When Less Is More: Minimally Invasive Therapies Herald Maximally Influential Changes

Medical Device & Diagnostic Industry Magazine
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An MD&DI November 1998 Column

A surgeon's vision of the future includes a critical role for the contributions of biomedical design engineers.

Among the most enduring images of modern medicine is that of the lone surgeon—the last line of defense—standing fast against disease and death with an armament of art, science, and cold steel. What, then, could provoke a distinguished member of this heroic band to depict his fellow practitioners as "Neanderthals . . . a species that certainly should become extinct in the next 20 years"? And why would such a heretic be the featured speaker at a gathering of biomedical engineers?

John E.A. Wickham, senior research fellow and surgeon at Guy's Hospital in London, is credited with coining the term "minimally invasive surgery" and with organizing the first MIS department, set up at the University of London's Institute of Urology in 1986. In his plenary address during the recent annual meeting of the Biomedical Engineering Society, held in Cleveland, Wickham proposed a scenario for the future of minimally invasive therapies that, if accurate, holds profound implications not only for health-care providers but for the device industry as well.

In brief, Wickham predicts that the traditional domains of the "open" surgeon will be rapidly taken over by teams of endoscopists and interventional radiologists, working closely with bioengineers and instrument manufacturers. These changes would apply to most current surgical specialties, encompassing urologic, obstetric/gynecologic, gastrointestinal, orthopedic, neurologic, cardiothoracic, and vascular procedures. The fact that minimally invasive operative methods are becoming more common is neither new nor surprising, given that the techniques can often reduce patient morbidity and save money compared with standard treatments.

But Wickham foresees a more extensive transformation resulting from the wide-scale adoption of minimally invasive therapies. Demands for new technology will include the need for more sophisticated equipment, ranging from miniaturized scopes to advanced tissue-manipulation and tissue-lesioning tools, active and diagnostic robotics, and next-generation imaging devices and optics. Anesthesia practices will follow trends in surgery, with more emphasis on peripheral nerve blocks and the development of "on/off," reverse-potential blocks. Operating suites and radiology rooms will have to be reengineered to accommodate new equipment, personnel, patient-transport systems, and work-flow patterns. Common ailments involving diverse organ groups will be treated at peripheral facilities staffed by "general" endoscopic surgeons and interventional radiologists, with the more complicated procedures done at regional centers by "intensivists" in the same disciplines.

How quickly these events are realized will largely depend, says Wickham, on "whether the diffusion of new technology is to be guided by physicians or by politicians." If health-care policy does not become more supportive of technological innovation, Wickham fears that the physician's "flexible, discretionary judgement necessary for patient well-being" will continue to be compromised by government regulation and market forces intent on preserving the status quo. He quotes J. S. Mill, who found that "the despotism of custom is everywhere the standing hindrance to human achievement." It might even keep some of the smarter Neanderthals standing around the tables a few extra years.

Promoting innovative technology is also the focus of the second annual Medical Design Excellence Awards, sponsored by MDDI's publisher Canon Communications. I want to remind our readers that the deadline to submit entries for the competition is February 8, 1999. Information on how to achieve recognition for the product(s) of your inspiration can be found at www.devicelink.com/awards.

Jon Katz
[email protected]

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