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MOMENTS IN MEDICINE
Fall | Winter 2009

Picking up the Pace

Every time Maria Perales slips on her walking shoes and hits the pavement, it’s another reason to celebrate. After four surgeries, three in the last year, walking is one of those little things in life that Perales no longer takes for granted.

Maria Perales never thought she would actually look forward to having surgery. But this time was different. After having undergone a lumpectomy, later followed by a double mastectomy and breast reconstructive surgery, undergoing an outpatient single incision laparoscopic surgery to remove her ovaries sounded like a piece of cake.

The day of surgery, Perales checked into the hospital at 7 a.m. By 2 p.m. that afternoon she was ready to return home. Even better, she was back to work in four days with not a scar on her body.

Chad Lagrange, MD

Single incision laparoscopic surgery, also known as SILS, is one of the newest advancements in minimally invasive surgery that is being performed at just a few centers in the country. Unlike laparoscopic surgery that typically involves three tiny incisions, SILS requires just one incision – through the belly button – leaving virtually no visible scar on the body. The Nebraska Medical Center physicians Kerry Rodabaugh, MD, gynecological oncologist, performed the procedure with Chad LaGrange, MD, a urologist who specializes in urologic minimally invasive procedures.

SILS is performed by making a small incision in the umbilicus, or belly button, where an access port is placed. Through this port, a flexible scope, a camera and tiny instruments can be slipped through and moved around inside the body, producing images from almost every angle and allowing the doctor to repair or remove organs or tumors.

“Our goal in surgery is always to do it laparoscopically whenever possible because of the reduced risks and many benefits it provides the patient,” says Dr. LaGrange. “Aside from the cosmetic advantages, we hope to find that SILS will greatly extend the benefits already provided in traditional laparoscopic surgery.”

The Nebraska Medical Center has become one of the nation’s leaders in pioneering new and innovative minimally invasive surgical procedures (also called laparoscopic surgery) that are making surgery less demanding and more comfortable for the patient. Minimally invasive procedures are just as effective and sometimes more effective than traditional surgery because they carry less risk of complications, less pain, shorter hospital stays and quicker healing and recovery times.

“For the patient, the primary advantage right now is the cosmetic advantage the SILS procedure provides by leaving virtually no scar,” says Dr. LaGrange.

Tiny surgical instruments are slipped
through the SILS access port allowing the
surgeon to repair or remove organs
and tumors with just one small incision.

For Perales, being given the option to have the SILS procedure performed to remove her ovaries couldn’t have come at a better time. Diagnosed with breast cancer in 2006, Perales initially opted for the simpler lumpectomy procedure that would remove the cancerous lump only. However, less than two years later when her cousin was diagnosed with breast cancer at age 30 and underwent a double mastectomy, Perales wondered if she had made the right decision. Breast cancer obviously ran deep in her family. Her aunt had also been diagnosed with breast cancer at age 38.

Perales decided to come to The Nebraska Medical Center to undergo gene testing. Tests revealed she carried the BRCA1 gene – a strong predictor of breast and ovarian cancers. Women who carry the BRCA1 and 2 genes have an 85 percent risk for developing breast cancer and a 45 percent risk for developing ovarian cancer. After meeting with the genetics counselor and discussing her options with Dr. Rodabaugh, Perales opted for cutting her risks by undergoing prophylactic surgery. This technique involves removing targeted organs even before cancer is found as a preventive measure in high-risk individuals. Perales decided to have both a double mastectomy and have her ovaries removed. By having her ovaries removed, Perales would drop her risk of ovarian cancer to less than 2 percent. A double mastectomy would drop her risk for breast cancer by 90 percent.

“Aside from the cosmetic advantages, we hope to find that SILS will greatly extend the benefits already provided in traditional laparoscopic surgery.”
Chad LaGrange, MD

The fact that her cousin had recently undergone a double mastectomy gave Perales the courage to proceed. “I had heard so many stories of women who had battled cancer only to have it come back a second time with a vengeance,” says Perales. “I didn’t want to become one of those women.”

The combined double mastectomy with reconstructive surgery was grueling: a 14-hour surgery, followed by five days in the hospital and another three weeks of recovery. While Perales grimaced at the idea of another surgery, she knew it was the right thing to do. When Dr. Rodabaugh suggested the SILS procedure, Perales didn’t have to think twice. She says the pain she experienced after the SILS procedure was minimal. “I remember moving more slowly the first few days, but I was never in a lot of pain,” says Perales. “When I followed up with Dr. Rodabaugh a few weeks later, I didn’t have any problems or complaints.”

“The procedure went really well,” says Dr. Rodabaugh. “I was very pleased with the outcome and how well Maria recovered. Dr. LaGrange had talked to me about considering using this procedure should I have a patient who needed her ovaries removed. After everything Maria had already been through, she seemed like the perfect candidate.”

The Robotic Da Vinci™ Surgical System

Throughout Perales’ trials, she relied on the support of her family to help her cope. She also took up walking to improve her general health and to stay stronger physically. Most days Perales will walk along the tree-lined streets of southeast Omaha near 13th and Missouri Streets. “When I first started, I couldn’t walk and talk at the same time,” says Perales. “Now I walk about two miles most days of the week. I think it helped me tolerate the surgeries better and to heal faster.”

While this was the first SILS ovary removal surgery performed at The Nebraska Medical Center, this was not the first SILS case for Dr. LaGrange. In his first SILS procedure performed earlier this year, Dr. LaGrange removed a large cyst from a kidney. He has since performed the procedure approximately a dozen times to remove kidney and bladder stones as well as a kidney.

Dr. LaGrange joined the staff at The Nebraska Medical Center about a year ago after completing a residency in urology followed by a fellowship in endourology at the University of Kentucky Medical Center in Lexington. Endourology focuses on the use of minimally invasive procedures to treat urologic conditions such as kidney stones, urinary obstructions and cancers. His extensive training in laparoscopic surgery provided him the background and expertise to teach himself the SILS procedure.

“Urology is an ideal specialty for laparoscopic surgery because the organs we operate on are usually larger and more difficult to get to and see,” explains Dr. LaGrange. “In a normal open surgery, we would need to make a large incision, and even then it would be like looking into a big, dark hole. The use of tiny cameras and instruments allows us to see and work in these hard to reach areas.”

On a broader scale, single-incision surgery represents an important step in moving closer to other innovative minimally invasive techniques, says Dr. LaGrange. One of those techniques is natural orifice transluminal endoscopic surgery, (NOTES). NOTES involves removing organs through natural body openings such as the mouth or vagina. Currently, a handful of medical centers across the country are performing the experimental procedure to remove organs within the abdominal cavity with fairly good success. As the technique is perfected, The Nebraska Medical Center anticipates adopting this procedure as well.

Robotics is another surgical technique that has the potential to benefit from the SILS procedure. Robotic surgery combines robotics and computer-enhanced technology to provide surgeons a greater degree of accuracy and precision. Robotic surgery provides a 3-D image rather than a 2-D image provided by laparoscopic surgery and magnifies the image 10 times its normal size. The robotic instruments, which have the ability to bend like the human wrist, allow the surgeon to move more naturally and freely within the body. Dr. LaGrange says robotics is usually reserved for the most complex surgeries.

“I used to work here a long time ago, so I knew this was the best hospital with the best doctors. so I wanted to go where I knew I’d be getting the best possible care.”
Maria Perales

The Nebraska Medical Center was one of the first sites in the country to acquire the technically advanced robotic da Vinci™ Surgical System in early 2000 and has become one of the area’s leaders in using this technically advanced surgical method. It is particularly effective in performing prostatectomies, or removal of the prostate, a procedure Dr. LaGrange has also perfected. Robotic prostatectomy using the SILS technique is Dr. LaGrange’s ultimate goal. “This is a more advanced and complex procedure that will be the next step in advancing the SILS technique,” says Dr. LaGrange. Ultimately, the use of SILS will bring us closer to perfecting NOTES, says Dr. LaGrange, the ultimate in minimally invasive surgery.

Perales says she feels very fortunate to be the beneficiary of such good care at The Nebraska Medical Center. “I used to work here a long time ago, so I knew this was the best hospital with the best doctors. So I wanted to go where I knew I’d be getting the best possible care.”

With four surgeries behind her, Perales is growing stronger and her walking shoes, which are showing signs of wear, are proof. I just keep moving forward, says Perales, one day at a time. Or should we say, one step at a time.

Previous article in the Fall | Winter 2009 issue of One Thousand And One:
Finely Tuned