Steven D. Schwaitzberg, MD, serves as the Director of the Surgical Research Laboratory and Director of the Center for Minimally Invasive Surgery at New England Medical Center (NEMC) in Boston, MA.
Dr. Schwaitzberg is a pioneer in the field of minimally invasive surgery. He has developed several techniques, written papers on the topic over the past several years, and trained dozens of residents at NEMC. In addition, Dr. Schwaitzberg is Associate Professor of Surgery and Head and Neck Surgery at Tufts University School of Medicine. He went to medical school and did his surgical training at Baylor College of Medicine in Houston, TX.
MedTech1: How long have you been director of the Surgical Research Laboratory and director of the Center for Minimally Invasive Surgery?
Dr. Schwaitzberg: Ten years. When I came back from Desert Storm, that is what I was appointed to do.
MedTech1: You perform minimally invasive surgery. Do you specialize in a particular field of surgery?
Dr. Schwaitzberg: My focus is broad. I have worked on minimally invasive head and neck procedures, but the majority of procedures I do are abdominal. The gallbladder, the liver, the spleen, the adrenal gland, the stomach, the colon, the appendix, the small bowel, hernia repair, and the spine are all done minimally invasively.
MedTech1: Are these surgeries experimental?
Dr. Schwaitzberg: As procedures are developed, our goal has been to develop minimally invasive approaches to commonly accepted surgical procedures. So what we are changing is not necessarily the operation but the access through which the operation is performed. If I define a gallbladder procedure as disconnecting the gallbladder from the body, and the old way to do it was to make a big incision, and the new way to do it is not to look at it with my eyes but look at it with a TV camera, I’m not sure we have really changed the operation. That is different from inventing a new surgery. We have worked on refining and minimizing access on many procedures that were commonly performed through a bigger incision.
MedTech1: In the case of a gallbladder surgery, for example, how small an incision can you make that will allow you to remove the organ from the body?
Dr. Schwaitzberg: Currently, 10 to 12 millimeters is the standard. However, we are conducting research and we hope to be able to remove gallbladders through 5-millimeter incisions within the next year.
MedTech1: How do you angle the gallbladder to remove it through such a small incision?
Dr. Schwaitzberg: It is a question of physics. Stretch and physics.
MedTech1: And you do all this via a TV screen?
Dr. Schwaitzberg: Yes.
MedTech1: When did the idea of minimally invasive surgery first become a new topic in medicine?
Dr. Schwaitzberg: The first laparoscopic operations were proposed in the 1920s with much cruder instrumentation than we have today. Gynecologists have been looking at the pelvic organs for more than 50 years. The original laparoscopic surgeons were internists who used the techniques to look at the liver. But in 1989, the laparoscopic surgery scene exploded, first in Tennessee and in France, by proving to the world that you could remove the gallbladder laparoscopically. The gallbladder was the first organ that caused the explosion in the late 1980s. There have been isolated pockets of surgery in different parts of the world. A pioneer named Kurt Semm, a gynecologist, had been doing relatively advanced surgery, including the appendectomy, 10 years earlier. But the popularization occurred around1988-89.
MedTech1: Is there ever a case in which you feel that laparoscopic surgery cannot be used on a patient?
Dr. Schwaitzberg: Certainly. And every person who goes to the operating room for a laparoscopic operation has to have some sense of what the rate of conversion to open surgery is. For instance, I quote to all of my elective surgery patients that there is a 2 percent chance that I am going to have to go from laparoscopic to incisional surgery. For emergency gallbladder surgery, the rate is more like 10 or 20 percent.
MedTech1: When patients are given the choice to have laparoscopic versus incisional surgery, do most choose laparoscopic?
Dr. Schwaitzberg: It depends on how well worked out the operation is. In 1992, there were still people saying the techniques were new enough that they would rather have an incision in order to remove their gallbladder. Nowadays, you would never hear that. Yet, if you talk about other organs, such as spine surgery or even cardiac surgery, some patients assess the global experience of the individual surgeon. Some may choose minimally invasive surgery, and others may choose more traditional approaches.
The operations can be technically demanding on the surgeons. Doing surgery on a TV screen requires a different skill set than doing surgery with your hands and instruments close up. So some procedures that are technically difficult still need a standard approach.
MedTech1: How many people are training with you now?
Dr. Schwaitzberg: We train our entire residency. We have graduated four residents a year for the last decade, which totals 40 people. [To get a sense of the number of trained surgeons around the country], multiply 40 by the number of training programs in different cities and states around the country.
MedTech1: Do you see technology improving every year?
Dr. Schwaitzberg: I have enjoyed, for the last three years, being the Chair of the New Technology Committee for the Laparoscopic Society, called SAGES (Society of American Gastrointestinal Endoscopic Surgeons). I have had an opportunity to watch the technology evolve and was asked to write a paper on where I thought the operating room was going in terms of the future in Contemporary Surgery last January. I was able to speculate on those advances I thought would take place.
MedTech1: What do you see in the next five years?
Dr. Schwaitzberg: I see a greater amount of computer integration into our equipment. I also see a greater amount of information gathering. I believe we will hook hospital networks directly into the operating room so we can take advantage of radiology services and real-time consultative services, among other things. I see diffusion of other technologies, such as voice activation, so that we will be able to control the equipment remotely. I see miniaturization of equipment. Our TV monitors will become flat panels. Lightweight goggles will replace TV screens altogether because of their improved ergonomics. For the surgeons, I see a trend toward a greater concern for the ergonomics of the operating room. The operating room now is not a particularly ergonomic environment, and there are papers written about repetitive stress injuries in surgeons.
We surgeons still use scalpels, hemostats, and pick-ups for many operations. But for other types of surgery where we can employ technology, it is completely different.
MedTech1: What is the most recent surgery you have done?
Dr. Schwaitzberg: I did a laparoscopic appendectomy on a fellow surgeon. Operating on a colleague is a tremendous responsibility and privilege.
MedTech1: Do you have a favorite type of surgery?
Dr. Schwaitzberg: I like doing endocrine surgery, which is surgery on the pancreas, the adrenal gland, the thyroids. The surgery is very challenging, the cases are very interesting, and you can really help the patients. That is the most important part.
The nature of surgery is that you meet people with a problem, and you hopefully solve their problem. You hope they, and you, go away a little better for the experience. The number of long-term patients that I’ve had over the years is small. But I have the privilege of meeting lots of new people.
We do cancer surgery as well as procedures that are not quite as terrifying, such as hernia surgery. Patients with hernias have problems that need to get fixed, but they generally experience a more pleasant office interaction because the patient is not afraid of dying. Each operation needs to be performed with a technical seriousness, but the situation is not tense in the same way a life and death procedure can be.