a chest surgeon being added to the mix for a combined open thoracoabdominal procedure; I dreaded the chest incision most of all.
However, much to my shock and happy surprise, the surgeon’s recommendation was abdominal laparoscopy! Not only was this technically possible, he said, but laparoscopy would be his preferred method. Laparoscopy? Chest surgery being accomplished through my abdomen, right? He insisted surgical exposure and postoperative recovery would be optimized with that approach. It was time to stiffen my resolve and just let him get on with the surgery, he said. And so the course was set.
Reflecting back, as a busy internist I had not stayed abreast of the latest surgical innovations, beyond being an occasional spectator from the sidelines. When laparoscopic cholecystectomy was proposed in the 1980s, however, I found myself jolted to a heightened level of awareness. At that time I was chairman of our hospital’s credentials committee. Though our gynecologists had been doing laparoscopic surgery for years, an unexpected surgery department request came across my desk, seeking to apply that same technology for taking out the gallbladder. Our committee was caught off guard.
Most of our surgeons were middle-aged and had emerged from residency before the surgical laparoscope was a treatment option. To learn the new technique after years in practice, they needed to choose among training options which included on-the-job familiarization with borrowed gynecology instruments, various local mentorship programs, and trips to a training center in Atlanta to learn the technique on Georgia pigs. With passion they argued laparoscopic gallbladder surgery was the way of the future and would be good for patients; it was time to get on board without delay. So the credentials committee’s conundrum was this: how might we approve a new surgical procedure, one in which no one had any formal training, to the menu of an older surgeon’s hospital privileges?
Before we could move ahead, some of us had to jettison our preconception that “lap choles” were a gimmick, possibly even a contest to see who could do the most work through the smallest hole. Had we persisted in that belief, of course, we would have been horribly wrong. But we did worry about longer anesthesia times, operating room bottlenecks, and a misstep onto the slippery slope of dueling laparoscopies with competitor hospitals. In our lighter moments we likened laparoscopic cholecystectomy to changing a car engine’s spark plugs through the exhaust pipe. Why would a perfectly good surgeon want to operate under such a handicap?
Then one day without warning our deliberations were rendered moot. Two of our surgeons had simply borrowed the gynecology instruments and proceeded to remove a few gallbladders on their own, not waiting for a blessing from the “powers” that be. Further, two other surgeons had just returned from a hands-on training course involving porcine gallbladder extractions, brandishing ornate certificates attesting to their newfound competence.
So, by default and by the simple flow of events, four surgeons had taken matters into their own hands, and then assumed the mantle of disseminating the technique to their colleagues. The credentials conundrum thus resolved itself serendipitously, expeditiously, and without a hint of elegance; our hospital was propelled to the early adoption of an important surgical innovation… no thanks to me or the committee, and without homage paid at the altar of due process. It felt like the Wild West.
In the years that followed, I had to marvel at the expanding applications for surgical laparoscopy. I began seeing patients whose entire spleen or kidney had been removed laparoscopically in pieces by organ morcellation – morcellation, for crying out loud! How does an internist even wrap his or her mind around that? And I would see patients who had undergone laparoscopic bowel resections, inguinal hernia repairs, and all manner of abdominal and even thoracic surgeries. As more of this technology evolved into common practice, I came to appreciate its enormous benefit to patients and realized we were not talking about an exhaust pipe procedure any more.
Fast forward to my own date with the laparoscope. The four-hour procedure went splendidly, with added help from a foregut surgeon (who ever heard of a foregut surgeon?). While still adrift in the fog of anesthesia, I remember listening in awe as my surgeon recounted how he had dissected the hernia sac and stomach from my aortic knob – my aortic knob, my aortic knob! Through the abdomen! And I believe I sensed a small gloat as he regaled me with further details of the laparoscope’s work on and below my diaphragm. I went home the next day with four small surgical wounds, a pleural drain, and not a whiff of narcotics.
As I began to write this account three days after surgery and returning from a long outdoor walk, I reflected upon my journey from uninformed skeptic to grateful laparoscopy super fan. Who would have imagined? I am now a humbled beneficiary of marvelous technology in the hands of wonderfully skilled surgeons. In discussing my experience with other non-surgical colleagues, I find I am not alone in my amazement (and ignorance!) at the sophisticated level of care our surgeons regularly provide. And as for those surgeons, I still wish I had become one of them. Maybe in another life…
WILLIAM S. SHIMP is an internal medicine physician who has practiced medical oncology in Minnesota for forty years. He is also an associate medical director for Oncology Analytics, Inc., a utilization management organization based in Plantation FL. He has authored many articles related to the science and economics of oncology care, and to the art of medicine as well. He currently resides in Northfield MN and can be reached at [email protected]. He wishes to thank his daughter, Ellen M. Fritz MA, for her editorial assistance.