M. Blair Marshall, MD, Chief, Division of Thoracic Surgery, MedStar Georgetown University Hospital, talks about a new minimally-invasive lung surgery option for patients with lung cancer.
Interview conducted by Ivanhoe Broadcast News in August 2017.
What made you turn to this groundbreaking, minimally invasive option and why don’t more doctors do this?
Dr. Marshall: Unlike operating in the abdomen, which is well-known where invasive surgery started, operating in the chest when you do it open requires you to spread the ribs to where the nerves are they spread the chest. As a result patients have a significant amount of pain with that type of surgery. So that was really the driving force to push the field of minimally invasive thoracic surgery.
Spreading leaves a lot of residual pain because of the nerves in there?
Dr. Marshall: Right. When you do the surgery minimally invasively it’s not as traumatic to the nerves so the patients have a lot less pain. Typically after a lung operation patients would be in the hospital five to seven days. But now you can take out half a lung and the patient can go home sometimes as soon as the next day after a lobectomy for lung cancer.
Would you briefly explain what you did with Eleanor when you did that surgery?
Dr. Marshall: Her operation was we would say thoracic surgery on steroids in that she needed a lobectomy but because it was involving the central airway really the only way to get it out with negative margins would be to do a pneumonectomy or take out the whole lung. That for an eighty-two-year old-woman, a right side laminectomy, would probably be fraught with a lot of complications and a very high risk of postoperative death. But because the rest of her lung below that tumor was normal we were able with our video camera approach to take out the tumor, take out the airway and then transplant the lower lobe and middle lobe back on. So she kept all that lung function without really taking out much at all because her whole upper lobe was completely blocked anyway.
You said minimally-invasive surgery and surgery with a camera; does it involve you using extensions on your tools, what does that feel like to your hands, how is that different?
Dr. Marshall: I think you know for most people it’s like transitioning from a fork to chopsticks. You know because you just don’t have that control that you’re familiar with, but much like watching Asians use chopsticks the more you use them the better you get. You can probably be faster than you are with a fork with them. It’s getting over that hurdle of learning something new. I think many thoracic surgeons are lifelong learners, always challenging ourselves to push the limits on what can be done, how to make things better for our patients. That’s where a lot of what I do comes from.
Were you one of the first people in the country to do this type of surgery?
Dr. Marshall: For the minimally invasive lobectomy no. But for sleeve resections I’m probably one of the most experienced in the country.
The sleeve resection is?
Dr. Marshall: That’s the re-transplanting back onto the lung.
Which is what she had?
Dr. Marshall: Yes.
You have an eighty-two-year-old patient on the table and you’ve got this wonderful technique; what does that feel like emotionally to you as a surgeon to be able to help them?
Dr. Marshall: We’re all very cautious. So at the time that you’re proposing something to someone and also at the time of the operation you know it’s not until they come back without any complications, looking great and resuming their normal lifestyle that you have that gratification. Because even my residents have the belief that something bad is going to happen all the time and if you do one, we believe we ward off the evil spirits not that I’m superstitious, but also always looking for any complication that could possibly happen at any time and try to prevent any consequences from it.
Such a forward-thinking approach to medicine and to surgery, how could you pass that on to people who are stuck in the older ways of doing things?
Dr. Marshall: I think a number of ways; I’ve thought about writing from open to minimally invasive and back again. Because many of the things that I’ve learned from being minimally invasive now if I have to do something more invasive I actually modify the technique. You can still gain some of the benefits of the less invasive approach even when you can’t do that. Some of the older surgeons they’re probably never going to train and they’re just going to retire. But there are younger surgeons who are not comfortable and I worked with them to help them transition. I’ve modified the open technique so that it’s less open and have them start putting a camera in so that when they’re uncomfortable with the view they can actually look into the chest and have more of an open level of comfort ability, but they still have the camera there and slowly learn that the cameras really are probably a better view. As they progressively become more familiar with the less invasive or smaller technique, they adapt the techniques in a more gentle fashion rather than being all or none.
This happened to you because as you were explaining you said that’s 2-D it’s not 3-D but eventually your eyes almost make it 3-D for you?
Dr. Marshall: Right.
How did that happen?
Dr. Marshall: That happened over decades of working on camera and part of it is I am always trying to push the limits with what can be done that’s smaller. Most surgeons in the country that do minimally-invasive surgery use a camera probably the size of my thumb. But I use one half that size because I have to go between the ribs and the nerves are there and the smaller the better; the less trauma to the nerves. I’ve always worked with the smallest cameras possible. Also because I work on camera for pretty much ninety five percent of what I do, my brain has adapted to the 2-D view and so you start picking up the reflection of the light on the instruments to know where the curve is on the needle that you couldn’t tell before. I explain to people it’s much like knowing identical twins. When you first meet a set of identical twins they look identical and you think you’ll never be able to tell the difference between the two. After you’ve known them for several years, they barely look related anymore and you can’t envision not seeing the differences. Those are the subtle changes that your brain perceives over a decade of exposure. That’s similar to what’s happened when you work on camera 2-D view for so long. Your brain starts picking up these clues of where the light reflects on the metal to show you where the curves are and give you a 3-D view.
What is the difference that you see in the healing pattern and the time that they spend in hospital after the minimal surgery as opposed to open?
Dr. Marshall: With the minimally-invasive technique Ms. Traylor was ready to go home on day three after surgery and I had just transplanted her lung back on. The only reason she didn’t was because we had a snow storm and we didn’t want her to slip and break a hip. So we kept her an extra day until the roads were clear enough. But it’s not even just the length of stay that’s improved but their postoperative recovery. Many of my patients are out resuming their lives because they only have small incisions; we haven’t cut any muscle and really left them with minimal wounds to heal from, so it makes such an impact.
Is there anything I left out that you want to mention?
Dr. Marshall: You can say it’s not only the size of the incisions, but before when we used to do open surgery patients had to get an epidural. An epidural helps with the pain, but it also changes their blood pressure. Now that we’re minimally invasive we never use an epidural so it saves them that complication, that exposure and we just use rib blocks in the chest and that’s sufficient to control their pain in the acute setting and then with pills when they go home.
END OF INTERVIEW
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