A physician from Uganda wrote to Misgav Ladach, a Jerusalem hospital: "I have only praise for your method, which is so painless for both doctor and patient." An obstetrician from Karachi, Pakistan, ended his letter: "I find this method fast, with minimal blood loss and minimal expense for hospital and patient a useful advantage for any medical center, but especially for those with limited resources such as ours." A doctor from Bikar in India even went so far as to say: "I feel this to be the single most important development in obstetrical surgery [in the past 85 years].".
by Wendy Elliman
Michael Stark, MD, medical director of the Misgav Ladach Hospital, originated the new method of performing the operation the removal of an unborn infant from the womb when a natural delivery would put mother or child at risk. "Its basically simple," he says. "I put together ideas and techniques from many different sources (notably those developed by Prof. S.J. Joel Cohen, formerly of South Africa), and managed to eliminate many of the steps taken in conventional C-sections. Because far fewer steps are performed, the procedure takes very little time eight to 15 minutes, instead of half an hour to an hour which means less anesthesia is needed. Theres also far less cutting, which means less bleeding and less suturing. And because of this, after surgery patients have less pain and less need for painkillers, less chance of fever and so less need for antibiotics, and a far faster return to normal functioning."
"It all went so quickly," describes one of Dr. Starks patients. "After just two minutes, I heard the baby crying. It was my second C-section. The first was a traditional one performed three years ago in the US. Then, I was hooked up to an infusion and couldnt eat or drink normally for two days. I was in bed for almost a week. This second time, when I was at Misgav Ladach, was completely different: I was on my feet within hours of surgery, I could eat and drink the same day, and I was even able to bend down and pick things off the ground."
The success of the new technique is, says Dr. Stark, because of its minimalist approach. "I believe in using only those surgical maneuvers which are vitally necessary, those which are least disruptive to the tissues," he explains. "If you can do something simply, you dont need to do it in a complex way. So, for example, I select a level of skin incision and separation of certain muscles well away from muscle insertion sites, so that less force is needed to open the incision, and vulnerable blood vessels and nerves thus suffer less damage. When ending the procedure, I suture the uterus with one layer of sutures rather than two, and close the abdomen with two layers of sutures rather than five. Its like plucking the strings of a musical instrument in the middle, rather than at the ends."
The analogy is especially close to home. As well as a physician, Dr. Stark is an accomplished pianist and a graduate of the Jerusalem Conservatory of Music. "In music, Im an esthete, a minimalist, always looking for the simplest techniques, for a way to play as smoothly and effortlessly as possible. So when I began looking for ways to improve C-sections, I looked for surgically minimalist approaches, both theoretical and practical."
The benefits of Dr. Starks surgical minimalism carry over from the patients to the hospitals and their personnel. With less cutting, bleeding and suturing, fewer instruments are needed. With the new procedure taking only a fraction of the time needed for the conventional method, operating room and staff time are reduced. And with markedly fewer short- and long-term complications, overall health-care expenses are decreased.
Since the Misgav Ladach team published a description of its new technique in the International Journal of Gynaecology and Obstetrics last year, it has been used in medical centers in Switzerland, Sweden, Italy, Germany, the US, Russia, Ethiopia, Kenya, Tanzania, Zambia, Uganda, India, Pakistan, Laos, Vietnam, China and Peru. The method has been tested in trials in Sweden, Italy and Kenya, and non-randomized comparative studies have been conducted in Israel and Switzerland.
Until the end of the 19th century, three of every four women who underwent Caesarean sections could expect to die from the procedure. The refinements and improvements in surgery, anesthesia and asepsis in the 20th century resulted in most women and their infants surviving C-sections, albeit with up to a month of extreme discomfort for the mothers. As we stand on the brink of the 21st century, new thinking in Israel has made childbirth by C-section safer, more economical and immensely easier on the mother, the baby and the surgical team.