5/1/08

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 is undoubtedly Ronan Treacy who can
finish a resurfacing in 20-25 minutes. 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.

Vijay Bose.
Consultant Orthopaedic Surgeon
Apollo Hospital
chennai

www.hipresurfacingindia.com