Surgical frontier holds promise for patients

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.

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 superhuman 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.

Dr. Gary H. Hoffman, a surgeon at Cedars-Sinai Medical Center in Los Angeles, says, “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-size 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.

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 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 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 traditionally has 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.

The procedure boomed after a 2004 report, nicknamed the “COST study” and published in 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.

Robots and other high-tech tools are pushing the limits of minimally invasive surgery, making complex treatment possible and appealing.

Compared with standard 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 “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.

“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 the University of California, Los Angeles. “Because of the nature of the robot, you can operate in tighter spaces.”

More hospitals are offering prostate removal via robotic-assisted, minimally invasive surgery because it reduces the risk of complications – 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.

Likewise, robotic surgery may prove to be useful in gynecologic surgery, where laparoscopy has not caught on because of the time 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.

The advances don’t stop with robots.

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 surgeons who are removing baseball-size tumors through the nose. 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 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 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 that was compressing the brain.

“I predict this will become a mainstay of neurosurgery,” says Kassam, co-director of the Minimally Invasive endoNeurosurgery Center.

Surgeons also hope to eventually enter the body through the mouth or anus, extending flexible instruments far into human anatomy and leaving the external surfaces without 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.