I say endoscopy, you say laparoscopy
When a little incision is a big deal
By KRISTA CONGER
Laparoscopic, endoscopic or minimal-access surgery. Whatever you call it, the benefits to the patients are the same: less pain, quicker recovery and smaller scars. That’s because surgeons choosing this approach forgo a traditional, open incision and instead thread a long, narrow lens outfitted with a fiber-optic light and camera into a dime-sized incision near the surgical site. While the proceedings are projected onto a video monitor, specialized instruments are threaded through additional tubes to perform the grasping, cutting and cauterizing that are the bread and butter of any surgery.
Such technical wizardry didn’t spring fully formed from the floor of the operating room. Although the Spanish physician Abul Kasim experimented with a lighted, mirrored speculum around A.D. 1000, the first productive endoscopic endeavors date to the early 1800s when physicians used the technique to examine a patient’s urethra and bladder.
Researchers graduated in the early 1900s from using the body’s natural orifices to creating their own entry points in the abdomen with small incisions, a kind of endoscopy known as laparoscopy. Similar techniques in the chest cavity are known as thoracoscopy. Although endoscopy was at first mainly used for diagnostic purposes, the technique’s surgical promise soon became apparent. In 1987 physicians in France performed the first successful laparoscopic gall bladder removal, and now many other procedures are conducted using a minimal-access approach.
However, the pluses for patients add up to minuses for surgeons, who trade the three-dimensional vision and unrestricted access of open surgery for the two-dimensional view of an external monitor and the limited machinations of instruments that are pale imitations of human hands and wrists. Minimal-access surgery also imposes a new, sometimes counterintuitive set of rules for physicians.
“There are a number of mental adjustments that must be made when you put a cannula or endoscopic tool through the abdominal wall,” says Thomas Krummel, MD, chair of surgery at Stanford and surgeon-in-chief at Packard. “In order to move the tip of the instrument to the left, you move your hand to the right, and vice versa. You also need to consider whether you’ve given yourself enough working space, how many incisions may be necessary and where they should be placed.”
Robotic surgery can overcome some of these problems. Modified endoscopic tools, manipulated by a robot in response to a surgeon’s hand and foot movements, can more closely mimic the dexterity of the human wrist and provide a 3-D experience in a specialized viewing box. In addition, a robot’s movements can be more precise and steady than those of mere mortals.
However, current instruments do a relatively poor job of providing the force feedback that tells a surgeon whether the sutures are tight enough or if an obstructing organ is being handled too roughly. Also, the machine is so large that it can be difficult to arrange around a tiny baby to achieve the proper angles.
Despite these drawbacks, many surgeons feel that human-controlled robots are the future of surgery. Pediatric surgeon Sanjeev Dutta, MD, collaborates with the engineering think tank SRI International to design future iterations of the technology.
“We’d like to miniaturize many of these tools to allow them to reach smaller and smaller areas like the cochlear space of the ear or very tiny ducts,” says Dutta, who brings medical students to his laboratory to work with engineers in the development process.
If he has his way, someday tiny robots will circulate through our bodies, operating from the inside out to remove arterial plaque or rejigger faulty heart valves. Controlling these micro-robots might well be the surgeon of the future’s greatest challenge.
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