From: Vijay C.Bose

Sent: Friday, January 20, 2006 10:01 AM
To: Vicky Marlow
Subject: Re: Incision

Hi Vicky ,
Thanks for the mail. All your queries are very relevant and
I am happy that you have raised them…

Yes, it is true that Minimally invasive approach has been
proven not to have great benefits over a conventional
incision in terms of blood loss, pain , or speed of recovery
in the same surgeons hands. It is only of cosmetic value.
All studies to investigate this have been done on two groups
of patients in which a single surgeon employs the two
approaches in the diff groups.
When a surgeon who is capable of doing a minimally invasive
approach does a conventional approach it is logical that the
conventional technique will be only marginally bigger and
therefore advantages do not show up in studies. However if a
minimally invasive approach of a surgeon is compared with a
conventional approach of another surgeon who never does
minimally invasive or never makes an attempt to reduce his
incision size (within comfort levels)- the differences will
show up.

When one compares an incision which is 5 cms for a particular
procedure with another which is 50 cms for the same
procedure – the differences will show up without any doubt.

However to see objective difference between an incision
which is 5 cms and 8 cms it is difficult This is a question
of degree.MIS approach has been accused to be just a marketing trick
which has caused more harm than good. This is true in many
instances however one must be careful not to confuse MIS
surgery with the concept of minimizing incision size.

When surgeons are focused on doing a surgery with a pre-
determined incision size like say 10 cms – they are hell
bent on doing this through this incision even though they
are struggling and probably getting many things wrong in the
deep bone work. This is certainly not good. Scientific
papers enumerating surgical disasters when this is employed
is common place.

The other side of the coin is when surgeons chop up patients
to extraordinary lengths. Certainly it is equally wrong to
cut up tissues unnecessarily when the same can be
accomplished to the same degree of accuracy by employing a
much smaller incision. In other words it is certainly the
duty of the surgeon to minimize the length of incision of
any elective procedure but ensuring that he is comfortable
and deep bony work is not compromised in any way. There
should not be any predetermined length but the surgeon must
consciously reduce incision size as a guiding principle.
Undoubtedly a hip incision that goes all the way to the knee
will have many other bad effects apart from the scar.Therefore there is no doubt that surgeons must be constantly
striving to reduce incision size without compromising any
other factor. However trying to work with a pre-determined
incision size is frequently a recipe for disaster. It is
also well accepted that revolutionary techniques like the
two incision technique for THR in which the surgeons previous
experience with THR is rendered completely useless is very
risky when compared evolutionary techniques in which
surgeons reduce incision size progressively.

Surgical speed is another interesting topic. The fastest
hand that i have seen wield the scalpel in undoubtedly Ronan
Treacy who can finish a resurfacing in 20-25 mts. However
Mr. McMInn who invented resurfacing and who of course trained
Mr. Treacy still takes close to two hours. The turnover time
will be 3 hrs.
I still take close to two hrs for a resurfacing with a
turnover time of 3 hrs. There are so many steps and no
matter how fast you do them it takes that amount of time to
do all the steps. The neck capsule preservation that i do
takes extra time as well. Attempting to reduce incision size
and using subcuticular absorbable stitches all add up the
time taken for surgery. If I don’t do all these I probably
can finish in an hour.
If I should finish a resurfacing within half an hour there
is no doubt I will be skipping steps.

I have now done more than 500 resurfacings.
I have had two failures so far. One was due to deep
infection and the other was to head collapse which led to
the development of the neck capsule approach.

If you have any further queries , please do write to me.
wishing you the very best

Dr. Vijay C. Bose
Consultant Orthopaedic Surgeon
Chennai, India