Brian R. Gantwerker, MD, of The Craniospinal Center of Los Angeles, currently uses minimally invasive spine techniques with patients and has seen the clinical and economic value of these less invasive procedures.
"Minimally invasive techniques are becoming the standard way to approach surgery because there is less postoperative pain, earlier mobilization, shorter hospital stays and better quality for the patient," says Dr. Gantwerker. "It's time for us to move forward into that realm. Surgeons who are facile with the minimally invasive approach stand to become leaders in the community and guide where things go."
Here, Dr. Gantwerker discusses six steps for optimizing the cost-effective qualities of minimally invasive technique.
1. Overcome the learning curve. For spine surgeons who were trained with the traditional open surgical techniques, there is still a learning curve to incorporating less invasive procedures into their practice.
"Doing minimally invasive surgery involves a certain amount of time for the learning curve," says Dr. Gantwerker. "Initially, sometimes it might take longer, but as the surgeon becomes more comfortable with the OR setting and the individual staff there, they all will become more efficient."
Even after mastering the technique in the cadaver lab, incorporating minimally invasive procedures into the OR will take time and the first few cases may last longer than open surgery. Whether operating through a tubular retractor or simply using a smaller incision than a traditional microdiscectomy, it takes time to get used to the restricted space.
"I think there is much more benefit to doing things in a minimally invasive way and allowing the first few lumbar microdiscectomies to take a few hours than sticking with the old procedures," says Dr. Gantwerker. "As the surgeon and team get more comfortable with each other, they can move quickly and cut it down to 90 minutes or an hour while maintaining patient safety. I don't think this is a barrier, I think it's a natural evolution."
2. Stick with experienced operating room staff. Spine surgeons must have a high level of expertise among their operating room staff to appropriately utilize OR time. Staff members should be familiar with the minimally invasive technique and experienced with the surgeon, which means working with the same team for every surgery if possible.
"Everyone should know everyone else and be comfortable in the operating room, who the patient is and what is being done," says Dr. Gantwerker. "There should be specialized teams formed where people know spine very well and others are cross trained to speed up the process. There is a lot of teamwork in the OR and everyone has to be comfortable working together and having an open and efficient discussion when issues come up."
Just like surgeons, the operating room staff will have a learning curve when you first begin performing the minimally invasive procedures. However, with the right preparation work and repetition, the staff will become as efficient as the surgeon in the operating room.
3. Make sure proper equipment is available. Equipment efficiency is one of the most important elements for making sure a case runs smoothly. Have the proper equipment available and make sure there is a replacement if necessary. Your nurse should be in charge of coordinating these materials before the case begins.
"If, for example, a certain cervical retractor isn't available, the nurse should communicate that to the physician and have alternative options ready," says Dr. Gantwerker. "All it really takes is a couple of hours when setting up the spine service to go over preferences. Make sure all spine surgeons are present so there is unification of practice; it will make the service line more efficient because there will be less hunting for different equipment."
4. Patient documentation and checklists should be ready on time. Make sure all the appropriate patient documentation and checklists are ready to go when you bring the patients back to their room. This will optimize your time with the patient and ensure a smooth hand off from the circulating nurse.
"When you don't have a good hand off from the circulating nurse, there is a delay," says Dr. Gantwerker. "The pre-op nurse could be an organizing station for all the critical data. Verification of consent, review of preop laboratories, marking of the patient, could all be done more quickly at this stage. I think communication is key for movement through the process."
The pre-op nurse can be an organizing person to make sure the patient's chart and data for the case is ready to go before the surgeon comes in to mark the surgical site. This will allow for a smooth operating room.
5. Conduct a time out while the patient is still awake. All operating rooms have a "time out" before beginning surgery to make sure everyone is on the same page about what procedure is being performed, what the surgeon needs for the case and confirm everyone has gone through proper infection control policy. Often, this comes as the last step before surgery, but Dr. Gantwerker suggests doing the "time out" before the patient receives anesthesia to further decrease the risk of complications.
"One way to do this is that when the patient comes into the room, do the time out while the patient is awake and then induce anesthesia," says Dr. Gantwerker. "That way there are no pauses at inopportune times and the patient participates in the process, which is the a great way to avoid errors and enhance safety."
The surgeon should also create a comfortable environment for the surgical staff during these time outs so they can raise questions without fear of being reprimanded for slowing down the surgeon. High quality will supersede high case volume in terms of cost and patient satisfaction, regardless of the surgical technique.
"Doing more cases isn't always the answer," says Dr. Gantwerker. "Doing cases safely and efficiently is key. Doing three or four cases and being able to say there isn't confusion or problems with the wrong level are better than having a high volume with a high risk for problems."
6. Fewer resources are used in minimally invasive surgery. Once surgeons overcome their learning curve, minimally invasive techniques often cost less overall than open surgical technique because operating room time is shorter, there is less blood loss and length of staff at hospitals is cut. Because the operating time is shorter, patients use less post-operative analgesia; because there is less blood loss, patients are less likely to need transfusions.
The patient's length of stay at the hospital is shortened, which is a great cost savings. Some procedures are now also being done in ambulatory surgery centers, which lowers the cost even more.
"There are smaller incisions, less post-op pain and quicker mobilization with minimally invasive spine surgery, which makes it conducive to the outpatient setting," says Dr. Gantwerker. "There are some exceptions where a minimally invasive surgery would not be appropriate for the outpatient setting, while others have 23-hour post-surgical stays. When the patients are safely managed, I think there is real regard given to those kinds of cases and surgery centers."
However, not all payors will cover spine procedure in ambulatory surgery centers, despite a growing body literature showing these procedures are safe and cost-effective in an outpatient setting.
"Surgery centers that do spine cases now can be leaders to convince others there is a real advantage to minimally invasive surgery and that it fits within the ambulatory surgical center (ASC)," says Dr. Gantwerker. "There are a lot of community leaders out there who have surgery centers with good reputations and outcomes. We need to get them together to speak to Congress or their local representatives and show them surgery can be done in the outpatient setting safely. Either we need to hop on the train or be left behind at the station."
There are downsides, however. Minimally invasive surgery requires increased fluoroscopy time. Increased radiation exposure of patient, surgeon and staff means possible long-term effects of radiation. Even with proper equipment, complications for surgeon and staff such as cataracts can still occur. Also, minimally invasive surgery does require additional training for staff with sometimes-complicated retractors and hardware. There is also initially a large up-front cash outlay for specialty equipment. In the long-term, though, with dedication of all the surgeons and staff, and commitment to excellent care and outcomes, centers can reap the benefits of a dedicated minimally invasive spine line.
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