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Kidneys, method of removal

How a hoover vacuum solved the riddle

 By Dr. Gifford Jones  Sunday, October 10, 2010

How many readers would prefer to have a gallbladder or uterus removed through a hardly perceptible scar rather than an eight inch incision? To be able to leave hospital in 24 hours rather than a week? And endure much less pain? Few would say “no” to this offer. Today, laparoscopy provides the magic bullet of surgery. But how could surgeons remove a solid kidney through a button-hole incision? Could a Hoover vacuum provide the answer?

Gynecologists have used laparoscopy for years to sterilize women, diagnose tubal pregnancy and unexplained pelvic pain. But it caused little public notice. Only when general surgeons began wielding the laparoscope to remove gallbladders (cholecystectomy) did the procedure catapult to unparalleled levels of popularity. Today, thousands of surgeons in North America are enrolling in special courses to learn this technique.

The procedure to remove a gallbladder can take 90 minutes or as long as three hours. Initially the abdominal cavity is blown up with carbon dioxide gas to gain better visibility. Then the laparoscope, a long metal tube outfitted with a miniature television camera, is inserted into the abdomen along with other instruments. Doctors conduct the operation through the television screen.

Surgeons have now gone a step further. A report from Washington University states that a team of surgeons used the technique to remove the diseased kidney (nephrectomy) of an 85 year old woman. This is a milestone. It marked the first time that a solid organ had been removed by laparoscopy surgery. The operation took seven hours.

Surgeons faced a major problem in the performance of this nephrectomy. How to remove a solid organ larger than a fist through an incision the size of the tip of your finger. To remove the distended gallbladder they ultimately sucked out the bile and then squeezed the collapsed organ through the tiny incision.

To do this surgeons devised an ingenious method. Some one must have thought of “Hoover’s vacuum”. They pushed a specially designed sac down one of the metal tubes and opened it up. The severed kidney was then maneuvered into the sac and its drawstrings pulled taut.

Next, the sac was pulled up to just beneath the skin. A morcellator was inserted into the neck of the sac to chop up the kidney. It was vacuumed out and the empty sac removed.

Laparoscopy cholecystectomy is here to stay. But removal of kidneys, spleens and performing bowel surgery for everyone is still several years away.

Never forget that risk is always a factor in any surgery or laparoscopy. Currently there are several new hazards for patients who agree to laparoscopic surgery.

Young surgical residents in training will emerge from medical training familiar with this new procedure. But surgeons who have been operating with the scalpel for several years face a difficult readjustment. It’s impossible to quickly switch from one surgical method to the other. The major difficulty is the video-eye-hand coordination required for television surgery.

Courses are available at many medical centers. But standards are far from uniform to guarantee superior training. Moreover removing a few sheep gallbladders and then returning home to operate on humans hardly makes one an expert.

A year ago I predicted some disastrous consequences and unfortunately these have proven to be true. Several patients have died from laparoscopy cholecystectomy. In some the abdominal aorta, the body’s largest artery, has been inadvertently severed. Other patients have had the common bile duct injured.

Patients who are willing to undergo laparoscopic procedures should ask the obvious question. What are the surgeon’s credentials? Has he performed two of these procedures or one hundred? And has he encountered any major complications?

There’s another important question to pose. If the surgeon has limited experience at the moment, will an assistant be present during the surgery who is more familiar with the procedure in the event technical troubles occur?

I’ve witnessed several surgeons doing laparoscopic cholecystectomy. There is no doubt that if things go well, it is a much kinder operation for the patient. But it is no place for amateurs.

The old adage still holds true that “Practice makes perfect”. There is no substitute for experience. The only way to go to surgery is on a first class ticket whether it be by the scalpel or by laparoscopy.

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Dr. Gifford Jones  Bio
Dr. Gifford Jones Most recent columns

W. Gifford-Jones M.D is the pen name of Dr. Ken Walker graduate of The Harvard Medical School. He’s been a ship’s surgeon, hotel physician and family doctor and later trained in surgery at McGill in Montreal, University of Rochester N.Y. and Harvard. His medical column is published by 60 Canadian newspapers and several in the U.S. He is the author of seven books. Dr. Walker has a medical practice in Toronto. His Web site is: http://www.mydoctor.ca/gifford-jones

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