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Minimally invasive surgery, the cutting edge

Munther J Haddad MBBCH FRCS (Glasgow) FRCS (Eng) FRCPCH
Consultant Paediatric & Neonatal Surgeon & Service Director
Chelsea & Westminster Hospital, London, UK
Honorary Senior Lecturer Imperial College School of Medicine
President of the British Association of Paediatric Endoscopic Surgeons  



muntherSince the beginning of the 20th century physicians have promoted laparoscopy as a valuable adjunct to the diagnosis of diseases of the abdominal cavity. In 1918, Goetze developed a needle which was characterized for its safe introduction to the peritoneal cavity. In 1938, Veress of Hungary developed a specially designed automatic spring-loaded needle, which although was not originally intended for laparoscopic purposes, this design would later develop into the Veress needle which is now the most important instrument to create a pneumo-peritoneum in modern-day laparoscopy.  Kurst Semm, a German gynaecologist, invented the automatic insufflator in 1966, which was capable of monitoring intra-abdominal pressures, thus reducing the dangers associated with insufflation of the abdomen and allowing for safer laparoscopy. This would later be known as the Semm insuff lator. It was the development of fibre-optics in the 1960s that allowed for the introduction of these two key areas of  laparoscopic technique: illumination of the operative field and image transduction, which further paved the way for the  wider application of laparoscopy in the 1970s. By the late 1970s laparoscopy was embraced by gynaecologists and had been thoroughly incorporated into their practice. Many gynaecological laparoscopic procedures were being performed in the operating room under sterile conditions, with Patrick Steptoe at the forefront of this.  It wasn’t until 1987 when the first video-laparoscopic cholecystectomy was performed by Phillipe Mouret, in France, that laparoscopic procedures began to revolutionise general surgery. This single new operative approach to gall-bladder removal gave rise to such enthusiasm among general surgeons, that it paved the way for other innovative laparoscopic procedures to be sought after. 
Since then the field of minimally invasive surgery has seen tremendous growth. During the 1990’s other abdominal  surgical applications of laparoscopy began to emerge, and there saw rapid development and acceptance of this  revolutionary new form of surgical therapy. Laparoscopic cholecystectomy has become not only the most desired form of  biliary surgery, but also the standard of care.
 As the 21st century advances, laparoscopic surgery is completely changing the outlook of surgical operations and has gradually phased out general surgery. This modality is now being increasingly demanded by patients due to the greater advantages minimally invasive surgery can deliver. Recently, the major drive in surgery has been the development and application of minimally invasive approaches to  traditional operations. In general surgery laparoscopic techniques can now be applied to the majority of intra-abdominal  procedures with evidence suggesting that the reduction in trauma to the abdominal wall and the physiology of the pneumo-peritoneum has a positive impact on patients undergoing abdominal operations. Therefore, it is evident to see that in surgery of the abdomen and peritoneal cavity open surgery is gradually being substituted by laparoscopic surgery due to the greater benefits the latter entails for the patient.

  • Less anesthesia/analgesia
  • Less blood loss, postoperative pain, and discomfort
  • Less body trauma/less scar tissue formation
  • Less risk of infection
  • Shorter hospital stay
  • Faster recovery/return to normal daily activities and work


  • Limited surgical field vision due to loss of 3D visualization
  • Loss of hand-eye coordination
  • Limited motion skills of hands, wrists, and fingers
  • Loss of sense of depth
  • Difficult sutures and ligations due to instrument rigidity
  • Lack of ergonomics causes discomfort, fatigue, and stress


The development of robotics

Although the benefits over open surgery are sizeable it can still be seen that laparoscopy itself has several  inherent drawbacks. Firstly, the three-dimensional operative field is reduced to a two dimensional image on the video unit.  Secondly, the use of long rigid instruments distances the surgeon from the patient’s tissue, which results in reduced  tactile feedback and spatial orientation. Thirdly, it would seem laparoscopic instruments have a reduced degree of  flexibility and are limited to up/down, left/right, in/out and rotational movements. Lastly, and some would argue more significantly it seems laparoscopy has evolved with little consideration for the comfort and ergonomics of the surgeon with many procedures resulting in awkward operating positions thus generating stress and fatigue. Frustration with the limitations of laparoscopic instrumentation and optics has encouraged the development of robotics within surgery. 
Although robotics has long been used in industry its adoption in surgery has been slow.  Laparoscopic surgery presents significant limitations such as a loss of the sense of depth in the abdominal cavity, tactile sensation and resistance, as well as loss of natural hand-eye coordination, manual dexterity and motion  limitations. Although skilled surgeons learn to adapt to these differences over time an integral benefit for the  development of surgical robots is the possibility of eliminating such limitations. 
The first robot widely used in laparoscopic surgery was AESOP, the Automated Endoscopic System for Optimal Positioning (AESOP) Robotic System. The first FDA approved robot available in the United States was the DaVinci® system, which was released by Intuitive Surgical Inc. (Sunnyvale, CA) on July 11, 2000. It comprises of a surgeon’s console with a high-definition three-dimensional vision system and two ports in which the surgeon places his hands. In addition to this there is a patient-side robotic cart with four arms manipulated by the surgeon. One arm is used to control the camera whilst articulating surgical instruments can be mounted on the three additional arms and introduced into the  body through trocars. The camera used in the system allows for true stereoscopic vision and depth perception.
The surgeon’s hand movements are now electronically translated to end effectors on the laparoscopic instruments  which increase instrument flexibility and dexterity allowing for much easier suturing and knot tying. The robotic computer can now eliminate hand tremor as well as providing motion scaling allowing for finer, more detailed work. Somewhat disturbingly, the DaVinci robot fully separates the surgeon from physical contact with the patient. 
However, the console does allow for a neutral body position, with arm and head rests which greatly improves the surgeons comfort during the procedure. Also, if the surgeon was to be fully separated from the patient the risk of sharps injuries is completely eliminated.
A laparoscopic cholecystectomy was performed in 1997 using a prototype of the Da Vinci® surgical system yet it was not until 2002 that first total robotic-assisted laparoscopic colectomy was reported in which actual tissue dissection and mobilization were performed using robot-assisted technology. 
Fundamentally, the primary objectives of robotic-assisted surgery are involved with restoring three-dimensional optics, developing intuitive controls and minimising operating time whilst at the same time transforming the procedure into an ergonomically comfortable experience for the surgeon.

Natural orifice transluminal endoscopic surgery (notEs): a new frontier in minimally invasive surgery?
The evolution of surgery over the past two decades has been one towards minimizing the incision no matter the  complexity of the operation undertaken. This, however, raises the question: “How can minimally invasive surgery become even more minimal?” Traditional flexible endoscopy, it seems, has been limited to the confines of the gastrointestinal lumen,  however, recent developments involving transluminal access to intra-abdominal structures holds the potential to revolutionize flexible endoscopy. Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a newly emerging surgical technique that involves the intentional puncture of one of the viscera (e.g., stomach, rectum, urinary bladder) with an endoscope to access the abdominal cavity through a natural bodily orifice such as the mouth, anus and vagina. 
In essence NOTES is a method of accessing the abdominal cavity through a natural orifice under endoscopic visualization.  The premise being to go beyond the luminal confines of the gastrointestinal tract to perform intra-abdominal procedures. With existing flexible endoscopic instrumentation, the wall of the viscera will be punctured and an endoscope advanced into the peritoneal cavity via natural orifices through a viscotomy, to perform various procedures. After the intervention is finished,  the scope will be pulled back into the stomach and the puncture closed. 
So far, reports in animal models indicate the use of this technique for procedures such as diagnostic exploration, liver biopsy, cholecystectomy, splenectomy, and tubal ligation. Currently, research has been confined to animal models, but it has been suggested that human experience has been gained by Dr. G.V. Rao and Dr Nageshwar Reddy at the Asian Institute of Gastroenterology, Hyderabad, India, where trans-oral, transgastric appendectomies have been performed.
Unlike standard surgical approaches, which require incisions to be made in the abdominal wall, NOTES completely avoids the need for abdominal incisions and therefore can offer specific advantages to select patient populations. Whilst early laboratory work focused on feasibility studies contemporary ones are investigating the development of the tools and techniques required for complex abdominal operations. 
NOTES has just recently entered the clinical arena, and may be considered to be the next frontier in minimally invasive  surgery yet a number of questions have been raised: ‘Is there a true clinical advantage to avoiding incisions in the abdominal wall?’, ‘Can the visceral wall be closed safely and reliably?’, ‘Does the flora of the natural orifice lead to peritoneal infection?’, and ‘Who should perform these procedures and how should the individuals be trained?’. 
These techniques have the potential to become an important component of surgical practice yet collaboration with industry is critical to the development of effective and novel advanced technologies and instruments capable of meeting the demanding and specific requirements of such a technique. Although still in its infancy, NOTES has the potential to further revolutionize the field of abdominal surgery.

Where do we see laparoscopic surgery 20 years from now? Although the potential of robotic surgery and NOTES is  just emerging, progress may come quickly. Laparoscopic gallbladder surgery was first performed in 1987, yet it became standard within five years. Minimally invasive surgery is becoming ever more minimal and the potential in combining NOTES and robotics is only starting to become evident.
Already, one research group has commented on the constraints on visual feedback and dexterity in NOTES and has developed small mini-robots which are inserted via a small gastrostomy into the peritoneal cavity and are controlled wirelessly. In June 2007 Scientists at the Technion University in Israel unveiled a micro-robot of only 1 mm in diameter that has the capacity to move within the human bloodstream. 
From this, one can surmise that future remote handling technology may well overcome the manipulative  restriction in current techniques, and some years from now surgeons could well be operating exclusively via a computer  interface. If computer-controlled machinery can mimic the awareness, adaptability and knowledge of a human surgeon technological improvements could lead to a new generation of robots and instruments that may well replace human surgeons altogether.
As we look to the future we must take a step back and ask ourselves how such advancements in surgical technique develop. Are such advancements bounded solely by the development of new instruments within industry, or by a lack of innovation on the part of the surgeon? Or, furthermore, is it a collaboration of the two that is needed for true progress?
Whilst it may be hard to pinpoint such a notion presently, I suppose we will just have to wait and see.