Keyhole surgery is a good substitute
Brandon Matt was having an extended bout of indigestion - or so he thought. He frequently had gastric discomfort, such as bloating, pain and a sense of fullness.
At 84 years old, Matt (whose name has been changed for reasons of patient confidentiality) already had a long list of age-related health woes, including cardiac problems, diabetes and hypertension.
A general practitioner recommended that Matt underwent an endoscopy to investigate his stomach ills.
During the procedure, a long, thin tube with a light and camera at the end was inserted into his stomach via his throat. Doctors found a suspicious looking ulcer in the mid-section of his stomach lining. A biopsy confirmed that Matt had stomach or gastric cancer.
Matt was referred to an oncologist. Surgery to remove the affected part of his stomach was the only available cure. However, after reviewing Matt's health condition, the oncologist concluded that open surgery was not a good option.
Matt was a relatively big man at over 1.8 metres tall and weighing more than 82kg. He was reasonably fit for his age. However, given his existing heart and pulmonary problems, open surgery would be much too strenuous and traumatic for his body. The amount of blood loss during and after surgery as well as the large wound that surgery would leave behind stacked the odds against a smooth recovery.
The oncologist referred him to Dr Michael Li Ka-wah, director of minimally invasive and robotic surgery development at the Hong Kong Sanatorium and Hospital. Matt's best hopes now lay in keyhole surgery to remove the cancer-stricken part of his stomach.
The technique would only require small incisions in the abdomen so that special endoscopes called laparoscopes could be passed into the abdominal cavity to carry out the operation. Carbon dioxide or nitrous oxide gas would be used to inflate the abdomen to create space for the surgeon to see and to work. This would result in much smaller wounds, less blood loss and pain, and a much quicker recovery time.
While reviewing Matt's medical history, Li found that the patient had open abdominal surgery many years ago for an unrelated condition. This meant that Matt very likely had adhesions - bands of tissues that form between abdominal tissues and organs, and cause them to stick together. Normally, these tissues and organs would have slippery surfaces that helped them slide against each other.
Adhesions would add to the challenges of minimally invasive surgery, says Li. But he remained undeterred, as it remained Matt's best chance of a cure. During surgery, Li discovered multiple adhesions in Matt's abdomen. He painstakingly cut through them to clear a path to the stomach. This alone took almost two hours.
Once Li reached the stomach, he found that the cancerous ulcer lay in the middle. If the ulcer had been located any higher in the stomach, Li would have had to remove the entire organ. But the cancer's position allowed Li to retain some of Matt's stomach.
Li then dissected the lymph nodes around the stomach. Cancer cells can break away from the lesion and travel to other parts of the body through the bloodstream or the lymphatic system. If the cancer cells enter the lymphatic system, they can end up in lymph nodes and start growing there. Often, the lymph nodes closest to the cancer site are affected first.
Cutting away the lymph nodes was a delicate process, as Li had to take care not to nick the major blood vessels running through the area.
After Li was done, the small incisions in Matt's abdomen were stitched up.
The next day, Matt's recovery seemed on track, as he was able to sit up and be fairly mobile. In the evening, however, he suddenly vomited blood.
Li and his team used an endoscope to investigate, and found that a blood vessel near the surgical site in the stomach was bleeding. He was able to stop the bleeding by using special clips to close off the blood vessel.
Meanwhile, good news came in from the laboratory. The pathologist found no sign of cancer in any of the 30 sample lymph nodes removed during surgery.
The rest of his recovery was uneventful, and he was discharged 10 days later.
In future, Matt will probably have to eat smaller, more frequent meals. The scarring in his stomach from the surgery will probably limit the natural ability of his stomach to stretch to accommodate food. The smaller organ size will also reduce the amount of food it can store.
Matt may also be at risk of some unpleasant effects such as weight loss, malnutrition, poor appetite, indigestion, diarrhoea and other digestive problems.
He will also have to closely monitor his nutrition as problems such as calcium malabsorption and anaemia can crop up.
Li says that minimally invasive surgery manages to bring results that are as good as those of open surgery, but with less trauma to the patient's body.