Cutting-edge surgery
Robots, cameras making minimally invasive operations routine
By Shari Roan
Los Angeles Times
Journal Gazette | 07/03/2006 | Cutting-edge surgery
The doctor sits in a darkened corner of an operating room about 10 feet from the gurney where his patient lies. His surgical team is staring at several large, flat-screen video monitors hanging from the ceiling.
On screen is a colon, shiny and pink. The patient is barely visible, shrouded in surgical sheets and dwarfed by a refrigerator-sized, four-armed robot positioned over his body.
But Dr. Alessio Pigazzi and his surgery team at City of Hope in Los Angeles are getting the best view and access. The robot holds slender surgical instruments, a tiny camera and a light, all threaded through dime-sized openings in the abdomen. The monitors reveal a bright, nearly bloodless landscape, magnified 10 times.
Using hand controls and foot pedals, Pigazzi controls the robot from a console, sliding the instruments into the tight confines of the rectum where a cancerous tumor sits – a space nearly impossible to see without the technology at his disposal.
“There it is,” he announces.
This is 21st-century surgery – little blood loss, rapid healing and minimal scarring – and it’s quickly replacing surgery in which scalpels slice long, bloody incisions through the body.
“People will soon look back at any large incision as barbaric and archaic,” says Dr. Paul A. Wetter, chairman of the Society of Laparoendoscopic Surgeons and a professor emeritus of gynecology at the University of Miami.
In the last few years, minimally invasive surgery has evolved from a popular technique used for simple abdominal surgeries – a gallbladder removal or hernia repair – to a method that can treat life-threatening cancer, heart problems and emphysema.
An increasing number of these surgeries are augmented with sophisticated computer and imaging technology such as robots. These techniques elevate ordinary doctor skills to the super-human level by providing magnified, high-definition images and by preventing mistakes, such as cutting into the wrong tissue.
Some doctors are even taking the first steps toward operating without incisions, using the body’s natural openings – nose, mouth and anus – to gain access to its inner workings.
Think of it as surgery without scars.
“Anything you can think of is now fair game,” says Dr. Gary H. Hoffman, a surgeon at Cedars-Sinai Medical Center in Los Angeles. “It’s to the point now where surgeons know no boundaries and are boldly trying to do all kinds of things.”
The first minimally invasive surgery, a gallbladder removal, was performed by surgeons in France in 1987. Today, as many as 90 percent of gallbladder surgeries are “laparoscopic” – minimally invasive surgery performed through the abdomen.
In these surgeries, dime-sized openings are made in the abdomen for the insertion of a tiny camera, fiber-optic light and instruments for cutting and cauterizing tissue. The surgeon manipulates the instruments while watching the movements on a monitor.
Most patients undergo the procedure as outpatients. They can return to normal physical activities shortly thereafter. In contrast, traditional gallbladder removal involves several days in the hospital, much more pain and four to six weeks of recovery.
Hernia repairs, appendectomies, even gastric bypasses are also routinely performed with small incisions in the abdomen. These operations are the first step in the evolution of minimally invasive surgery.
“This first stage is sort of like where the first automobiles were,” Wetter says. “They were made with bicycle parts. Modern vehicles are nothing like that. We’re moving into a new phase in which instruments are designed with minimally invasive surgery in mind instead of taking big instruments used in open surgery and just miniaturizing them.”
Some physicians are using minimally invasive techniques in spinal fusion surgery (which traditionally requires a 6-inch incision in the back). Others are using the methods to remove part of the bowel in people with Crohn’s disease, to replace faulty heart valves and to repair aortic aneurysms. (Open cardiac surgery typically requires a lengthy incision through the chest and the splitting of the chest bone to expose the heart.)
Still other surgeons are repairing the anus or intestines in infants with birth defects, removing women’s ovaries or uterus without opening the abdomen and removing kidneys from live donors while saving them significant pain and recovery time.
More far-reaching may be surgeons’ growing enthusiasm for removing cancer without making a large incision. Cancers of the colon, rectum, esophagus, kidney, liver, lung, uterus and prostate are offered as minimally invasive procedures at a growing number of hospitals.
Cancer surgery has traditionally been governed by the premise that more is better – the more tissue removed, the greater the chance for a cure. But traditional invasive surgeries leave many cancer patients too weak to start chemotherapy or radiation for several weeks. Minimally invasive cancer surgeries allow patients to move swiftly to the next phase of treatment.
Colon cancer surgery is at the forefront of this trend. According to Solucient, a health-care information company, minimally invasive colon surgeries surged by 32 percent from 2004 to 2005. About 150,000 people in the United States are diagnosed with colorectal cancer each year, and as many as 20 percent of such surgeries are performed with the less-invasive techniques.
Jerry McCampbell, a science teacher from Idyllwild, Calif., discovered he had colon cancer in February. Now, after experiencing both minimally invasive and traditional surgery, he has no doubts about which type he prefers.
In the March surgery, Pigazzi removed McCampbell’s tumor through several puncture-like openings in his abdomen and a 2-inch incision in the abdomen for a temporary colostomy (an opening in the colon to the outside for passing waste). Weeks later, the colostomy was removed and the colon reattached in a traditional surgical procedure.
“After the first surgery, I was barely on painkillers at all,” says McCampbell, 56. “But after the second surgery, I couldn’t get enough painkiller. The pain was out of control. It took about three weeks to recover from that surgery.”
A shorter overall recovery time is not the only advantage. McCampbell lost about half a cup of blood during his initial surgery, far less than the five to six cups typically lost in a similar open surgery, says Pigazzi said.
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