[LUM#5] Surgery, gentle surgery

[LUM Magazine] - Published on April 4, 2017 in Science-Society

As explorers of the human body, surgeons are seeing their practices evolve thanks to "minimally invasive" surgery: techniques that reduce the difficulty of operations and make life easier for patients.

It's a real gentle revolution. A surgical technique that offers equally effective procedures, but with less impact on the patient. How does it work? Instead of making large incisions with a scalpel to expose the organs to be treated, doctors make tiny incisions through which they insert their instruments. The main advantage of this technique is that it reduces surgical trauma and allows patients to recover more quickly.

In Montpellier, Professor Charles Marty-Ané is a pioneer in the use of minimally invasive surgery to treat lung cancer patients who need to undergo a lobectomy, an operation that involves removing the lobe of the lung where the tumor is located. To perform this operation using conventional "open" surgery, doctors perform a thoracotomy: the patient's chest is opened wide so that the doctor can access the lung. "This type of procedure causes severe chest pain because it requires cutting through muscles," explains Charles Marty-Ané. This pain can have serious consequences after the operation. "The patient is in so much pain that it is difficult for them to breathe, and above all, they can no longer cough, which prevents them from eliminating lung secretions and increases the risk of complications and secondary infection."

Three small holes

The alternative in minimally invasive surgery? Video-assisted thoracoscopy. "Three incisions measuring just one centimeter on the side of the chest, through which instruments and a camera are inserted, providing a panoramic view of the rib cage and guiding the surgeon's movements," explains Charles Marty-Ané. Once the lung lobe has been sectioned, it is removed through one of the incisions, which is slightly enlarged for this purpose. What are the advantages for the patient? "A considerable reduction in post-operative pain and pain-related complications," replies the surgeon. Patients thus see their recovery time shortened and are discharged from the hospital 2 to 4 days after the operation, compared to 8 to 10 days for thoracotomy. "They return to normal life more quickly," emphasizes the specialist.

Thoracoscopic lobectomy is rapidly gaining popularity and is set to become the standard technique. Although it has developed slowly since its inception in 1995, it now accounts for 30% of lobectomies in France. However, it still lags far behind countries such as China, Korea, Japan, and the United States, where 40% of lung lobectomies are performed using this procedure. However, these countries are still far behind the thoracic surgery department at Montpellier University Hospital, a true pioneer in this field: "Over the last five years, 74% of lobectomies have been performed by thoracoscopy,"explains Charles Marty-Ané (600 closed chest surgeries performed in Montpellier). This year, his department has exceeded 1,000 procedures of this type, giving it unique expertise in France and even in Europe.

Choosing the best solution

While minimally invasive surgery represents a real revolution in the treatment of lung cancer, its advantages are less obvious in other disciplines, particularly cardiology. Open surgery involving sternotomy, which involves opening the sternum to access the heart, is generally well tolerated by patients and remains the gold standard in most cases. "To perform minimally invasive surgery, you need a well-trained team and the right equipment, but above all, you have to carefully select the patients," explains Professor Roland Demaria, a cardiac surgeon at Montpellier University Hospital. For the time being, minimally invasive surgery is mainly used for patients in good physical condition whose heart valves need to be repaired or replaced. "Ultimately, very few patients are eligible for these techniques,"emphasizes Roland Demaria.

For surgeons, the future of the discipline lies more in modern interventional cardiology, a hybrid discipline born out of close collaboration between surgeons and cardiologists. "This collaboration allows us to choose the best solution for each patient by discussing each case with the entire medical staff," explains Roland Demaria. Interventional cardiology makes it possible, for example, to replace a faulty aortic valve without having to open the patient's chest. "All you have to do is make an incision in the groin and insert a new valve, which is then guided up to the heart through the artery. The procedure is much less invasive for the patient than conventional surgery," emphasizes the surgeon.

The use of these techniques often allows patients to return home sooner. And patients who leave the hospital sooner to return to work are also patients who cost less ( Medical-economic analysis of thoracoscopic lobectomy versus thoracotomy for lung cancer: study protocol for a multicenter randomized controlled trial, in BMJ journals, 2017). "At €1,500 per day of hospitalization, the savings for the healthcare system are far from negligible," says Charles Marty-Ané.

Keywords: LUM#5, LUM Magazine, Medicine, Research, Health