Surgery choices

September 15, 2006 3:16 PM

Which surgery would you have?

So you have a medical problem that is painful, not immediately life threatening, and requires surgery. The doctor recommends you choose between three procedures.

1. Minimally invasive procedure (MIP). Your abdomen does not have to be cut open.
Length of operation: <1 hour. hospital stay: 1 day. time for return to full activity: 2-3 weeks . probability of success: 75%. 2. laparoscopic invasive procedure (lip). your abdomen receives several small incisions for the insertion of small instruments. length of operation: 4-5 hours. hospital stay: 2-3 days. time for return to full activity: 3-4 weeks. probability of success: 90-95%. 3. really invasive procedure (rip). your abdomen receives a long incision for full open surgery. length of operation: 1 hour. hospital stay: 3-5 days. time for return to full activity: 4-6 weeks. probability of success: 95%. all three options require general anesthesia. should procedure fail, another can be tried later: having the mip now doesn't preclude future rip. font size=2>(If you really want to know, the surgery is for a urological problem called UPJ obstruction and the surgery options are endocscopic pyelotomy, laproscopic pyeloplasty, and open pyeloplasty. But I'm not looking for specific medical advice on these particular surgeries so much as how people think about the balance between invasiveness and success rate.)

Which surgery would you choose, and why?

posted by betterton to health & fitness (25 comments total)

The more invasive the better. I may be biased from a bad experience with laparoscopic to remove my appendics, instead of the traditional way.
posted by Chessbum at 3:23 PM on September 15, 2006

If it's not life-threatening, then start low and work your way up. There's no reason to cause yourself more grief than necessary.

On the other hand, if it was something like an appendix (like Chessbum's) or cancer, or something. I'd get the procedure with the highest success rate, regardless of how much pain and suffering.

Additionally, if doing the low procedure precluded me from having more invasive procedures, I'd probably also go with the one with the highest success rate.
posted by unexpected at 3:28 PM on September 15, 2006

I had the opposite experience than chessbum.

I had a laparoscopic appendectomy last year.

I only had to spend one evening in the hospital, walked out on my own accord the next day and had a quick recovery -- a few days.
posted by ericb at 3:28 PM on September 15, 2006

I say the least invasive the better. I've had successful endoscopic and laproscopic procedures without any complications. Why be cut open if you don't need to be? And it sounds like the probability for success with open pyeloplasty isn't much greater, if at all, than the with the laproscopic pyeloplasty.

Does your doctor recommend one of these procedures over the other?
posted by curie at 3:34 PM on September 15, 2006

Laparoscopic surgery rocks! After a g.i. procedure I woke up with three band-aids on my tummy and almost no pain. Lap appendectomy is a bit more involved (gotta make one of the holes big enough to take something out!). Avoid full incision invasive abdominal procedures if you can- complications later in life can include adhesions & hernias- yuck!
posted by squalor at 3:35 PM on September 15, 2006

You're getting general either way, and that's the suckiest (and most dangerous) thing about any surgery. If you go with LIP, success depends on how frequently your MD has done the procedure -- if they're a recognized whiz at it, then your % will go up (this is true of any laparoscopy -- the more you do it, the better you get at it, like Donkey Kong). A good laparoscopy beats open surgery any day, but only if the doc knows what he/she's doing. Adhesions may be a problem, though, so it also depends on what else you got going on down in those parts. The lower innards are notorious for forming sticky growths.

Fyi, I come from a long line of country doctors (I am NOT one, however), and unlike Chessbum, the mantra in these parts is the less invasive, the better. Always.
posted by turducken at 3:36 PM on September 15, 2006

curie: The doctor has not made a recommendation, and wants me to choose. I am getting a second opinion for more information.

turducken: The surgeon is experience in laparoscopic procedure.

And Argh: the formatting of my very long question somehow got all messed up, though it looked ok on preview. I apologize for the lameness.
posted by betterton at 3:41 PM on September 15, 2006

What does experience mean--there is a difference between 10 and 200--if his experience warrants it I would go with the MIP Best Wishes
posted by rmhsinc at 3:46 PM on September 15, 2006

I say go for #3. While there is a risk of problems in any surgery, I
I'm willing to bet that the chances of the doctors botching the job and making you worse is still significantly less than 5%. So your concern should be about increasing the odds that your surgery is successful, not decreasing the odds of surgical complications. And you can take further comfort from the fact that option #3 actually makes a second or third surgery less likely.

I admit to being one of those people who is not afraid of doctors at all (and I have had at least four surgeries under general anaesthesia). That said, I think it's annoying and stupid that yours won't make a recommendation.
posted by bingo at 3:53 PM on September 15, 2006

I don't think this question can be answered without knowing the odds of each procedure making things worse.

Assuming each procedure is perfectly safe even if unsuccessful, then obviously run the gamut from least to most invasive.

In the real world... hell, I'd still go for option 1. But I'm not worried about general anaesthetic.
posted by Leon at 4:06 PM on September 15, 2006

In this sort of situation, I usually ask the doctor "If you were in my situation, which would you choose?", although if you don't have a good relationship with your doctor he may be tempted to just say the one which has the best chance of success regardless of the severity of the operation.

I would say that #2 maximises the chance of success while minimising the recovery time and scarring.
posted by tomble at 4:11 PM on September 15, 2006

I gotta agree that laparoscopic surgery rocks!

I had my gallbladder removed that way, didn't even have to spend the night at the hospital (released a few hours later as an out patient) and the recovery time was so much less (and easier) than if I would have had to be cut wide open. Three tiny scars are also a lot less to deal with than the huge one a big incision will leave behind.

If your doctor is qualified for laparoscopy and that procedure is appropriate for what you need done, I'm not sure why the more invasive technique would even be an option. If your doc is confident that laparoscopy would do the trick, that will be the far easier choice for you as far as healing and recovery go.
posted by RoseovSharon at 4:21 PM on September 15, 2006

Hi:

Time for some arbitrary math!

For each procedure, assign invasiveness, success rate and recovery time to integers on a scale from 1 to 10, with 1 denoting "best outcome" and 10 denoting "worst outcome".

That is, for "recovery time", something with a long recovery time will have a value closer to 10 than 1. For success rate, something with a high success rate will have a value closer to 1 than 10.

Multiply

I * SR * RT

You can simply do the straight multiplication, and choose the procedure for which the result is closest to 1, or you can also consider the following:

• The more invasive the surgical procedure, the greater the chance of an increased recovery time. The body reacts poorly to invasion, regardless of the mitigation, and every cut counts. The small incision through which a laparascope is inserted is markedly less traumatic to the body than a major incision that must be retracted.
• Surgery is trauma. Controlled trauma, but trauma nonetheless. The more invasive the surgery, the more you are subjecting the body to traumatic experience.
• The skill and experience level of the surgeon are directly relevant to the traumatic level of the surgery. More experienced surgeons do more with less: they cut less, they manipulate less, and they work in smaller spaces than less experienced surgeons.
• General anesthesia affects the body more greatly with age. I am much less able to bounce back from general anesthesia at 34 than I was at 19.
• Any abdominal surgery is going to sideline you for a while: the abdominal muscles are core muscles for such prosaic activities as sitting, laughing, rolling over, and so forth. You will have to take it easy no matter what's done, but you may want to consider the difference in recovery time in terms of "it'll be X weeks before I can laugh or cough".

Hope this helps.
posted by scrump at 4:34 PM on September 15, 2006

You haven't mentioned insurance. Does your carrier cover all three procedures, and to the same extent?

turducken and scrump mentioned anesthesia; a very good point to raise. Is the minimal procedure (#1) necessarily under general? If it could be a local, that might be a factor in its favor. Otherwise, tomble's reasoning mirrors my thinking, were I in your situation.

Good luck, whichever door you choose!
posted by rob511 at 5:07 PM on September 15, 2006

Are you prone to scarring and inflamation? Discuss this with the surgeon. If you are I would go the minimally invasive route. Adhesions are related and you want to do everything possible to reduce them if you are prone.
posted by caddis at 5:35 PM on September 15, 2006

You've consulted with your doctor, but what does the surgeon say? What has she or he had the best results with and recommend? I imagine I'd trust their word . . . there's a tendency among cutters to be a bit odd, but there's at least an equally strong one to seriously know their stuff.
posted by tellumo at 6:07 PM on September 15, 2006

I would take #2 the LIP. Highest odds with least amount of invasion and recovery. I am assuming that failure just means no success and that no damage is done during procedure that cannot be reversed.
posted by JohnnyGunn at 6:52 PM on September 15, 2006

I had a laproscopic procedure and was up and around (albeit moving slowly) within a couple of days. The same procedure, full-on invasive mode, would have left me in hospital for a week. No complaints from me.
posted by SPrintF at 8:19 PM on September 15, 2006

I think this "probability of success" metric is far too simplistic, and potentially misleading.

Check out my answer to Should I get chemo? No one has addressed my point there yet, and I might be totally missing something..

I'm tempted to discount the success rate numbers completely. Are those numbers pulled from a posterior, or are they documented in medical journals, etc. etc.

I think the "which would you choose question", followed up with a very thorough examination of the surgeon's real life experience (how many times, but also how many times in the last 6 or 12 months).

Of course I'm a medical sceptic who hasn't personally faced this kind of question, which is making me seriously consider deleting this whole response..

too late...
posted by Chuckles at 10:57 PM on September 15, 2006

Having just gone through one of the 'superbug' infections after a relatively minor surgery (partial thyroidectomy), I would go for the one with the highest success rate. No sense risking other side effects by having to do multiple procedures.
posted by Kickstart70 at 11:16 PM on September 15, 2006

If you're in Canada, you have the (however imperfect) Hospital Morbidity Database as a guide. In the U.S., you have nothing but your doctor's idea of "statistics," and maybe a second opinion, and your dedication to prayer to guide you.

The U.S. healthcare "system," if such a joke as that can be promulgated straight faced, has fought tooth and nail, quite successfully, to avoid the creation of any kind of nationwide statistical collection and publication of morbidity data, which would be of any use to layman in pre-procedure decision making. If you are a patient headed to a U.S. hospital, it is practically impossible as a laymen to find out if you are going to a surgical butcher shop, or a capable place. What you get instead is the kind of self-serving drivel the Queens Hospital of New York published recently, which took a total of 5 (yeah, five!) procedures, over a six year term, all selected by the hospital, to cite against statistics reported for cardiac procedures by the New York State Department of Health. At best, it's a PR piece, but mainly, it's just a stupid administrative defense that will be cited before some lame legislative committee, the next time "quality assurance in health care" is an item on some legislative committee's agenda.

They're planning to cut you, and bill big bucks to your insurance company. They are not your friends. You have every right to make the bastards pull citations that you can understand for their glib numbers, before they stick any kind of knife in you. This is literally, as adversarial as life gets, even in dark alleys.

I've got $20 bucks that says they can't, or won't, if they are American docs. Purely on liablity insurance grounds. The last thing American docs want is a patient who is concerned about surgical quality assurance before they go under the knife.

But do ask your questions around in the legal community in your area, before signing up for surgery. The worst cutters are well known in the legal trade, believe me. Spend a few bucks and a few hours if you need to, finding out who is generating the most malpractice law suits in your area, for your class of surgery. And stay away from that/those jerks, and their practice partners, if any. You might be surprised what the leading medical malpractice law firms in your area know about the relative skill levels of surgeons in your area, for various procedures. And after all, the docs effectively sent you into the arms of the lawyers, by avoiding making their numbers readily available...

I was chagrined to find out that my orthopedic surgeon was the most sued doctor in my city, just after I had him replace both my hip joints, and then sue me for his costs when one of the joints failed 3 years later, and he had to replace it. I mentioned the problem to an attorney I knew, and he told me the surgeon's name with a smirk. There is no worse feeling in the world than having a lawyer smirk your doctor's name in such a situation.

After I picked up my jaw from the floor, I filed against the doctor in small claims court, and he dropped his suit. My "evidence" was an Xray of the busted joint, driven up into my pelvis, taken at the emergency room, before "my" surgeon got called in again, and some notes the woman who drove me to the ER made about my desire to get back the broken joint's parts for metallurgical analysis, which, (surprise!), never happened. Amazingly, all his diagnostic films were "unavailable" from the hospital library when I went to pull them, before going to small claims court.

And no, the great man didn't show in small claims. Just his collection agent lady. The judge even grinned when he ruled for me...

Wouldn't have been any satisfaction at all, though, if I'd of died on the table...
posted by paulsc at 12:27 AM on September 16, 2006

I went with invasive stomach surgery (double inguinal hernia) - actually, I didn't have a choice, that's what happened. I have a scar from hip-to-hip.

I lost all sense in my skin from the scar down over my pubic bone to my penis (where, thankfully, I still have feeling). I can't stand being touched in that area.

It took months to properly heal, and I also suffered some adhesions that occassionally tore (stretching backwards one day in the shower, I passed out from the sudden pain). I still have issues related to that operation - 15 years ago.
posted by strawberryviagra at 4:16 AM on September 16, 2006

Depends on the surgeon.
posted by ikkyu2 at 8:12 AM on September 16, 2006

A few questions I always ask before having any type of surgery:
1. Is the surgeon you are working with board-certified? If not, find another one.
2. Does the surgeon have specialty training, like a fellowship, in this procedure/ttype of procedure? Or in laproscopic surgery in general?
3. Something to consider: sometimes people do not turn out to be good candidates for laproscopic surgery, and there is no way to tell until you're under the knife. So they end up doing the open surgery.
4. Who does your PCP/GP/internist/urologist suggest?
5. Check the licensing board's database to see if any complaints have been filed against the surgeon.

I had a lap appendectomy almost one year ago. I was surprised at how little pain I felt while recovering. I was in the hospital for less than a day. They pretty much send you home once you can urinate and you eat something. You still have to be extremely careful about activity afterwards, though. You can't really do much of anything for 4-6 weeks so you avoid adhesions. Lap surgery still leaves scars too. Not as big as open of course.

(Any type of procedure, including lap, puts you at risk for becoming infected. In fact it can be argued even walking into a hospital puts you at risk. C. diff is a common hospital-acquired bacterial infection, for instance. You can never avoid that aspect of it. They will give you prophylactic antibiotics during your procedure and send you home with some to take for 5-7 days afterwards.)
posted by FergieBelle at 8:26 AM on September 16, 2006

Depending on your surgeon's abilities, I'd vote for #2 - minimally invasive and almost as good probability for success as #3.
posted by deborah at 12:41 PM on September 16, 2006