Minimal Access Laparoscopic Surgery
Ever since laparoscopic surgery emerged nearly two decades ago, patient demand for minimally invasive procedures has soared. As miniaturized instrumentation has been refined, minimal access techniques have gradually replaced many traditional surgical protocols.
“We have reached the point that we perform almost every operation laparoscopically,” said Alfredo Carbonell, D.O., FACS, FACOS, a surgeon with Prisma Health Minimally Invasive Surgery division.
“There is no question that operating through smaller incisions results in less morbidity, decreased length of stay, quicker recovery and lower costs. And there are additional advantages unique to each procedure.”
Alfredo Carbonell, D.O., FACS, FACOS
Interest in minimally invasive surgery has given rise to more fellowship programs. Fellows must perform a sufficient number of minimal access surgical cases to ensure their outcomes are equal to those of open procedures. The Prisma Health multispecialty physician group practice, has three fellowship-trained minimally invasive surgeons – Alfredo Carbonell, D.O., FACS, FACOS; William Cobb, M.D., FACS; and John Scott, M.D.
“When we look at a problem, the first thing we think about is how it can be done through small incisions while preserving the tenets of open surgery,” said Dr. Cobb. This commitment to high-level care using minimally invasive laparoscopic surgery techniques draws patients to Prisma Health from Greenville, Asheville, Columbia, and areas throughout the Southeast.
Most general surgeons gain adequate training during their residency to perform basic laparoscopic surgery procedures, such as removal of the gallbladder or appendix. To sufficiently gain skills in the techniques of more advanced procedures, surgeons should be additionally trained in these techniques. This training is usually attained either through self instruction over time or, more effectively, with a dedicated training program after general surgery residency that focuses on the techniques of advanced laparoscopic procedures to include hernia repair, surgery for reflux disease, and removal of solid organs (spleen, adrenal, and kidney).
Within the Division of Minimally Invasive Surgery, there are three surgeons who have completed fellowships in advanced laparoscopic surgery. Additionally, the division provides a fellowship training program for surgeons who have finished general surgery training. Our fellowship program is the first and only training program of its kind in the state of South Carolina.
Gynecologists were the first to use laparoscopic surgery. General surgeons quickly seized on the technique for use in cholecystectomy. Today, Nissen fundoplication, gastric and colon resections, solid organ retrieval and repair of paraesophageal, ventral, incisional and inguinal hernias can be performed laparoscopically.
Patients with hernias can undergo laparoscopic repair at The Hernia Center. “Whether the hernia is large, complex, occurs in a large patient or has recurred multiple times, we offer a protocolized approach using outcomes data for how the hernia should be managed,” Dr. Cobb remarked.
This minimally invasive surgery approach requires four incisions of five millimeters. In addition to providing less postoperative pain and quicker recovery, laparoscopic hernia repair greatly reduces the risk that the mesh used for the repairs will become infected.
Moving Tradition Aside
Within weeks of Dr. Carbonell’s arrival at Prisma Health in fall 2007, he began performing innovative minimal access procedures on the pancreas and stomach. For pancreatic surgery, he can access, drain and debride diseased or dead tissue through two small holes in the flank. He also can laparoscopically resect the pancreas as well as gastric stromal tumors.
“Stromal tumors contained in the stomach are ideal for a laparoscopic approach – the procedure requires only one or two nights in the hospital,” said Dr. Cobb, who has helped publish the medical community’s largest series of cases on stromal tumors that have been resected laparoscopically.
Drs. Carbonell and Cobb collaborated with urologists at Prisma Health to develop minimally invasive approaches for partial and total nephrectomy and laparoscopic cryotherapy for renal cell carcinoma. The minimal access surgeons and urologists found that by performing these surgeries as a team, they could help reduce complications.
“Minimal access surgery has become our standard of care for solitary renal masses,” said Dr. Cobb. “Blood loss is minimal, and the conversion rate to open surgery is less than 2 percent when we assist urology.”
Together the surgeons have published more than 60 articles, primarily on laparoscopic treatment of advanced hernia disease and gastrointestinal surgery.
New Facilities for a New Approach
Laparoscopic surgery is highly dependent on technology, and with 29 minimally invasive surgery suites, Prisma Health’ facilities are leading the way in Greenville, Asheville, Columbia, and throughout the region. In a typical procedure, large, crystal- clear images of the inside of the abdomen display on high-definition, flat-screen monitors visible to everyone in the OR.
“It is better than open surgery because the images are magnified and in high definition,” stated Dr. Carbonell. “It affords a view we could never have had before.”
X-ray images display on a screen adjacent to the laparoscopic images. This practice aids in teaching as well as patient care and safety. All Prisma Health surgical residents rotate through the Minimally Invasive & Bariatric Surgery division, and chief residents spend three months exclusively with Drs. Carbonell and Cobb.