Minimally invasive surgery has revolutionized surgical procedures.

Central Park in New York City. (Dr. Noorali Bharwani)
Central Park in New York City. (Dr. Noorali Bharwani)

In minimally invasive surgery, doctors use a variety of techniques to operate with less damage to the body than with open surgery. Minimally invasive surgery is associated with less pain, a shorter hospital stay and fewer complications.

This advantage is achieved by using a technique called laparoscopy where surgery is done through one or more small incisions, using small tubes and tiny cameras and surgical instruments.

Laparoscopic technique was one of the first types of minimally invasive surgery. Another type of minimally invasive surgery is robotic surgery. It provides a magnified, 3-D view of the surgical site and helps the surgeon operate with precision, flexibility and control.

It was in 1902, Georg Kelling from Dresden in Germany performed laparoscopic surgery using dogs. In 1910, Hans Christian Jacobaeus from Sweden used the approach to operate on a human. Over the next couple of decades, the procedure was refined and popularized by a number of people.

Laparoscopic gallbladder surgery (cholecystectomy) was introduced about 25 years ago. In 2011, cholecystectomy was the 8th most common operating room procedure performed in hospitals in North America.

Now laparoscopy has become the approach of choice for cholecystectomy. Other laparoscopic surgical procedures are appendectomy, nephrectomy, hysterectomy and other gynecological procedures. Just like anything else in life, these procedures are not without complications – during or after surgery.

If the laparoscopic surgery is difficult to perform and if the surgeon feels this may cause harm to the patient then the procedure is converted into an open one. Patient has to understand this and give consent to the surgeon to do whatever is safe for the patient.

To make sure that the surgical procedures are carried out safely, the operating room follows a protocol, which takes into account the following:

  • Perform a surgical pause (time out) to confirm the procedure with the team prior to initiating surgery.
  • Verify that the correct materials or equipment was available and functional prior to use.
  • Consider potential harm from misuse of surgical equipment.

Possible intra-operative injuries include damage to the bowel, blood vessels, ureter, reproductive organs, or nerves. The complication rate during surgery increase if the patient is obese and there are adhesions from previous surgeries.

How quickly you can return to normal activities after a cholecystectomy depends on which procedure your surgeon uses and your overall health. People undergoing a laparoscopic cholecystectomy may be able to go back to work in a matter of days. Those undergoing an open cholecystectomy may need a week or more to recover enough to return to work.

In 95 per cent of people undergoing cholecystectomy as treatment for simple biliary colic, removing the gallbladder completely resolves their symptoms. Up to 10 per cent of people who undergo cholecystectomy develop a condition called post-cholecystectomy syndrome. That means patient has symptoms typically similar to the pain and discomfort of biliary colic. Small number of patients may get chronic diarrhea after surgery. This can be controlled with medication like cholesteramine.

Overall, it is a very safe procedure.

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What you should know about medical assistance in dying – MAID?

Toronto Waterfront (Alia Bharwani)
Toronto Waterfront (Alia Bharwani)

“I’m not afraid of being dead. I’m just afraid of what you might have to go through to get there,” said Pamela Bone. Bone, 68, was a columnist and associate editor of the Age, one of Australia’s most respected newspapers. She died of terminal cancer. She was also a passionate campaigner on the right to die.

In Canada, following a Supreme Court ruling, medical assistance in dying became legal on June 6, 2016.

Recently (June 2018), the Canadian Medical Protective Association (CMPA) wrote, “Despite current federal and Québec legislation that makes medical assistance in dying (MAID) legal, there continues to be uncertainty among some physicians about their rights and obligations, and the processes to be followed in this area.”

A June 2016 Canadian Medical Association (CMA) survey revealed 25 per cent of responders (doctors) would be willing to provide MAID and 61 percent would not. Under the new law, Canadian doctors are not compelled to provide MAID. In these cases, the doctor is required to provide a referral to a health care professional or agency willing to carry out the patient’s wishes.

What kind of challenges physicians may face in determining eligibility for MAID? CMPA says there are several areas of concern. First, how can a doctor define and predict “reasonably foreseeable death” before enlisting an individual for MAID? Can a doctor be a conscientious objector if MAID does not agree with his/her beliefs? And there are other issues not well defined in the law.

Court challenges are underway in British Columbia and Québec in which the issue is whether the requirement that “natural death be reasonably foreseeable” is too restrictive and violates patients’ constitutional rights.

Physicians should remember that unlike most other healthcare services, MAID is governed by criminal law. Failure to ensure that the safeguards and eligibility criteria, as well as the reporting requirements for MAID are met could result in criminal charges and imprisonment of up to 14 years, in addition to College sanctions, civil legal actions, or both, says CMPA.

There are several other issues to be considered when implementing MAID:

  • Is there a risk that the law will be abused to weed out society’s undesirable people? In Canada, patients need to meet specific eligibility criteria put in place to safeguard vulnerable people. The patient must be mentally competent and give informed consent.
  • Is MAID a legal way to commit suicide? Committing suicide and going through physician-assisted dying are legally two different things. A medically assisted death is well planned and thought out, while suicide is often impulsive, violent and carried out alone.
  • Prior to Canada’s new law, it was illegal for anyone to counsel or coerce someone to die by suicide. The current Criminal Code now includes an exemption for physicians, nurse practitioners, and pharmacists – they are now allowed to counsel patients.

Alberta Health says its goal is to provide access to physician-assisted death, while protecting vulnerable Albertans and respecting the rights of physicians and other health professionals. To achieve this goal, the law should provide better clarity to protect the health care providers if they have to help those who are eligible for MAID.

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Are most doctors biased against the use of medical and recreational marijuana?

Health care professionals are worried about the long-term use of medical and recreational marijuana. (Dr. Noorali Bharwani)
Health care professionals are worried about the long-term use of medical and recreational marijuana. (Dr. Noorali Bharwani)

Government of Canada’s plan to end the prohibition on recreational pot use is going through the parliament and will soon become a law.

Although cannabis plant has a history of medicinal use dating back thousands of years across many cultures, scientifically the use of medical cannabis is controversial.

Unfortunately, we do not live in a perfect world. Majority of the people are blessed with good health. Some of them maintain their good health by way of pursuing healthy lifestyle.

Others are not so fortunate. Some suffer from chronic incurable diseases, chronic pain, and significant disabilities. They need more than regular comfort and painkillers.

As doctors, our job is to relieve pain and suffering. So what is the role of marijuana in relieving pain and suffering? How can we prevent abuse? Can we find a right balance between proper use of marijuana, harm reduction and abuse? That is not going to be easy.

We are still struggling to get alcohol abuse under control. Alcohol abuse has already taken many innocent lives by way of motor vehicle collisions, brain damage and domestic violence.

Now the health care system and law enforcement agencies will have to deal with marijuana abuse and its unfortunate consequences. Although marijuana is legalized for medical use only, it is already available in the market for drug abuse. Soon recreational use of marijuana will become legal.

Legalising recreational marijuana is going to be a money making business. Ottawa has agreed to give the provinces and territories 75 per cent of tax revenues from the sale of marijuana. But the doctors are worried. Statistics show Canadians have one of the highest rates of non-medical marijuana usage in the world.

A report in the Globe and Mail (December 13, 2017) by Geordon Omand says, “There is little to no research to support the supposed benefits of medical cannabis, and what evidence exists suggests that using marijuana as medicine may do more harm than good.” Family doctors’ associations support this statement across Canada.

There is limited evidence to suggest cannabis can reduce nausea and vomiting during chemotherapy, improve appetite in people with HIV/AIDS, and reduce chronic pain and muscle spasms.

Like any other medication marijuana is not without adverse effects. Short-term use increases the risk of both minor and major adverse effects. Common side effects include dizziness, feeling tired, vomiting, and hallucinations.

Long-term effects of cannabis are not clear. Concerns include memory and cognition problems, risk of addiction, schizophrenia in young people, and the risk of children taking it by accident. American Academy of Paediatrics opposes the legalization of medical cannabis.

The College of Family Physicians of Canada has advised its members to use cannabis for chronic pain or anxiety only for those patients who have not responded to conventional treatment. It should not be used for anxiety or insomnia.

According to the Canadian Medical Association Journal (August 9, 2016) Canadian doctors are divided about how permissive new marijuana rules should be. A recent Canadian Medical Association survey shows just over half (51.7 per cent) oppose allowing cannabis use in public spaces. Many preferred setting the minimum age for purchase at 21 or 25 (45.7 per cent).

The guidelines and policies issued to date by most medical licensing bodies consistently state that more information is required on the medical risks and therapeutic benefits of marijuana.

Physicians have been advised to have necessary clinical knowledge to engage in a meaningful consent discussion with patients.

Health care professionals, law enforcement agencies and many families are going to face lots of challenges in the futures. Hope all goes well.

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Tanned Skin is Damaged Skin

Protect your health by using broad-spectrum sunscreen, insect repellent with DEET, good quality sunglasses and a wide-brimmed hat. Apply the sunscreen first, then DEET.
Protect your health by using broad-spectrum sunscreen, insect repellent with DEET, good quality sunglasses and a wide-brimmed hat. Apply the sunscreen first, then DEET.

Blistering sun is here. People are out and about. The winter was so long that it is a relief to get out and walk, jog, golf, bike, get some tan and vitamin D and do other activities. Not to mention people enjoy some beer and barbequed meat.

While you are enjoying all that do not forget to dress properly and use sunscreen. At the same time do not forget to use DEET, good quality sunglasses and wide-brimmed hat. It is important to prevent skin cancer. Each year we go through this drill to emphasise the importance of preventing disfiguring skin cancers including lethal melanoma.

There are three types of skin cancers. Basal cell cancer (BCC) and squamous cell cancer (SCC) are not lethal but can leave you with scars and deformities. Then there is melanoma. If not detected and treated early melanoma can be lethal.

When exposed to sunrays, some people burn easily and others slowly. Those who burn easily have a higher risk of skin cancer than others. But everybody is at some risk of getting skin cancer including people with dark skin.

Here are eight Health Canada sunscreen safety tips:

  1. Choose a high SPF. Use a broad-spectrum sunscreen with a Sun Protection Factor (SPF) of at least 30. The sunscreen should also say “broad-spectrum” on the label, to screen out most of the UVA and UVB rays.
  2. Look for “water resistant” sunscreen.
  3. Read application instructions. For best results, be sure to follow the instructions on the product label.
  4. Use lots of sunscreen. Use the recommended.
  5. Apply it often. Apply sunscreen before heading outside and use a generous amount. Reapply 20 minutes after going outside and at least every two hours after that. Cover exposed areas generously, including ears, nose, the tops of feet and backs of knees. Reapply sunscreen often to get the best possible protection especially if you are swimming or sweating heavily.
  6. Protect yourself. Sunscreen and insect repellents can be used safely together. Apply the sunscreen first, then the insect repellent.
  7. Sunscreens and babies. Do not put sunscreen on babies less than six months of age. Keep them out of the sun and heat as their skin and bodies are much more sensitive than an adult’s.
  8. Test for an allergic reaction. Before using any product on you or your child check for an allergic reaction, especially if you have sensitive skin. Apply it to a small patch of skin on the inner forearm for several days in a row. If the skin turns red or otherwise reacts, change products.

All sunscreens have a sun protection factor (SPF) on their labels. Imagine that your skin normally begins to burn after 10 minutes in full sun without any protection. A 30 SPF sunscreen would provide 30 times the protection of no sunscreen. Anything higher than SPF 30 has no major advantage.

Sunscreen remains effective for three years, but it does expire, so check the date on the container. Remember, tanned skin is damaged skin and it can turn into cancer. Have a safe and wonderful summer.

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