December 29, 2008 

During the second half of my surgical internship, I was assigned to the VA Hospital in Richmond. At that time, and it probably hasn’t changed, everyone wanted to go to the VA because you got to do surgeries that were way beyond your usual fare. As an intern, I got to do surgeries that I normally wouldn’t be given to do for at least another two years, or so, at the regular hospitals. 
 
When you think about it, that’s really unfair to the vets. I mean, here are guys that have sacrificed for their country and here they’re being used as guinea pigs for some young punks looking to learn surgery. But, of course, at that time, all I cared about was doing more surgery. The fairness of the situation never even entered my mind–that’s just the way things were.
 
Anyway, one of the patients on my ward was a guy who had been operated on by every house officer who had rotated through that surgical service since he had been admitted over three years before. The guy was an old man, a real basket case. 
 
He couldn’t even eat because he had NO intestines left. He was fed through a vein, by I.V. hyperalimentation–a very fancy term for total parenteral (by vein) nutrition. Every few weeks or months, he would develop some complication or another that required another surgery. There was hardly anything left of him, but he kept on chuggin’ along, educating generations of interns.
 
Then, one of the residents told me how he came to be like this and my blood just froze. You see, he originally came in for a “minor surgery.” He was just supposed to have a simple bunionectomy. But, hard luck guy that he proved to be, it got infected.
 
So he got a second surgery to drain the infection. And I.V. antibiotics, of course. But, the surgical site turned into osteomyelitis–bone infection. And of course, this required another surgery.
 
Then, he needed a toe amputation. Then another. Then, his veins clotted up, so he needed a central I.V. line, for long term antibiotics. Which also got infected and needed removal. And a new central line. Then, one day, he got horrible stomach pains, which required a full work up. Turns out he had now developed a real problem: mesenteric embolism — a shower of clots that blocked off the arteries which feed the intestines. Without blood, the intestines literally die and develop gangrene. Which requires their removal. Naturally, you try to leave what you think will live and only remove the dead or dying tissues.
 
But the same thing happened again. And again. Each time, taking more and more of the man’s intestines, until finally, he had nothing left. By the time I showed up, he was The “Phantom” of the V.A.–a shell of his former self–quite literally.
 
And then he got really sick and resistant to the antibiotics. Turns out he had developed a subphrenic abcess (a big infected collection of pus, under the liver) and it was my job to take him to the OR and drain this mess. Which I did. If that didn’t gross me out, nothing ever would again.
 
Well, he rallied, but eventually it was just too much for the poor man. He died. Finally at peace. I came upon him one morning, while making rounds, already cold. And I also noted that he had perfect vital signs charted, right up until 8AM, when I found him. Hmmmmm…Guess the VA night nurses were too busy with other things to notice that this patient had passed on. 
 
I was sent to the autopsy, to learn what had finally gotten him. And I was shocked to see that when they opened him up, there was almost nothing left–he was like a used up, empty shell. Cause of death? Organ failure–take your pick. Poor guy. No one deserves this.
 
And I reflected, not for the first or last time, that our bodies were merely machines, shells driven by an animating spirit and that whatever made us “us,” the soul, if you will, was long gone from him. 
 
The horror of all this is that it started with a “minor surgery,” a “simple procedure.” And like that poem, “For Want of a Nail, the Kingdom Was Lost,” one thing led to another, and another, until the final, pathetic denouement.
 
Lessons learned here? 1. Ain’t no such thing as a “minor surgery” (only minor surgeons). 2. “One never knows, do one?” 3. Murphy is always waiting. 4. Whenever possible, avoid surgery…and you avoid its complications.
 
And after a lifetime in the OR, I’ve distilled the lessons I’ve learned in my newest healing program, HOW TO AVOID KNEE SURGERY, which you can get here at   http://drbillsclinic.com/avoid_knee_surgery.html
 
Think you need surgery if you have a torn meniscus?  Maybe you do. But then again, maybe some of the tips I teach you in this program can relieve your pain, but keep you out of the O.R. See for yourself, at  http://drbillsclinic.com/avoid_knee_surgery.html
 
Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved

I was in my study this morning, reviewing some of the articles in my inbox on orthopaedic problems and knee pain, when I came across an article in the October 14th Wall Street Journal by Thomas H. Burton. He was writing about one of the latest trends in arthritis surgery of the joints, called minimally invasive surgery, often referred to as an acronym — MIS.
 
Like the name suggests, this is a technique in which prosthetic joint replacement, mainly of the hip and the knee, is performed through a smaller (shorter) incision than normal. This means that sometimes the incision is much shorter, like only 3 to 4 inches, when the normal length may be as much as 8-12 inches, usually depending on the weight of the patient–fatter people need longer incisions (a hole has to be bigger at the top than the bottom and the fatter a person is, the deeper the hole is going to be).
 
The theory is that a smaller incision maintains the integrity of the big muscles around the joint and allows for less pain, faster healing and quicker return to full function. But here’s the problem. Because of the more limited vision into the joints allowed by the smaller incisions, the chance of complications is higher, sometimes much higher, than with more traditional approaches. It makes sense if you think about it.
 
In this respect, a MIS is as good as a mile;-) While it is true that a perfectly done MIS can heal faster, with less tissue damage, the poor visualization it affords the surgeon makes its risks much higher. So, is it worth it? Well, yes and no.
 
Yes, but only if you can find a very experienced surgeon in the technique. Total hip and knee replacements are highly technique-dependent surgeries. That means that the best results tend to come from the best trained, most experienced surgeons. This is even more true for the MIS.

No, because if you don’t get one of those best trained, most experienced surgeons, then your risks of complications is greatly increased. These would include soft tissue injuries, from stretching the smaller incision so the surgeon can see; incorrect bone cuts with incorrect angles, simply because the surgeon just can’t see enough of the bones to make accurate cuts; debris left in the joint, because the small incision obscures the joint so the surgeon can’t see to remove it. Also included are fractures of the bones, when attempting to impact the implants into place, malposition of the implants, often leading to dislocations, or joint instablity; and nerve injuries from traction, again in an attempt to see better through the small incision.
 
As you can see, the trade off is a chance for faster healing versus higher risks for multiple complications. All of these, the good and the bad, are a consequence of the smaller incision.
 
Funny thing is, my teachers always said to make a larger incision, because 1. you can see what you’re doing and all the anatomy and 2. there is less tension and therefore less trauma to the tissues, less edema (swelling) and 3. you can see and stop any bleeding blood vessels (“It heals from side to side, not end to end...”). 
 
But the MIS is in vogue right now–despite NO long term evidence that its results are as good as standard surgical approaches. You didn’t know that there are actual fashions in surgery? Oh, yes. Very much so. 
 
I’ve seen this before. At first, there’s a rush of enthusiasm and the public (who only know about the supposed benefits) DEMAND the new, in vogue procedure. Then, as its indications are expanded and surgeons, who are NOT as experienced, feel pressured to do the new procedure (or risk losing patients), the complications begin to emerge. As the problems begin to mount, and some true disasters are reported, the enthusiasm wanes and finally everyone goes back to the traditional approaches, or at least modifies the indications for the “new” technique.
 
As if you needed another reason to stay OUT of the operating room…. Or, you can try one of a number of proven, reliable, simple, non-surgical treatments that can help you AVOID SURGERY. It’s your choice. There are lots of cases in which surgery is UNNECESSARY. You lose nothing by trying one of the conservative, non-operative treatments I teach in HOW TO AVOID KNEE SURGERY. See it here at http://drbillsclinic.com/avoid_knee_surgery.html
 
If you want to see treatments to relieve knee pain and specially modified exercises to restore function, using conventional, alternative and complimentary methods from across the entire medical spectrum, go NOW to http://drbillsclinic.com/avoid_knee_surgery.html
 
Til next time, my friend, be well.
 
Yours for a pain-free tomorrow,
 
Dr. Bill 
 
P.S. For DR. BILL’S LITTLE GREEN BOOK ON ELIMINATING KNEE PAIN, a concise, but complete handbook on the root causes and the various options for treating knee pain, go to http://drbillsclinic.com/eliminate_knee_pain.html
 
P.P.S. For DR. BILL’S PAIN-FREE PROGRAM: EXERCISES TO PREVENT OR ELIMINATE KNEE PAIN, please go to
 http://drbillsclinic.com/exercise_eliminate.html
 
P.P.P.S. For the giant, comprehensive ADVANCED MASTERS’ COURSE: HOW TO ELIMINATE KNEE PAIN–ONCE & FOR ALL!, everything you need to know on causes and solutions for knee pain and the complete exercise program, too, go to
 http://drbillsclinic.com/advanced_masters.html
 
FREE BONUS CD with any order: THE HEALING POWER OF POSITIVE PAIN PERCEPTION
 
Copyright, 2008 by William Thomas Stillwell, MD
All rights reserved