Patient Care

STONY BROOK CENTER FOR MINIMALLY INVASIVE SURGERY

The Stony Brook Center for Minimally Invasive Surgery, established by the Department of Surgery, is dedicated to the performance and advancement of the most sophisticated care using minimally invasive laparoscopic operations that offer eligible patients considerable benefits when compared with conventional "open" surgery:

In addition to providing clinical services, the Center offers instructional courses and seminars in laparoscopic surgery for practicing surgeons.

The Department of Surgery provides minimally invasive "videoscopic" surgery for treating a wide range of medical problems other than gastrointestinal disease, which is the specialty of the Center for Minimally Invasive Surgery. Our cardiac surgery service uses minimally invasive thoracoscopic and robotic procedures to perform bypass surgery (click here) and valve procedures (click here), and our thoracic surgery service uses minimally invasive procedures to treat chest diseases, in particular lung cancer; our otolaryngology–head and neck surgery service uses minimally invasive endoscopic procedures to treat nasal sinus disease, to remove pituitary tumors, to remove part or all of the thyroid gland, and to remove salivary gland stones; our pediatric surgery service uses minimally invasive endoscopic and thoracoscopic procedures to treat certain maladies in both infants and older children; and our vascular surgery service uses minimally invasive endoscopic procedures to treat certain circulatory disorders. Other forms of minimally invasive surgery — such as endovascular surgery — are performed by the Department's specialists as well.

About Laparoscopic Surgery

Also known as endoscopic or videoscopic or surgery, laparoscopic surgery is an expanding group of different kinds of operations performed with newly developed surgical instruments and methods that cause the least amount of physical stress to patients. It involves the use of a small scope (laparoscope) which magnifies the body's internal structures and projects the image onto a video monitor in the operating room.

That laparoscopic surgery requires only small incisions — and thus is minimally invasive — is a distinguishing feature of this revolutionary approach to surgical care.

Without the trauma of the large incision used in conventional operations, both pain and healing time are greatly reduced. There are also smaller scars as a consequence of the smaller incisions. Other appealing benefits include shorter hospital stays OR no hospital stays at all, less need for postoperative pain medication, and earlier returns to work and normal activity/diet.

Surgery to treat a variety of common abdominal problems such as gallbladder disease, hernias, appendicitis, and chronic heartburn caused by reflux disease used to require large incisions, about a week in the hospital, and a six- to eight-week recovery time. In most cases, laparoscopic surgery has reduced the treatment to same-day outpatient surgery with just one- to two-week recovery at home; some patients can return to work in just a couple days after their operation.

Dr. Roberto Bergamaschi, professor of surgery and chief of colon and rectal surgery, and Dr. Kevin T. Watkins, associate professor of surgery and chief of upper gastrointestinal and general oncologic surgery, are co-directors of our Center for Minimally Invasive Surgery. Both surgeons are recognized as national and international leaders in the field of laparoscopic surgery.

Dr. Watkins comments: "The proven effectiveness of laparoscopic surgery has led to its expanding use. Because the stress to the body is greatly reduced by this minimally invasive approach, our patients — both adults and children — are extremely satisfied with the operative outcomes, in particular the minimal pain, scarring, and recovery time."

Dr. Bergamaschi

Dr. Huston

Dr. Lee

Dr. Merriam

Dr. Paccione

Dr. Scriven

Dr. Vosswinkel

Dr. Watkins

Members of our general/gastrointestinal surgery service, colon and rectal surgery service, and upper gastrointestinal and general oncologic surgery service make possible the range of our minimally invasive laparoscopic services, several of which are unique in Suffolk County. Our pediatric surgery service also provides advanced minimally invasive surgery (laparoscopy and thoracoscopy), which is performed by Dr. Thomas K. Lee and Dr. Richard J. Scriven.

Our Multidisciplinary Approach to Managing Esophageal Disease

The expanded use of minimally invasive laparoscopic surgery has become particularly important in the treatment of esophageal diseases, including gastroesophageal reflux disease (GERD) and motility (muscle function) disorders such as achalasia (severe swallowing difficulty). To provide the best possible patient care, our surgeons work closely with Stony Brook's gastroenterologists — in particular, Drs. Joseph Anderson, John W. Birk, Douglas L. Brand, Ramona Rajapakse, and Isabelle vonAlthen — who maintain a sophisticated endoscopy laboratory as well as the only esophageal motility laboratory in Suffolk County, which is run by Dr. Brand.

These laboratories use state-of-the-art equipment to evaluate patients with symptoms of esophageal disease. GERD, for instance, is a chronic, recurrent disorder that results when stomach contents reflux into the esophagus. It is characterized by heartburn, eructation, and epigastric pain. Diagnosis is normally presumptive and made by the physician based on recognition of common symptoms. But the symptoms cannot reliably predict the severity of the disorder or indicate the patient's risk of developing complications, including reflux esophagitis, stricture formation, and Barrett's esophagus which is associated with cancer.

University Hospital's endoscopy and motility laboratories provide the information needed for the most accurate diagnosis of GERD and gastroesophageal motility disorders, and for determining the appropriate treatment plan. "Anyone with intractable heartburn needs evaluation," Dr. Watkins says, adding that "our multidisciplinary approach to managing esophageal disease ensures patients of the best possible evaluation. He also emphasizes that "laparoscopic anti-reflux surgery has revolutionized the management of heartburn, and that most patients can now get permanent relief by laparoscopic surgery requiring only an overnight stay in the hospital."

Minimally Invasive Surgery We Perform

Laparoscopic adrenalectomy. When the removal of one or both adrenal glands is indicated, laparascopic surgery has proven to be a safe and effective alternative to open surgery. Comparative studies have demonstrated the advantages of the laparoscopic approach when compared to traditional open approaches to adrenalectomy, documenting a more rapid and comfortable recovery, shorter hospitalization, and fewer complications. In fact, laparoscopic adrenalectomy is now considered the method of choice for adrenalectomy.

Laparoscopic anti-reflux fundoplication. Performed to treat chronic heartburn caused by gastroesophageal reflux disease (GERD), this anti-reflux surgery can be carried out safely and effectively with similar positive results to the conventional open operation and with all of the advantages of the minimally invasive approach. Open anti-reflux surgery involves opening the chest and wrapping part of the stomach around the esophagus to prevent stomach acids from surging up into the esophagus because of a weakened muscle between the two organs. The standard operation called Nissen fundoplication has been around for years, but is considered too invasive for all but the most severe cases of chronic heartburn. With the new laparoscopic procedure, patients are generally out of the hospital in one to two days instead of a week, with five tiny scabs rather than a 5- to 7-inch scar.

Laparoscopic appendectomy. Advances in laparoscopic procedures include minimally invasive surgery as a safe and effective technique for managing acute appendicitis. The patient also benefits from a shorter hospital stay, faster return to normal activities, and a decreased need for pain medication when compared to the open/traditional method of having the appendix removed. The overall majority of patients return to a normal diet anywhere from several hours post-operatively to one day following surgery, and require less pain medication. Bowel function returns quickly and patients are discharged quicker from the hospital. Because the traditional "abdominal transverse" incision is not required and is instead replaced by small and precise incisions, the procedure is performed with enhanced cosmetic results.

Laparoscopic cholecystectomy. This operation for the removal of a diseased gallbladder has quickly replaced the conventional approach as the procedure of choice. Introduced in the late 1980s, it changed the practice and expectations of general surgery, as it captured the attention of the surgical profession and the public and spawned the tremendous growth in minimally invasive surgery.

Laparoscopic colectomy. Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Laparoscopic treatments for benign colonic disease and as palliative operations for advanced malignant disease have gained widespread acceptance as safe, efficacious, and beneficial treatment options. Moreover, recent clinical studies have demonstrated that laparoscopic treatment for malignant colorectal disease is a viable alternative in selected patients.

Laparoscopic common bile duct exploration. In the past, if bile duct stones were found on x-rays taken during surgery, the procedure was converted to an open operation. Now, with laparoscopic common bile duct exploration, removal of the stones as well as the gallbladder, if indicated, can be addressed with just one minimally invasive operation. We have all the latest complex equipment, including minute laparoscopic flexible choledochoscopes for looking inside the common bile duct at the same time as looking inside the abdomen. Our surgeons have the expertise to explore the common bile duct both through the cystic duct as well as directly through the common bile duct.

Laparoscopic feeding jejunostomy. Using a mini-laparoscope less than a quarter inch in diameter, this operation is done to create a small hole in the small intestine for the insertion of a feeding tube. It is currently performed by Stony Brook surgeons in trauma patients as well as other patients when indicated, such as those with advanced head and neck cancer, esophageal cancer, or stomach cancer. Laparoscopic surgery for inserting feeding tubes is a safe and cost-effective operation to gain access to the small intestine. The procedure can also be used for simultaneous cancer staging.

Laparoscopic inguinal hernia repair. This laparoscopic operation involves the insertion of a mesh material for correcting hernias in the groin. Recent studies have shown that it is a good technique with low recurrence and complication rates. Patients have found this operation to be remarkably pain-free, and 50% of them require no pain medication after discharge from the hospital. Most can return to work within one week of the operation.

Laparoscopic liver biopsy. A liver biopsy is a procedure in which a sample of liver tissue is removed for examination under a microscope. This procedure is used to test for liver diseases such as cirrhosis, hepatitis, and tumors. It may also used to check the progress of treatment in diseases such as chronic hepatitis. Laparoscopic liver biopsy has been shown to be a safe and effective alternative to conventional open biopsy.

Laparoscopic liver surgery. The latest advances in laparoscopic surgery have made possible a growing number of operations to treat the liver. Stony Brook is among the few medical centers in our region where surgeons have the specialized experience and equipment to perform these advanced laparoscopic operations. The following liver (hepatic) operations are performed laparoscopically at Stony Brook:

l Radiofrequency ablation (RFA) of liver tumors: Removal of cancer of the liver by surgical means is the treatment of choice. In many patients surgery is not possible because of the extent of the tumor or the presence of cirrhosis that poses an excessive risk of liver failure after the surgery. RFA is a procedure used to destroy liver cancer. RFA is frequently an option in patients in whom surgical removal of the tumor is not an option. RFA is a safe and well-tolerated procedure that is associated with few complications. It is not a curative procedure, but rather a procedure that may lead to increased survivability and quality of life.
l Wedge resection (removal) of liver tumors: Wedge resection is a procedure to remove liver tumors that are situated on the surface of the liver. This approach leaves a surrounding margin of about ½ inch of normal liver. Wedge resection of the liver is preferred since only small amounts of liver tissue are removed during this procedure. It is a surgical option only for tumors that are situated on the surface of the liver. These tumors can be safely removed without injury to the blood vessels of the liver.
l Removal of left half of the left lobe of the liver (left lateral segment): This procedure, called lateral segmentectomy of the liver, is done to remove tumors in the left half of the left lobe of the liver, which is often involved when certain cancers spread throughout the body. In some patients, liver tumors may be confined only to the left lateral segment. Under these circumstances, removal of the left lateral segment may provide an opportunity for cure.
l Hepatic artery infusion (HAI) chemotherapy: This is a procedure to inject chemotherapy directly into the liver. HAI chemotherapy is designed to improve chemotherapy benefits for liver cancer by increasing the amount of chemotherapy delivered to the site of the tumor. This approach often leads to a better response of the liver disease compared to regular chemotherapy and delays further growth of the tumor. HAI therapy shows a trend toward increased survival rates, as well as reduced systemic side effects that are associated with regular chemotherapy. This reduction of side effects enhances quality of life.
l Drainage of liver abscesses: Laparoscopic drainage of liver abscesses, combined with intravenous antibiotics, is a safe alternative for patients requiring surgical drainage when medical treatment has failed.
l Drainage or removal of liver cysts: Laparoscopic drainage of symptomatic liver cysts is a simple, safe, and effective method to relieve symptoms with minimal surgical trauma. Drainage of such cysts is recommended as the primary operation. Compared with the traditional open surgery, laparoscopic drainage is associated with lower blood loss, lower morbidity, and shorter hospital stay. Removal of liver cysts is best reserved for recurrent symptomatic cysts and cystic lesions suspicious of tumors where it can be safely performed and associated with a zero recurrence rate.

Laparoscopic myotomy. Performed to treat achalasia (severe swallowing difficulty) which increases pressure at the lower esophagus, this operation disrupts the muscular fibers of the lower esophagus and allows the food to get to the stomach without delay; an anti-reflux procedure (partial fundoplication) is performed to avoid postoperative gastroesophageal reflux. This operation has established itself as the procedure of choice for treating achalasia. It is safe and effective, and recovery is fast, usually with an overnight or outpatient hospital stay. Minimally invasive surgical techniques have had a profound impact on the treatment of achalasia over the past decade and several modifications of both the myotomy and the concomitant anti-reflux procedure are currently advocated. Nearly all of the more contemporary published studies report a 90% or greater success in relieving dysphagia (inability to swallow), one of the most common symptoms of achalasia.

Laparoscopic pancreatic surgery. This new form of minimally invasive surgery represents the latest advances in laparoscopic surgery. Only the most experienced laparoscopic surgeons are able to do it. At Stony Brook, we have such surgeons, who not only can perform laparoscopic pancreatic surgery, but are among the nation's leaders in this kind of minimally invasive surgery. Our surgeons probably have more experience performing laparoscopic pancreatic surgery than any others on Long Island. The following pancreatic operations are performed laparoscopically at Stony Brook:

Laparoscopic paraesophageal hernia repair. Paraesophageal hernias — in which the stomach protrudes through the opening (hiatus) in the diaphragm where the esophagus meets the stomach — are associated with advanced age and co-existing medical problems. True paraesophageal hernias (not the sliding type associated with reflux) with incarcerated stomach put patients at risk for gastric volvulus (intestinal obstruction due to knotting/twisting of the bowel), which is a potentially lethal problem. Therefore, all such hernias need to be repaired. Laparoscopic repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. In a 1998 comparative study, short-term outcomes for laparoscopic repair were found to be superior to open repair, suggesting that the laparoscopic approach is the preferred approach to paraesophageal hernia repair.

Laparoscopic perforated peptic ulcer repair. A peptic ulcer is an open sore in the lining of the esophagus, stomach or duodenum. In 2002, researchers reported at the World Congress of Endoscopic Surgery (SAGES) that laparoscopic repair of perforated peptic ulcers is safe and effective, and is not painful.

Laparoscopic peritoneal dialysis catheter placement. Laparoscopic secure placement of continuous ambulatory peritoneal (abdominal) dialysis catheters is a simple, safe, and viable operation, even in patients with previous lower-abdominal operations. The same technique can be used to rescue dysfunctional catheters that are displaced or obstructed by adhesion and omental wrapping, thus increasing catheter longevity. Laparoscopic placement allows for thorough inspection of the peritoneal cavity and greater distal catheter inspection and placement, as well as reducing the risk of iatrogenic intra-abdominal visceral or vascular injury.

Laparoscopic small bowel resection. When a portion of the small intestine needs to be removed, laparascopic surgery is a safe and effective alternative to open surgery. It allows for accurate diagnosis and treatment of different problems affecting the intestine.

Laparoscopic splenectomy. As a result of ongoing advances and increased proficiency in the performance of laparoscopic procedures, laparoscopic splenectomy has evolved in the treatment of diseases of the spleen. In carefully selected patients, this operation has proven to be as safe and effective as conventional open surgery.

Laparoscopic ventral hernia repair. Ventral hernias are anterior abdominal wall hernias, which may occur independently (primary ventral hernia) or, more commonly, in conjunction with an incision from prior abdominal surgery (incisional hernia). All such hernias should be fixed once found, and they can be repaired using mesh in a laparoscopic procedure. Laparoscopic ventral hernia repair, a recent development, has been shown to be safe and effective in the repair of ventral hernias. In a large study published in American Surgeon in 1999, laparoscopic repair was found to compare favorably to open surgical repair with respect to wound complications, hospital stay, operative time, and recurrence rate.

Using the Laparoscope

Use of the laparoscope and similar scopes (e.g., endoscope, thoracoscope), among other new high-tech surgical instruments, has been the hallmark of minimally invasive surgery.

The laparoscope (photo below) is a slender tube, less than three-eighths of an inch in diameter, with magnifying lenses at both ends, like a telescope. However, instead of gazing into outer space, a laparoscope looks at inner space.

When used for instance in abdominal surgery, a small incision is made in the abdomen through which the laparoscope is inserted via a hollow trocar-tube into the abdominal cavity. There it enables surgeons to look at a hernia, diseased gallbladder, inflamed appendix, or other problems.

Surgeons perform surgery using microsurgical instruments inserted through trocar-tubes placed in similar incisions. The elimination of the large incision used in conventional operations makes this type of surgery less traumatic and, therefore, less painful. Thus, a patient can avoid or lessen a hospital stay and recover much faster.

The major limitation of laparoscopic surgery used to be that the surgeon was only able to see in just two dimensions. The lack of depth perception slowed many operations, and made certain tasks, such as suturing, difficult. To resolve this problem, surgeons use a video-computer system to perform in three dimensions.

Now, surgeons can see images from the laparoscope just as if they were viewing through a large incision. The new videoscopic approach, which adds to the laparoscope a video camera and light source, has revolutionized simple laparoscopic surgery.

For appointments/consultations with a physician of the Stony Brook Center for Minimally Invasive Surgery, please call 631-444-4545.