Time to retire the scalpel?

THE doctor sits in a darkened corner of an operating room about 10 feet from where his patient lies on a gurney. Members of his surgical team stand around the room’s periphery, staring at several large, flat-screen video monitors hanging from the ceiling.

On screen is a colon, shiny and pink. The patient himself is barely visible, shrouded in surgical sheets and dwarfed by a refrigerator-sized, four-armed robot positioned over his body.

He almost appears to be alone, even adrift, with a team of physicians and nurses trying to reach him from afar.

In reality, surgeon Alessio Pigazzi and his team at City of Hope are getting the best possible view and access. The robot’s arms hold 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 commands 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 -- with little blood loss, rapid healing and minimal scarring -- and it’s quickly replacing surgery in which scalpels (in, hopefully, steady hands) slice long, bloody incisions through the body. In this dynamic movement, doctors aim to fix the body without hurting it.

“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 only the last few years, minimally invasive surgery has evolved from a popular technique used for the simplest of abdominal surgeries -- such as a gallbladder removal or hernia repair -- to a method that can treat even life-threatening diseases such as cancer, heart problems and emphysema.

An increasing number of these surgeries are augmented with sophisticated computer and imaging technology -- such as robots. Such 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 tentative steps toward operating without incisions, using the body’s natural openings -- the 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 clinical attending surgeon at Cedars-Sinai Medical Center. “It’s to the point now where surgeons know no boundaries and are boldly trying to do all kinds of things.”

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Evolving procedure

The first minimally invasive surgery, a gallbladder removal, was performed by surgeons in France in 1987. Today, as many as 90% of gallbladder surgeries are laparoscopic (minimally invasive surgery performed through the abdomen).

In these non-robot-assisted surgeries, several 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 from outside the body while watching his or her movements on a monitor.

Most patients undergo the procedure as outpatients. They are back at work within a few days and 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.

Now hernia repair, appendectomy, even gastric bypass are also routinely performed with only small incisions in the abdomen. These operations have proved to be but 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 reduce lung capacity in emphysema patients, to remove part of the bowel in people with Crohn’s disease, to replace faulty heart valves and to repair aortic aneurisms. (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 time spent recuperating.

The benefit goes beyond the immediate patient. “Minimally invasive surgery has increased the number of people willing to donate their kidney,” says Dr. Chandru Sundaram, director of minimally invasive urologic surgery at Indiana University School of Medicine.

The more far-reaching advance, however, may be in surgeons’ growing enthusiasm for removing cancer without making a large incision. Cancers of the colon, rectum, esophagus, kidney, liver, lung, uterus and prostate are now 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 invasive surgeries leave many cancer patients so weak that they are unable 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 healthcare information company, minimally invasive colon surgeries surged by 32% from 2004 to 2005. About 150,000 people in the United States are diagnosed with colorectal cancer each year, and as many as 20% of such surgeries are now performed with the less invasive techniques.

The procedure boomed after a 2004 report, nicknamed the COST study and published in the New England Journal of Medicine, showed that patients who have minimally invasive surgery have no higher rates of cancer recurrence than traditional, or open, surgery patients.

Before that study, doctors worried that using minimally invasive techniques might cause cancer to spread because surgeons couldn’t see all of the cancer and might leave some behind or because cancerous cells might break off from the tumor during removal and spread to other parts of the body, Hoffman says.

Jerry McCampbell, a science teacher from Idyllwild, 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 body for passing waste). Several 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, who adds that he felt good within a week. “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.”

Dr. Joel Bauer, vice chairman of the department of surgery at Mount Sinai Hospital in New York City, says the overall recovery time is the primary benefit of minimally invasive surgeries. “The big difference is not that we can send them home a day or two earlier,” he says. “The big difference is in the six weeks or so after the surgery. These people are at least two weeks ahead [in their long-term recovery] at every stage.”

A shorter overall recovery time is not the only advantage, however. McCampbell lost only about half a cup of blood during his initial surgery, far less than the five to six cups that are typically lost in a similar open surgery, says Pigazzi, head of minimally invasive surgery at City of Hope. A transfusion was not necessary, a big advantage because transfusions can temporarily weaken the immune system and lengthen recovery time.

Moreover, cancer patients with minimal incisions can begin chemotherapy and radiation treatments weeks sooner than open-surgery patients, giving any remaining cancer cells less time to grow before the secondary treatments are applied.

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Robo-surgeon

Now robots and other high-tech tools are pushing the limits of minimally invasive surgery, making complex surgery ever more possible and appealing.

Compared with straightforward laparoscopy, robotic surgery allows doctors a magnified, three-dimensional view of the body, increases the surgeon’s dexterity and range of motion and removes hand tremors.

Although the value of robots is hotly debated (one doctor calls the robot at his hospital “a fancy coat rack”), more surgeons are turning to the technology for operations in areas of the body that are hard to reach and even harder to see, such as the pelvis. In McCampbell’s surgery, for example, robotic surgery helped minimize the risk of a permanent colostomy, Pigazzi says. The tumor was so deep in the rectum that traditional surgery could have permanently damaged the sphincter and surrounding nerves.

“It’s like operating inside of a Coke can,” says Dr. E. Carmack Holmes, professor of surgery at the David Geffen School of Medicine at UCLA. “Because of the nature of the robot, you can operate in tighter spaces.”

More hospitals are also now offering prostate removal via robotic-assisted, minimally invasive surgery because this approach seems to reduce the risk of serious complications -- such as urinary incontinence and impotence -- that can occur in open prostatectomy. A 2003 study in the Journal of Urology found that open-surgery patients lost five times as much blood, had four times the risk of complications and remained in the hospital three times longer compared to robotic prostatectomy. Robotic-procedure patients regained urinary function in about six weeks -- four times faster than open patients -- and also had much improved sexual function.

More than 30,000 robotic prostatectomies are projected for 2006, up from about 8,000 only two years ago.

“Robotic prostatectomy is rapidly becoming the procedure of choice for that type of disease,” says Pigazzi. “With minimally invasive robotic surgery I can see those nerves better. Our goal is to see things better and have better outcomes.”

Likewise, robotic surgery may prove to be useful in gynecologic surgery, where laparoscopy has not caught on because of the time the gynecological procedures tend to take. The sole robot approved for use in the United States, the Da Vinci Surgical System, was granted Food and Drug Administration approval for use in gynecological surgeries last year.

Proponents of robotic surgery predict the technology will also spread because it’s easier for surgeons to learn compared with the training involved in laparoscopy. Fifteen hospitals in Southern California now have the $1.5-million Da Vinci system.

“The application of robots in minimally invasive surgery is new, and it’s receiving a lot of hype,” says Holmes. “Having a surgical robot has sort of become a status symbol for hospitals.”

The advances don’t stop with robots.

A dozen medical technology companies are devising computerized simulators that will allow young surgeons to practice performing minimally invasive surgery before they take their act into a real operating room.

And at Purdue and Indiana universities, engineers and surgeons are designing a new generation of smaller, less expensive robots that could provide surgeons with tactile feedback, says Sundaram. That project is in its early stages.

“The next step in robotics is in cost, size and application,” he says. “It should be applicable to more surgeries.”

Future surgical robots will likely provide better images to the surgeon, says Sundaram. For example, information from CAT scans, MRIs and PET scans could be programmed into a robot, allowing a doctor to “see” what is behind a structure, such as a blood vessel, crucial nerve or adjacent organ. “You could feed information into the robot and then it will not allow you to cut a vital organ” by mistake, he says.

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Phasing out incisions

The most mind-bending frontier is natural orifice surgery.

“We’re moving toward the kind of surgery where the person wakes up and doesn’t realize anything has been done,” Hoffman says.

Dr. Amin Kassam of the University of Pittsburgh Medical Center, is among a handful of U.S. surgeons who are removing even baseball-sized tumors through the nose, expeditions that are gradually creeping further into the brain. The traditional approach to removing brain- and skull-based tumors is a craniotomy. It requires surgeons to make a long incision across the forehead, then peel back the skin of the face and open the top of the skull with a saw.

In endonasal surgery, however, Kassam threads a camera and specially designed surgical instruments through the soft nasal tissue and network of air cavities. He then drills a hole the size of a thumbnail in the skull and enters the brain to reach the tumor. Large growths are broken into small pieces and pulled out, one by one, through the nose without disturbing surrounding brain tissue.

So far, he has used the technique to remove a variety of head, neck and eye tumors within his reach (he can’t go everywhere in the brain just yet), to treat a brain aneurism and, in one patient, to remove the upper part of the spine which was compressing the brain.

Kassam’s preliminary data on cancerous tumors shows no higher rates of recurrence -- although definitive, long-term data is still years away.

“I predict this will become a mainstay of neurosurgery,” says Kassam, co-director of the Minimally Invasive endoNeurosurgery Center. “But my concern is that people learn to do this the right way. We took nine years to learn to do this. It’s important that it be done in a cautious and meticulous manner.”

Surgeons also hope to eventually enter the body through the mouth or anus, extending flexible instruments into far reaches of the human anatomy and leaving the external surfaces without so much as a stitch. Doctors could make an incision in the stomach wall, for example, to gain access to the abdominal cavity. Such work is in the early stages, but researchers at Johns Hopkins University and elsewhere have done these types of operations on animals.

The benefits of that approach are a long way from being proven. But each operation performed with as little trauma as possible inches surgery toward its gentler future.

Four hours after his March operation began, Jerry McCampbell was on his way to recovery, his tumor handed over to the pathology lab for study, and Pigazzi was rushing to his next appointment, confident his patient had received the most curative and comfortable solution he can offer. “One of the worst things you can do in any field,” Pigazzi says, “is be on the wrong side of progress.”