Rambodoc at large

When it comes to the future of surgery, there are three kinds of surgeons: those who watch it happen, those who make it happen, and those who wondered what happened.
While most of the world’s surgical community would easily fall in the last category, Jacques Marescaux is one of the movers and shakers of surgical development. Marescaux wears too many laurels to enlist. An iconic surgical pioneer, he made history with ‘Operation Lindbergh’, an epochal event in 2001 when he, from New York, performed a laparoscopic gall bladder surgery on a patient 4000 miles away in Strasbourg, France. As an example of robotic telesurgery, this event opened up to the world a bewilderingly fast evolution of surgery. Surgery, as we know it today, is going to be archaic and laughable in the future. Or is it?

NO SCARS AFTER SURGERY?
Marescaux is now working on a surgical project on ‘no-scar surgery’ at the European Institute of Tele Surgery (EITS). Called NOTES (Natural Orifice Transluminal Endoscopic Surgery), this project involves research on removal of organs inside the abdomen, like gall bladder, appendix, adrenal, spleen and pancreas using endoscopes passed through the mouth, anus or vagina. In a typical procedure, a specially designed flexible endoscope is passed through the mouth and a small hole created in the stomach wall. Through this hole, the surgeon passes instruments to dissect out the target organ, eventually to extract it out through the stomach and then out the mouth. End result: no scars on the belly, no pain of cuts and wound infections! Is that really possible?
Nageshwar Reddy and GV Rao of the Asian Institute of Gastroenterology, Hyderabad, conducted the first human cases of removal of appendix through the stomach. Presenting his experience at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Conference at Dallas in June 2006, Rao said, “We put in a laparoscope in addition to doing the transgastric appendectomy just to be safe”. So, what is the safety issue here? Says Marescaux, “This approach is very difficult to use in humans because of the difficulty in closing the stomach hole. We are developing a method to close the hole that will be easier than stitches and clips, though we cannot reveal the method right now”. Why not? Companies like Karl Storz and Ethicon Endo-Surgery are pouring in millions of dollars to develop the first commercially available endoscopic NOTES device. Naturally, confidentiality is the keyword for researchers. With a spreading feeling that NOTES could change the face of surgery, work is on to be the first off the block to market the devices. Ethicon recently gave a one million dollar grant to SAGES for research on the new science.
At present frenetic work is on to develop and refine newer endoscopes that can accommodate multiple sturdy instruments through them as well as make stomach wall closure safer.

So, to repeat our question, is no-scar natural orifice surgery realistic?
Moshe Schein, author of multiple surgical books and Associate Editor of the World Journal of Surgery, is critical: “The idea is superficially appealing. But, to me, violating the integrity of the stomach wall to take out the gallbladder is against the basic rules of surgery, including the KISS principle (Keep It Simple, Stupid). Do you really want to produce a hole in the stomach, and then having to fix it—risking leaks—in order to take out an appendix or gallbladder? Not on me!” Marescaux, ever the visionary, is clearly optimistic, “ I believe NOTES is more minimally invasive than the laparoscopic approach, though I don’t know if this will replace laparoscopy in the future”. When will we see it in action, in the real world beyond animal labs? “One to two years ” is his stunning assertion.
Richard Satava, Professor of Surgery, University of Washington Medical Center, Seattle sums up: “The most important feature of this new approach will be if there is significant improvement for the patient over current laparoscopic procedures – success must be determined by patient outcomes.”


ROBOT: MASTER OR SLAVE?

Contrary to popular notion, robotic surgery does not mean the surgeon being replaced by a robot. The four- armed robot, wielding cameras and multiple instruments, is merely the slave by the patient’s side, obeying commands from its master, the surgeon, who sits outside on his console, moving his hands on joystick equivalents while looking at his own monitors. The interposition of machine between surgeon and patient eliminates the surgeon’s hand tremors. In addition, the three-dimensional ‘In-Site’ ten-fold magnified vision makes surgery easier and safer. The robot can maneuver its instruments like a human wrist, something that is impossible in laparoscopic surgery, making complex operative steps easier.
Ashok Hemal, Professor of Urology at the AIIMS in New Delhi and formerly at Vatikutti Urology Institute, Henry Ford Hospital, says, “Mani Menon and his team there have done around 2700 robotic radical prostatectomies, with excellent results”. Menon has standardized this traditionally bloody and complex operation for prostate cancer by using the da Vinci robot. The artist Leonardo, who conceived the world’s first robot, is now the flag bearer in name not only of a best selling book by Dan Brown but also of the fast evolving field of surgical robotics. This robot is a virtual monopoly product of Intuitive Surgical, a $260 million US company, with 509 installations around the globe. India has four of these, with AIIMS holding two, Escorts Heart Institute at New Delhi and The Cardiac Research and Education Foundation at Hyderabad accounting for the rest. So why are heart hospitals going in for the da Vinci?
Operations like coronary artery bypass and mitral valve reconstruction can now be done by the key-hole approach and are being touted as two of the most marketable robotic procedures, apart from radical prostatectomy, hysterectomy and weight loss (bariatric) surgery.
Thought by many to be the future of surgery, robotics does not come cheap. The da Vinci is priced at $1.7 million (nearly seven crore rupees), with an additional annual service contract of more than $100,000. Each procedure needs instruments that cost between $1000 and $1500, provoking people like Schein and Danny Rosin to scoff at the benefits. Rosin, Senior Surgeon at Sheba Medical Center, Tel Aviv University questions whether “it is a solution waiting for a problem”. Hemal is cautious, “This expensive technology needs a good surgeon. By itself, it cannot make for good results. Robotics only expands the horizons of laparoscopic surgery, it cannot replace it”. In the US and Europe, robotic procedures are increasing, with more than 8000 prostatic cancers coming under the da Vinci’s arms every year. In India, though, hospitals are doing very little work to justify the huge investment. At AIIMS, Hemal has done 50 robotic radical prostatectomies.
While rare and difficult to implement, robotic telesurgery is evolving. Like Operation Lindbergh, the surgeon operates from a distance, using a sophisticated telecommunications system using high output fiber optics that results in little transmission delay. Mehran Anvari of McMaster University in Hamilton, Ontario, Canada performs advanced robotic surgery in North Bay, 300 km away from where he sits at his hospital.
Mobile robots are also being used for simpler jobs, like seeing patients from home or office. The RP-6 mobile telemedicine robot made by a Californian company called In-Touch is a robotic platform with a flat-panel monitor supported by a telemedicine connection. The nurse can go with the robot on rounds, and the patient can see and converse with the doctor over the telemedicine link. Satava remarks, “There has been surprisingly good acceptance of this technology, especially where physicians do not have much time for rounds. Patients quickly become accustomed to seeing their doctor on the video monitor, and frequently prefer this method of communication because the surgeon takes more time and has better eye contact with the patient – rather surprising!”

NO SMALL MATTER:
The world’s first medical micro robot, invented by Dmitry Oleynikov, Associate Professor, Department of Surgery, University of Nebraska Medical Center looks like a lipstick case and can navigate inside the abdominal cavity on wheels and tracks, capturing pictures with its own inbuilt camera and lights, all the while being controlled by an external remote control. Though the device today can do little beyond biopsies and recording pH, temperature and pressure, it is of sufficient potential for NASA to be interested in exploring its possibilities in space.

An Israeli company, GI View Ltd., is developing a new technique for screening colonoscopy called ‘Aer-O-Scope’. This device propels and navigates itself up the colon when placed in the rectum. Moshe Schein, in spite of being known as a conservative surgeon, is enthusiastic about the tech: “Recent studies show that GI physicians miss polyps during screening colonoscopy. I think it is because they are doing too many of these procedures per day (often up to 30) to do a complete check. Now imagine a small robot with a video camera, traveling on minute tracks, like a Merkava Tank, inserted in the rectum, walking up through the colon, and photographing everything. The video is loaded into a computer and interpreted.”

John Mellinger, Chief of Gastrointestinal Surgery, Medical College of Georgia, who recently wrote an article on Endoluminal surgery in Surgical Endoscopy says, “The entire colonic status is seamlessly reconstructed from the images we get from this painless procedure”.

AN EYE FOR PERFECTION:

Every surgeon makes mistakes. Often human anatomy and disease create illusions in appearance that fool even the most expert eyes and hands. During a gall bladder surgery, the bile duct can be injured, as can the urinary tube (ureter) during removal of the uterus, each with devastating consequences. If the surgeon could see each structure clearly separate from the other, it could reduce or eliminate injury. Augmented Reality, initially a neurosurgeon’s guide map, is now a high priority at Marescaux’s European Institute of Tele Surgery (EITS). EITS have developed software to reconstruct laparoscopic images in 3D system. The patient first undergoes a CT scan that a computer reconstructs in 3D and in color. Therefore, veins are colored blue, arteries red, and so on. When the patient is on the table for surgery, the CT reconstructed images are superimposed on the monitor that is showing the actual operation in real time. Marescaux demonstrates this in the laparoscopic removal of an adrenal gland tumor, where he uses the technology at will to show the perfect location of the major veins that lurk beneath the fat. Injury to these veins could lead to massive bleeding and death. Now, here is a method for reducing surgical errors and improving patient safety! Danny Rosin thinks this concept is “a promising technology that is not that far from more widespread use. The success of stereotactic neurosurgery with navigation systems is a proof that this can be useful.”
Marescaux is convinced that the future of abdominal surgery lies in Augmented Reality combined with Robotics, in both laparoscopic surgery and NOTES ‘no-scar’ surgery. As the rest of the world looks on, Marescaux uses a Persian phrase: "The madman forces doors, the wise follow”. As one preparing for it today, tomorrow seems destined to be his.