A revolution in gallbladder surgery almost a decade ago helps explain the current frenzy over minimally invasive cardiac surgery.
For a century, general surgeons had treated patients suffering from persistent, painful gallstones by removing the gallbladder, a pear-shaped pouch located next to the liver, through a six-inch abdominal incision.
That changed forever in 1987, when French surgeons developed techniques for operating on the gallbladder through a series of half-inch incisions, using a miniaturized video camera and long-handled tools. In 1988, the first Americans performed the minimally invasive gallbladder removal, known as laparoscopic cholecystectomy, or "lap choly" for short.
Immediately, the race was on to learn the new technique. And the speed of its adoption startled even ardent supporters.
"Within two years it went from none being done to the majority," says Paul Wetter, M.D., chairman of the Miami-based Society of Laparoendoscopic Surgeons.
By 1992, laparoscopic cholecystectomy was being used for about 80% of the half-million gallbladders removed each year, according to the National Institutes of Health.
Today, open gallbladder surgery is the exception. More than 90% of elective and half of emergency gallbladder surgeries are performed laparoscopically, surgeons estimate.
"Every general surgeon now does it because they've either been trained at it (during medical school) or thrown in the sponge and said I have to learn it," says Desmond Birkett, M.D., chairman of general surgery at Lahey Hitchcock Clinic, Burlington, Mass.
Underpinning the excitement over minimally invasive cardiac surgery is the hope that the history of gallbladder surgery will repeat itself.
With the old-fashioned gallbladder operation, patients typically face a five-day hospital stay and at least a monthlong convalescence. By contrast, patients undergoing the laparoscopic operation suffer much less pain, often are discharged the same day and have a recovery period averaging one to two weeks. The clincher, for some, is the operation hardly leaves a scar.
Patients clamored for the minimally invasive gallbladder surgery when it was introduced.
In fact, Birkett says, gallbladder surgeries spiked dramatically upward for a year or two. Many patients who had previously chosen to suffer with their gallstones opted for the easier surgery.
As would be expected, competition among surgeons and hospitals was fierce. For those who offered laparoscopic cholecystectomy first, the procedure proved an immediate bonanza. For years, payers reimbursed the cheaper laparoscopic approach at the plush rates pegged to open surgery. And early proficiency also helped establish lasting referral patterns.
But during the early days, complication rates greatly surpassed those in the conventional surgery as novices struggled to master the challenging new techniques that were unlike anything they had learned in medical school.
Many training courses hastily thrown together to meet overwhelming demand left surgeons ill-prepared to do the operations in the real world, some surgeons say. Compounding the problems was lax enforcement of credentialing requirements, they say.
But after the problems from the early gold rush were overcome, laparoscopic cholecystectomy outcomes confirmed that the early optimism about the approach was well founded.
The overall cost of the procedure is about the same or slightly less than conventional surgery (See chart).
Laparoscopic cholecystectomy has helped spur other minimally invasive surgical innovations, including those in heart surgery.
But success and failure are best appraised in hindsight.
"The biggest dilemma we have is that new technology is being developed faster than our ability to evaluate it by traditional methods," says Wetter of the Society of Laparoendoscopic Surgeons.