The day operation has ended the long hospital stay thanks to new approaches to surgery. Éibhir Mulqueen reports
A quiet revolution has occurred in surgical procedures as the traditional image of a team of surgeons hovering over a patient's body is replaced by keyhole surgery, ushered in by the use of microchip cameras and TV monitors.
Instead of peering into a body cavity, surgeons are increasingly using telescopic procedures, looking at an enhanced image on screen of the area being treated.
David Bouchier-Hayes, chairman of the Department of Surgery at Beaumont Hospital, Dublin, has a particular interest in laparoscopic and vascular surgery - he lectures and demonstrates surgical techniques for Royal College of Surgeons' students.
He describes the late 1980 and early 1990s as a watershed period when there was a switch from open surgery to laparoscopical surgery for abdominal procedures, marking an adaptation of technology to minimise patient trauma.
Laparoscopy involves making a small incision in the abdominal area through which an instrument with a very small camera and light source is inserted. Images are then sent through a fibre optic cable to a television monitor. The surgeon performs the procedure by watching the monitor.
"Surgery and, indeed, all medical treatments have a downside. Yes, they can cure your condition but they do impose an injury. Laparoscopic surgery decreased the trauma to the body caused by surgical procedures," he explains. "It was the arrival of the microchip which allowed us to project images onto a video screen that started the laparoscopic general surgery era."
Laparoscopy, Bouchier-Hayes says, has been around, particularly in gynaecology, for a long period of time and had been mainly used diagnostically. But the technique of inserting a telescopic instrument to do surgery now has wide applications.
Arthroscopic procedures are used for knee surgery. For chest operations, a thoracoscope is used and the procedure is known as hysteroscopy for operations on the uterus.
Anti-heartburn operations - preventing gastro-oesophageal reflux - are carried out using this method, reducing a hospital stay of seven to 12 days to 24 hours.
"The patient benefit is the surgery-related injury is reduced. When you reduce the injury, you reduce the hospital stay and you reduce the cost.
"Other operations that are now carried out, not quite routinely but with increasing momentum, are various forms of removal of part of the large bowel for either inflammation or cancer.
"These, in the past, were traditionally done by the open technique. The majority are still performed by the open technique but increasingly the laparoscopic method is applied.
"I think within a relatively short period of time the majority of abdominal surgery will be done by the laparoscopic route," he adds.
The technique can also be applied in cardiac surgery "and, again, the benefits are the same". Open surgery is still the most common method but the revolution in treatments has resulted in the evolution of new endo-vascular procedures.
"The radiologists who are imaging the cardiovascular system did this by the introduction of dye into an artery and this outlined where the arterial obstructions were.
"What the radiologists and cardiologists introduced was angioplasty, inserting a 'balloon' in the arterial passageway, which would then stretch it.
"Here again you avoid the cost of open surgery," says Bouchier-Hayes.
He describes the advent of drug eluting stents as "a major impact in the management of coronary heart disease".
A stent, "a cylinder of sophisticated chicken wire" is passed into the blood vessel in compressed form and, when released, springs back to its original calibre. The stent slowly releases drugs to control cellular proliferation. "If you stop that cellular proliferation, you stop that renarrowing after angioplasty and stenting," he says.
Laparoscopic imaging and stenting are combined to treat another form of arterial disease where a blood vessel bursts, described as an aneurysm. The less invasive method is like building a boat in a bottle, he says.
"Abdominal aortic aneurysm is a major physical assault. The patients always require intensive care. Indeed, it takes three to four to five months to get yourself back to pre-operative fitness.
"Instead of spending a number of days in an ICU and 10 days in hospital, these people can be nursed in the ordinary ward and can sit up that evening and have a meal. It is done under local anaesthetic.
"If you give an individual a choice of a big wound from stem to stern or a small inch-and-a-half wound in the groin, I can tell you what they will choose."
David Waldron, a gastro-intestinal surgeon at the Mid-Western Regional Hospital in Limerick, also cites the advent of stapling as a major change in performing surgery.
"The use of stapling devices, particularly for bowel surgery allows surgeons to get at deeper parts of the pelvis. It makes the surgical procedures less prolonged and easier."
In tandem with the introduction of day-care centres specialising in minor surgical procedures, hospital surgeons tend to specialise in one particular area. "Teams of surgeons in hospitals tend to do the heavy, elective work rather than everyone being a general surgeon."
He says the private sector is leading the way in the development of day-care centres. "Improvements in anaesthetics has been a major move forward to encourage day-care facilities along with better ambulant care.
"You can perform less-aggressive surgery for conditions such as haemorrhoids and hernias which previously would have involved spending up to a week in hospital. Nowadays they are being done with less invasive surgery."