Minimally Invasive Surgery

by Dr. Philip S. Chua.

Sept 18, 2010
The trend in surgery today is towards minimally in vasive techniques, all geared for patient comfort, lesser blood loss, lesser pain, lesser morbidity, shorter hospital stay, faster recovery, less obvious scars. These procedures are performed by surgeons specially trained in robotic surgery and/or minimally invasive surgery.
For example: while standard open cholescystectomy (surgical removal of the gall bladder) requires a 5-8 inch incision in the right upper quadrant of the abdomen, all laparoscopic cholecystectomy needs are four small one-inch ports (thumb-size incisional holes), which post-operatively are smaller and much lesser painful compared to the large incision in the open technique.
The Access and Monitoring
The abdominal cavity (or the chest, for heart, lung and esophageal surgery) is accessed thru small ports, and the cavity is inflated with carbon dioxide (safe and harmless for this purpose) to provide a large and unobstructed view of the organ being operated on, as the rest of the other organs are pushed away from the operative site.
Trocars (5-10 mm. tube cylinders) are inserted through the thumb-size ports, and through one of these trocars is inserted a flexible fiberoptic scope with a lens (lighted magnifying video-camera) at the tip, which will send real time and live images to a TV monitor for everyone in the operating room to view as the surgeon manipulates the various instruments to perform the surgery. Thru the other ports are inserted the long stem needle (suture) holder, scissors, grasping/dissecting instrument, endoknife, suction tip, etc. The images on the monitor are magnified to about 5 the normal size of the structures for easier surgery.
The Surgical Procedures
Minimally invasive procedures are now performed for almost all surgeries: neuro (brain and nerves), cardiovascular (heart and blood vessels), gastrointestinal (food pipe, stomach, intestines, pancreas, liver, gall bladder), orthopedic (bones), and gynecological (womb, tubes, ovary).
The “Non-surgical” Procedures
The following are the minimally invasive medical procedures: endoscopy (scoping the food pipe, stomach or colon), sub-dermal implants (pacemaker and IV access ports), arthroscopoy (scoping the knee), endovascular surgery (intra-arterial surgery), spinal and brain electrode implants, coronary angiogram and angioplasty/stenting, interventional radiology, etc.
Just like in conventional surgery, there are possible complications that could occur with minimally invasive procedures. Reaction to medications or anesthesia, a bit of hypothermia, internal organ injury, bleeding, infection, blood vessel tear, blood clots in the lungs, breathing problem, and rarely, death.
While the minimally invasive surgery benefits the patient a lot, it is harder technically for the surgeon, because of the space and mobility restriction inherent in minimally invasive procedures.
Conversion to Open
When uncontrolled bleeding, organ damage, or lack of clarity as to the anatomy is encountered, or when the patent does not tolerate the procedure, with unstable vital signs, a conversion to the conventional open technique, with the standard full incision, is done in a timely fashion, usually “ASAP,” within minutes, to enter the chest or abdomen, whichever the surgical site is.
Robotic Surgery
In 1985, with CT scan guidance, a robot, the PUMA 560, was used to place a needle thru the skull for brain biopsy. Three years later, the PROBOT, built by Imperial College London, was utilized to do prostate surgery. Four years thereafter, in 1992 Integrated Surgical System’s ROBODOC milled “out precise fittings in the femur for hip replacement.” The robotic systems was refined and Intuitive Surgical came out with the da Vinci Surgical System.
Like playing most of the computer games at home or in game parlors today, where the players use joysticks to control the desired moves, the da Vinci robotic machine requires the even more precise hand-eye coordination in a new spatial dimension the surgeon has to get used to. With training and more frequent application, the operator gets to be adept at it.
Remote or Telesurgery
Telesurgery, also known as remote surgery, a form of telepresence, is an operation performed on a patient in a hospital by a surgeon who is at another location. This new technique in surgery has been used in the battlefield army makeshift hospital where the patient’s trauma required a surgical specialist not available on site.
This cutting edge science combines the elements of robotic system and today’s lightning speed communication technology, like high speed data connection and management information system. Telesurgery is “an advanced telecommuting for surgeons, where the distance between the surgeon and the patient is immaterial.” This makes available the expertise of a super-specialized surgeon to any patient anywhere in the world, and allow such surgeon to do surgery with neither of them traveling.
The Lindberg Surgery
On September 7, 2001, a remote surgery was performed across the Atlantic Ocean by Dr. Jaques Marescaux in New York. One of the earliest such telesurgery done, it was a gallbladder operation on a patient 6,330 kilometers away, in Strasbourg, France. The surgery was called Project Lindberg, honoring Charles Lindberg’s transatlantic flight from New York to Paris.
Unmanned What?
If the Lindberg was mind-boggling, here’s one that will surely bring back the memory of R2D2 in the 1977 Star Wars classic: Unmanned robotic surgery.
The first unmanned robotic surgery was performed in Italy in May 2006.
As a cardiac surgeon, I am concerned that human surgeons might soon be out a job, as the robots, the RoboDocs, take over.
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