Most surgical procedures are trade-offs: there is usually more than one option for any condition, and patient input and preferences must always be considered. This article will guide you through some of the most common surgical sacred cows.
A surgeon in the United States is extensively trained. In addition to four years of medical school, surgeons must undergo a minimum of five years of residency training, and even more if they specialize (e.g., neurosurgery, pediatric surgery). Moreover, the hours one must put in during a surgical residency are notoriously long and hard. A 70-80 hour or longer work week is not unusual. But even with all their training, surgeons by nature must also possess an exceptional degree of self-confidence. It isn’t easy to put a scalpel to a living, breathing patient with all the potential risks it entails.
Unfortunately, this same difficult training and extreme self-confidence can sometimes lead surgeons to dogmatic opinions regarding what is best for their patient. It’s really a double-edged sword. You certainly wouldn’t want a tentative surgeon caring for you. You want someone who exudes confidence. But at the same time you want your surgeon to carefully and patiently explain all the risks and benefits of what they are proposing and any alternative treatments if they exist.
When Dogma Leads to Tragedy: the Radical Mastectomy
Throughout the history of surgery, this dogmatic approach — albeit always with the best intentions — has led to many unfortunate issues. Probably the most notorious example is the radical mastectomy.
William Halstead, the father of modern American surgery, and the majority of his contemporaries believed that cancer spreads from an initial tumor out into ever enlarging concentric circles. From this idea the surgical dogma was firmly established that for breast cancer and for many other cancers, the more tissue one removes, the more likely one was to effect a “cure.”
When removing the breasts did not increase longevity, Halstead moved on to removing the lymph nodes around the affected breast. From there, he went on to remove muscle and huge blocks of tissue — always in the unwavering and unyielding belief that this would lead to a cure.
This huge resection, with the ominous name “radical mastectomy,” led to horribly disfigured women with chronically swollen arms that could hardly be raised in the air. And even when studies began to appear in the 1930's showing that simply removing the tumor (a lumpectomy) combined with radiation resulted in similar cure rates without the horrid complications, it took a full 90 years for the radical mastectomy operation to fall into disfavor!
Sacred Cows
These same issues where surgical dogma leads to “sacred cows” persist today.
Sacred cows are surgical beliefs that there is one and only one way to treat different conditions.
Let’s tackle some of the biggest sacred cows of the medical world:
Robotic surgery for urological, gynecological, or general surgery leads to a better result with fewer complications.
Chronic knee pain from osteoarthritis should be treated with knee replacement.
Uncomplicated acute appendicitis is a surgical emergency.
An angioplasty is the best treatment for relieving angina.
Diverticulitis needs to be treated surgically with a resulting colostomy bag (a pouch for waste).
Routine periodic exams in healthy adults must be performed to detect the early presence of disease.
Robotic Surgery
If you are having a hysterectomy for cervical cancer or your prostate removed for prostate cancer, there is a good chance your surgeon will wax lyrical about the benefits of robotic surgery. He might talk about the shorter recovery times, the lower infection risks, the reduction in complications — basically how it’s the cat’s meow.
Keith Srakocic/AP
First of all, a robot is not doing your surgery, your surgeon is, using a big machine with lots of mechanical arms. These robots are expensive (over $1M) and that cost has to somehow be recouped by the hospital. Your bill might be the same as for the non-robot surgery, but somewhere down the line the robot has to get paid for and medical costs will increase.
But the real issue is that in spite of your surgeon’s certainty that there are major benefits to robotic surgery, the proof is not there. According to JAMA, the premier journal of the American Medical Association, there is no “robust” evidence showing robotic surgical procedures are any better than the current existing open or minimally invasive techniques.
And making matters even more disconcerting, the Food and Drug Administration recently issued a patient safety advisory on robotic surgery suggesting these devices have yet to prove their mettle when it comes to cancer surgery.
I am not advocating abandoning robotic surgery; rather, I am simply stating that the jury is out on its benefits and whether it’s safer or actually more dangerous than the traditional, more boring way to do things. Once again, the recurring theme is that you, the patient, need to be your own advocate.
Knee Replacement
Knee replacements are one of the most common procedures done in the U.S. (over 600,000 annually and expected to increase to 3.5 million by 2030). JAMA recently stated:
In the knee replacement trial, both joint arthroplasty operations and 12 weeks of nonoperative management successfully relieved osteoarthritis symptoms; however, surgery provided greater relief but resulted in more complications.
Knee replacement surgery is very expensive and very painful. In addition, about 1.3% of folks die (true after any kind of major non-cardiac surgery) in the first 30 days after surgery. Kaiser Health News noted that “[r]esearch suggests that up to one-third of those who have knees replaced continue to experience chronic pain, while 1 in 5 are dissatisfied with the results.”
A study published last year in the BMJ (British Medical Journal) found that knee replacement had minimal effects on quality of life — especially for patients with less severe arthritis.
There is also evidence that three months after surgical versus conservative treatment, 25% of surgical patients still suffered from cognitive dysfunction (a decline in mental sharpness). Since the non-surgical approach seems to work, it might indeed be a better choice but here again the more informed you are, the better. Talking to your surgeon is always the best advice.
Acute Uncomplicated Appendicitis
Although the topic of acute appendicitis is very controversial and most surgeons disagree vehemently, there is evidence that you don’t have to operate immediately; instead, you can try antibiotics first.
If you’re older and frail, the risk of dying from major surgery is quite high with about 14% of patients dying within one year. And since about two-thirds of patients who had acute appendicitis treated with antibiotics never required surgery, it may indeed be safer to try a conservative approach first. But since surgery for acute appendicitis is indeed firmly entrenched surgical dogma, it’s best to do your homework and carefully discuss with your surgeon and anesthesia Perioperative Surgical Home (PSH) team. I am not necessarily advocating a non-surgical approach; I am simply saying it’s one option you should at least know about!
Angioplasty
In heart disease, mankind’s biggest killer, cardiologists have long restricted their attention to the arteries that are almost completely blocked. It is these severely clogged arteries that limit blood to the heart and cause chest pain or angina during exercise. The technique of angioplasty was first perfected in 1977 to treat this by inserting little tubes or balloons into the clogged arteries to open them up, thus relieving the angina.
Angioplasties have grown enormously in the past 40 years. In a recent editorial in the prestigious journal Lancet, two cardiologists note that angioplasties have become “routine, ingrained and profitable.” There are two problems:
First, medical treatment appears to work equally well for stable angina, and is devoid of the excessive cost and potential serious, possible deadly complications from angioplasty.
Second, these severe blockages are usually not the ones that kill you, since over the long course of time it took the arteries to clog, the heart developed secondary collateral channels to keep enough blood flowing. The blockages that kill you are often the smaller ones — the ones that aren’t treated by heart surgery or angioplasty.
Colectomy for Diverticulitis
Traditionally, a colectomy (resection of part of the large intestine) has been used to treat severe diverticulitis, which is an inflammation or infection in one or more of the small pouches in the digestive tract. The problem is that a colectomy usually results in the patient requiring a stoma or colostomy bag for waste. The technique of surgical lavage (lavage means washing out) can often treat the diverticulitis without requiring a stoma, which is often preferable for many patients. Lavage is comparatively safe but can lead to more reoperations. Which to use is a decision you should have an active say in!
Routine Physical Exams
It’s worth mentioning that dogmas or sacred cows are also present in many other branches of medicine. In 1922 the American Medical Association (AMA) recommended routine periodic exams in healthy adults to detect the early presence of disease.
Now almost 100 years later this firmly entrenched dogma of annual physicals for everyone is being reexamined and challenged. In fact, these annual exams in healthy individuals can sometimes lead to unnecessary tests and treatments and may indeed do more harm than good.
Be Your Own Advocate
There is often more than one option for any proposed surgical or medical procedure.
Learn all you can and ask as many questions as you need to. The surgeon’s office or a facility that subscribes to the American Society’s Perioperative Surgical Home (PSH) is the best place to do this.
Be open to going against the grain and exploring alternatives. Do your homework. Be involved in the decision-making process.
After all, it’s your body. Don’t be afraid to fight for it!
Recommended Reading
Surgery, The Ultimate Placebo: A Surgeon Cuts through the Evidence by Ian Harris
Undo It!: How Simple Lifestyle Changes Can Reverse Most Chronic Diseases by Dean Ornish, M.D. and Anne Ornish