|HEALTH TRIBUNE||Wednesday, April 19, 2000, Chandigarh, India|
|Not just keyhole
By Dr G.R. Verma
If we look back at the spectacular surgical advances of the 20th century, it would be laparoscopic surgery and organ transplantation that would cross our mind first. Laparoscopic surgery, which was once called keyhole surgery, has made rapid strides in every branch of surgery. The biggest advantage for the patient is the psychological boost that he is spared long incisions and the associated pain, anxiety and prolonged hospitalisation. Any surgery inflicts two types of trauma. One is the trauma of access and the other is that of actual operation. Laparoscopic surgery minimises the trauma of access to a great extent.
Not just keyhole
If we look back at the spectacular surgical advances of the 20th century, it would be laparoscopic surgery and organ transplantation that would cross our mind first. Laparoscopic surgery, which was once called keyhole surgery, has made rapid strides in every branch of surgery. The biggest advantage for the patient is the psychological boost that he is spared long incisions and the associated pain, anxiety and prolonged hospitalisation. Any surgery inflicts two types of trauma. One is the trauma of access and the other is that of actual operation. Laparoscopic surgery minimises the trauma of access to a great extent. However the trauma of surgery remains almost the same. To achieve the maximum advantage of this revolutionary surgery one should master the technique of making it safe for the patients.
At present, credentialing in general surgery is relatively simple. The general surgeon is assumed to have acquired knowledge and the operative skill within his speciality during the period of his residential training. All abdominal procedures are performed through more or less similar incisions. The same instruments are used to remove or reconstruct the organs or tissues within the abdominal cavity.
Most new procedures were either new applications of standard surgical techniques or modest technical variations that could be adopted easily. Similarly, the skill in non-surgical advances, e.g. the use of new thrombolytic agents made by heart specialist, can usually be acquired by reading, and attending seminars. They do not require hands-on experience before being incorporated into clinical practice.
The unprecedented publicity generated by the rapid adoption of laparoscopic surgery by surgeons and patients has put a great responsibility on surgeons. Basic and advanced laparoscopic surgical procedures use technology and instruments unfamiliar to most of the practising surgeons who had finished their residency training before 1990.
Laparoscopic surgery can be divided into two categories basic and advanced. Basic laparoscopic procedures are those that require simple dissection or excisional techniques that can be accomplished with the use of scissors, clips electrocautery and staplers. Advanced laparoscopic procedures are more complicated that require the mastery of intra-corporeal/extra-corporeal knot-tying and suturing, mobilising, cutting and suturing the intestine, securing the vascular pedicles and applying intestinal and vascular staples. Therefore, unless the surgeon is well trained, the operation becomes bloody and messy and he has to open the abdomen to complete the operation. Advanced laparoscopic surgery is rather difficult and different from an open operation as well as basic laparoscopy. Currently, other than gallbladder stones, appendix and hernia operations, intra-abdominal surgery is considered to be-advanced laparoscopic procedures.
Adequate education and training in laparoscopic surgery are essential to minimise the learning curve. The preferred method of learning is to assist an experienced surgeon and then perform an operation with the guidance of an expert. The necessary "video-eye-hand" coordination takes some time to master.
A Japanese study has clearly demonstrated that major complications following laparoscopic cholecystectomy were three times more common when the initial training period consisted of only two supervised operations rather than the recommended ten.
A study of laparoscopic urological surgery showed that the urologist who attended only one introductory training course had significantly more complications than those who obtained additional training before performing such operations.
The individuals who perform laparoscopic cholecystectomy should (1) be trained general surgeons with current competence in performing open cholecystectomy and in managing predictable complications of operations (2). They should have expertise in laparoscopy acquired through previous clinical experience or instructions (3). They should also have acquired experience in supervised laparoscopic cholecystectomies.
Technology has allowed the surgeon to incorporate laparoscopic surgery in everyday practice. We could not offer the laparoscopy we use so effectively today without the technology that industry has delivered to us. A product of industrial achievement is the economic impact of laparoscopy. Since we offer this achievement to patients, the definition of the quality and the value must be defined. The value of the procedure can be defined as a quality product provided at a reasonable cost. We can deliver quality only when the procedure is appropriately utilised and the outcome falls within the standardised short and long term results. In other words, the cost of the procedure must be reasonable to achieve the envisaged outcome.
India is a poor country. Most of our patients cannot afford the initial high cost of the operation. But one thing is certain. Once the procedure proves to be valuable, the cost tends to come down because of the competition among the instruments and equipment manufacturers. Realising the future potential of this surgery, many Indian companies have come in the line of competition and provide instruments at an affordable cost. We as surgeons, should also try to bring down the cost by modifying a laparoscopic procedure with innovative ideas to decrease the need for costly equipment and at same time maintain the quality.
Alexander Walt once said that the "industry had allowed us to utilise the advanced technology. But our responsibility with this technology is to avoid gimmicks and provide true quality at a reasonable cost."
The cost/benefit advantage of videolaparoscopy will be continuously evaluated. Industrial competition will allow the cost of instrumentation and technology to decrease further and as the surgeon develops better techniques, hospitalisation, morbidity and mortality will also decrease. The goal continues to remain improved patient-care and safety. The challenge for the future will be to strive for this goal cost-effectively.
The future of laparoscopic surgery is exciting. Despite the prediction that in the next 25 years conventional major abdominal surgeries will be nearly extinct, the author believes that certain diseases and most of the abdominal emergencies would warrant open abdominal operation.
The surgeon must understand the limitations of this technology and, of course, his own dexterity before embarking on this challenging venture to avoid complications. If laparoscopic cholecystectomy is associated with a higher incidence of complications than traditional cholecystectomy, its promise of decreasing pain, disability and cost will be unfulfilled. The practising general surgeon should learn laparoscopic techniques because much of the future abdominal surgery will ultimately reside in applying "less invasive" methods.
In the practice of this innovative surgery, there are diverse physical and psychological abilities among individual surgeons. Differences exist in the steadiness of the hand, agility, rapidity, preferences and surgical knowledge. Moreover the performance of the surgeon may vary during the course of a given procedure. Studies have demonstrated that surgical complications decrease with experience. But no data exist to assess the effects of the individual differences on the ultimate patient results. These factors may account for the deviations noted when comparing the surgical outcome with different clinicians.
Robotic assistance for laparoscopic surgery has dramatically grown in the last five years. The most recent advances in robotic technology have made it possible for us to simultaneously manipulate the camera and a variety of instruments, enabling the full robotic assistance to perform different types of procedures. Many industries have realised the advantages of using an untiring, efficient and precise machine (robot). Automated systems would be advantageous in performing manoeuvres that require a high degree of precision or are repetitive and tedious. The robotic laparoscopic camera maintains the surgical point of interest in the centre of the video frame, provides the required target magnification by moving in and out of the abdominal cavity and acts automatically, modulated by vocal orders from the surgeons. The camera has been successfully used in human laparoscopic cholecystectomy. It also replaces assistants during surgery.
Besides the camera now even the laparoscopic tools have been robotised to simulate the hand movements inside the abdomen. One such invention is Endohand. It is a miniature three-fingered hand that is controlled by direct mechanical linkage to the silicon glove interface with the surgeon's thumb, index and middle fingers. The surgeon's fingers control the three fingers like prongs of Endohand inside the abdomen. A second version of Endohand has also been developed. It is controlled through a computer interface. The operator wears the glove, which is connected to a computer rather than directly to the effecter hand. A second computer is connected to a motorised drive unit, which moves the effecter hand as directed by the remote glove interface.
With the development of the latest generations of robotics and with the addition of information technology it is possible to operate in any corner of the world while sitting at one place. This type of surgery is called telesurgery.
Depending on the sophistication, various terms are used for this type of surgery (1) Teleoperation: It is a process of remote manipulation with one-to-one master (surgeon)-slave (robot) relationship under the direct control of the master. (2) Telepresence surgery: Once again it is remote manipulation with one-to-one master-slave relationship but with so much additional inputs (such as 3-D vision, stereophonic sound, tactile and force feedback) that an illusion is created of actually being at the remote site. (3). Telerobotics: It is a manipulation where the slave manipulator (robot) has "intelligence" and acts on it's own while the master (surgeon) performs a supervisory role.
Science has opened opportunities for further research. It is a continuous and ongoing process. There exists a wide gap between what we practise and what may be achieved with the incorporation of the latest know-how. A surgeon has to maintain a pragmatic and unbiased evaluation of the new technology. He should not be vulnerable to the strong pressure exerted by instrument manufacturers. These persons try to convince one that every new invention in the field of laparoscopic surgery is unique and beneficial to the patient. Clinical objectivity and professional independence must be maintained. The purpose of any new technology is not to satisfy the marketing needs of the industry but to ensure that it improves the patient's safety and has as its primary objective the patient's interest and cost-effectiveness.
Hair tends to be the body's indicator of good health or the lack of it. It can be beautiful and healthy only when it is maintained in good condition.
Hair types: Basically there are three types of hair: Oily, dry and normal.
Oily hair: When the sebaceous glands (oil glands) secrete excess oil, it travels down the hair shaft, which appears lank, dark and coarse.
Dry hair: Dry hair is the result of a lack of sebum (oil) on the hair, causing it to dry out. The hair looks limp, becomes less elastic and is prone to breakage.
Normal hair: It is healthy and silky without over-dry ends or over-oily roots.
Each hair is made of keratin, a protein substance growing out of follicles or pores in the scalp. That is why good circulation in the scalp is essential for healthy hair. The life span of each hair can vary from a few months to several years. Losing 60 to 80 shafts of hair daily is normal. On the healthy head new hair is growing all the time unless there is some deficiency in diet, ill health, hormonal imbalance and inadequate blood supply to the scalp. Each hair shaft lives up to four years and can grow again and again for 25 years. Hair grows at the rate of one to 1.5 cm every month. It is, therefore, a myth that hair stops growing after 21 years of age.
Shampooing and conditioning are the only treatment your hair cannot do without. The right shampoo for the right type of hair has to be chosen carefully.
Lemon shampoos: They contain citric acid and are ideal for oily hair.
Egg shampoos: They contain lecithin and are good for damaged hair.
Oil-based shampoos: These are useful for dry hair.
Conditioning shampoos: These contain lanolin. They are good for excessively dry hair.
Herbal shampoos: They contain amla, ritha, shikakai, aloevera, commomile and methi-good for all types of hair.
Dandruff shampoos: They contain precipitated sulphur, salicylic acid, selenium, cetavelon, pyrithione and ketoconazole.
Henna shampoos: They have a lightening effect on the hair.
Balsam shampoos: They contain gums and resins which coat the hair shafts and give them a shine and gloss.
Hair loss: A variety of conditions such as pregnancy, delivery, fever of long duration (especially typhoid), emotional tension, drug intake (especially anti-cancer drugs) and surgical procedures can lead to hair loss. This does not require any treatment except reassurance.
Androgenic alopecia: This type of alopecia is inherited and dependent upon androgenic hormones. Newer anti-androgen drugs are effective but if they fail, hair transplantation is the only answer.
Alopecia areata: This is common in children and young adults and manifests as patchy loss of hair. The disease can lead to diffuse hair loss not only from the scalp but also from the eyebrows, eyelashes even the whole body.
Alopecia senilis: It is the permanent loss of hair due to old age.
Hair styles: A hairstyle should determine and emphasise the individual features of a person and at the same time comouflage any imbalance of features. The shape of the face and head, the texture and density of the hair, and the height and weight of a person are all important factors to consider while choosing a hair style.
Square face: It has a straight hairline and a square jawline. To give softness to the sharp angles and contours, a tapered cut and the hair flowing down the jawline will be suitable.
Round face: Haircuts that give length and flow downwards in curves suit a chubby face. The hair on the forehead should not be pulled back. A few strands coming down the sides of the face or a fringe will look good.
Pear-shaped face: It has a narrow forehead and a broad jaw and chin. Here the forehead should be exposed and the hair should be swept back on the sides of the forehead.
Heart-shaped face: It is the other way, a narrow chin or jaw and a wide forehead. There should be more volume of the hair on the neck and around the jawline and the chin area.
Oblong face: For an unusually long face, straight slim hair lines should be avoided. Fringes and flicks on the forehead soften the look.
Spindle face: It has a narrow forehead as well as a narrow chin and jawline. Here the forehead has to be framed with a sufficient volume of hair while doing the same at the chin with the hair flat on the sides of the cheek.
Hair colours: Hair colouring has become the need of all age groups. Black is no longer beautiful. People demand more natural shades of brown or dark brown with those shimmering streaks or highlights a little here and there.
Temporary colours: Hair sprays and colour mascaras are sprayed on or brushed into the hair for temporary effect. These are popular gimmicks at modelling and photo stints. Temporary colours are quick and easy and can be shampooed easily from the hair.
Semi-permanent colours: These colours last through four to six shampoos before they are gradually removed from the hair. These colours blend grey hair with natural hair easily and are the first step before a permanent colouring.
Permanent colours: They remain permanent till the hair grows out. Almost any shade desired can be achieved with a permanent colour.
Vegetable tints: They are obtained from plants such as henna, amla, sage etc. These colours penetrate into the cortex and build upon the hair so much that they preclude any other chemical tinting.
Metallic tints: Lead, silver and copper are the commonly used metals which should not be used because of the severity of the damage they do to the hair.
Oxidation tints: They are aniline derivatives and can lighten the colour of the hair and deposit colour at the same time. Almost any natural colour can be duplicated and 100 per cent grey coverage can be achieved.
Hair perms: This is a process of forming curls. They have been in great demand ever! The process is fairly time-consuming and expensive. Increasing the volume of hair is another reason why perms are done. Curly hair appears to be more dense. The regular oiling of the hair before shampooing and later on a good moisturising conditioner take care of the drying effect this treatment leaves on one's hair.
Hair food: Healthy and glossy hair depends on a wholesome and nutritious diet. Since hair is made from a form of protein, a protein rich diet can help it grow strong and healthy. Vitamin B-complex is very important.
Tooth and truth
What is a root canal? starting with the tooth in general, the outermost layer is the enamel, which overlaps the dentine. Underneath your tooth's outer enamel and within the dentin is an area of soft tissue called the pulp, which carries the tooth's nerves, veins, arteries and lymph vessels. Root canals are very small and thin divisions that branch off from the top pulp chamber down to the tip of the root. A tooth has at least one but not more than four root canals.
Toothache: When the pulp becomes infected because of a deep cavity or fracture that allows bacteria to seep in, or there is an injury due to trauma, it can die. Damaged or dead pulp causes increased blood flow and cellular activity, and pressure cannot be relieved from inside the tooth. Pain in the tooth is commonly felt when biting down, chewing on it and applying hot or cold food and drink.The therapy : The tooth does not heal by itself. Without treatment, the infection spreads. The bone around the tooth begins to degenerate, and the tooth may fall. Pain usually worsens until one is forced to seek emergency dental attention. The alternative usually is the extraction of the tooth, which can cause the surrounding teeth to shift crookedly, resulting in a bad bite. Though an extraction is cheaper, the space left behind requires an implant or a bridge, which can be more expensive than root canal therapy. If you have the choice, it is always good to keep your original teeth.
After the tests: After your dentist performs tests on the tooth and recommends therapy, he starts the treatment. It usually involves three to four appointments. First, you are given a local anaesthetic to numb the area. Then an opening is made from the crown into the pulp chamber, which, along with any infected root canal, is cleaned of all diseased pulp and reshaped. Medication may be inserted into the area to fight the bacteria. Depending on the condition of the tooth, the crown may then be sealed temporarily to guard against recontamination, or the tooth may be left open to drain. If you are given a temporary filling, usually after two visits, it is removed and the pulp chamber and canal(s) are filled with rubber-like gutta percha or another material to prevent recontamination. If the tooth is still weak, a metal post may be inserted above the canal filling to reinforce the tooth. Once filled, the area is permanently sealed. Finally, a crown is normally placed over the tooth to strengthen its structure and improve the appearance.
Risks and complications: More than 95 per cent of the root canal treatment is successful. However, sometimes a case needs to be redone owing to the persisting diseased canal offshoots. This rarely occurs.
After the treatment: The natural tissue inflammation may cause discomfort for a few days, which can be controlled by an over-the-counter analgesic. A follow-up examination can monitor tissue healing. From this point, you should brush and floss regularly, avoid chewing hard food on the treated tooth and see your dentist regularly.
Dr Ashish Sharma gives free consultation to the poor and the needy every Sunday at SCO 827, Sector 22-A, Chandigarh.