Surgeon Without Scalpel

Dr. Pradeep P. Sharma

FALS (Hon), FIMAS (Hon), FISCP (Hon), Fellow (Israel)

Big Surgeons Always Take Big Incisions

This was taught to us many decades back during our surgical residency. However it was found that BIG INCISIONS were associated with more postoperative pain thereby prolonging the hospital stay, wound associated morbidities like dressings, cosmesis, infections, dehiscence, hernia, keloids etc thereby delaying the time of back to work. In this era of fast food and fast life style, every one of us yearns to get back to work as early as possible. Hence surgeons started exploring the possibility of performing the same surgeries but through smaller incisions. This was the basis of the beginning of the era of what is called as MIS – Minimal Invasive Surgery.

Advances in the technology aided in the rapid development of the MIS. High definition 3 chip camera which could be inserted into the body cavities through incision as small as 5 to 10 mm gave an inside pictures of the organs with better clarity and magnification than seen by naked eye. Hand instruments as thin as 2 to 5 mm made movements in the body cavity as precise as the hand movements in open surgery. Energy sources like Harmonic Generator, Ligasure and Enseal made the surgery nearly bloodless even through these small incisions. Staplers made possible joining the intestines together as good as or even better than open surgery. Xenon and LED light sources gave illumination so good to visualize all the intricacies of the operative field thereby even helping to avoid damage to neighbouring structures.

Till few years ago, MIS only meant a Lap Appendicectomy, Lap Cholecystectomy and maybe a Lap Hernia repair. Today the principles of MIS have been incorporated in almost all the specialties of Surgery like Gynecology, Orthopedics, Neurosurgery, Cardiothoracic Surgery, Pediatric Surgery, Oncosurgery, Bariatric Surgey etc.

Even in the field of General Surgery it has expanded to include the following:
  1. Robotic Surgery
  2. Single Incision Laparoscopic Surgery: SILS
  3. Hybrid Laparoendoscopy
  4. Video Assisted Thoracoscopic Surgery: VATS
  5. Video Assisted Neck Surgery: VANS
  6. Transanal Endoscopic Surgery TEM / TAMIS / TEO
  7. Natural Orifice Transluminal Endoscopic Surgery: NOTES
  8. Hybrid NOTES Surgery

    Let me brief you regarding all the above techniques.

    Robotic Surgery

    I am sure you all must be aware of the Robot or in short a human like machine which can perform a task as good as or even better than a human hand. The same principle is used in Robotic surgery. Da Vinci Robot has been developed wherein the instruments are inserted like Laparoscopic Surgery through small punctures. These are connected to the robotic arms (these vary from 2 to 4 arms depending upon the generation of the robot). The operating surgeon sits on the console and performs the surgery indirectly controlling the robotic arm by mimicking finger movements. Advantages of Robotic surgery are precision due to 3 D vision, ease of movement, avoidance of human fatigue and tremors during prolonged surgeries, performing movements at difficult angles not possible in open and laparoscopic surgery etc. Disadvantages include the high cost presently due to the equipment installation cost, cost of disposables, extra time required in docking the robot. The morbidity is same as Laparoscopic surgery as the surgery is performed through same small punctures. It is a misconcept that Robotic Surgery is foolproof and autonomous. NO……… it is not so as ultimately it is under the human control. It can make mistakes if the surgeon sitting on the console is inexperienced. One has to remember that a Robot cannot make a bad surgeon excellent or good.

    Single Incision Laparoscopic Surgery: SILS

    In this technique we take a 5 to 7 mm incision in the umbilical cicatrix and insert the SILS port through the same. The viewing camera and operating instruments are passed through the same port. The ultimate effect is a single incision. Advantages of this technique are improved cosmesis as the incision gets hidden in the umbilicus and reduced . Disadvantages are prolonged operating time due to clashing of instruments (chop stick effect). Presently Appendicectomy, Cholecystectomy, Hernioplasty, Sleeve Gastrectomy are done by the SILS technique.

    Hybrid Laparoendoscopy:

    Endoscopic surgery like Colonoscopic and Gastroscopic Surgeries have been quite well established. Removal of Polyps, Early cancers, Foreign bodies are commonly removed by such techniques. Sometimes, when such lesions are present as inaccessible points in the gastrointestinal tract, one can perform Laparoscopy during the same time, manipulate the organ and provide assistance to the Medical Gastroenterologist.

    Video Assisted Thoracoscopic Surgery: VATS

    Thoracic pathologies mostly require a large incision over the thorax entailing cutting large part of the thoracic muscles and sometimes even cutting and / or removal of the ribs. Thoracotomy is associated with lot of pain and discomfort in the post operative period as well as respiratory complications. Many a times such pain can continue for months together thereby delaying return to work. Applying the principles of MIS in thoracic surgery can help to reduce the morbidity associated with thoracotomy. Presently we are performing surgeries like Decortication, Lobectomy, Thymectomy, Oesophagectomy, Sympathectomy through the video assisted procedures. VATS does not require any special instrument. However it requires a Surgeon to be experienced with Open thoracic surgery.

    Video Assisted Neck Surgery: VANS

    Surgeries on the neck entail large incision on the neck which can entail significant cosmetic problems. Presently commonly performed surgeries like Thyroidectomies can be performed through small incision placed away from the neck in the axilla. However the technique is still under evaluation.

    Transanal Endoscopic Surgery: TEM / TAMIS / TEO

    MIS can be performed through Endoscopy passed through the anal canal in the same way like the SILS and procedures for benign sessile polyps, rectal prolapsed, early stage cancers, advanced cancers in elderly unfit patients can be performed though this technique. Thus, a major Laparotomy with all its associated complications can be avoided.

    Natural Orifice Transluminal Endoscopic Surgery:

    NOTES Performing a surgery along with avoiding a scar has always been the dream of any surgeon. Laparoscopic surgery though minimally invasive, still involves small incision over the body. NOTES surgery involves passing endoscope through one of the Natural lumens like the Oral cavity, Anal canal, Vagina in a female, Urinary bladder in a male. Presently, the technique is in its infancy as lack of a rigid platform is the main obstacle but as the technology advances I am sure most of the surgeries would be done through the natural orifices. Imagine removal of Gall Bladder, Appendix and Colon without an incision over the body. Vaginal Hysterectomy can possibly be considered as one of the first NOTES Surgery and I am sure all of you are aware of the advantages of this technique. POEM Per Oral Endoscopic Myotomy for Achalasia Cardia is now rapidly establishing as an alternative for Open or Laparoscopic Surgery and is another classic example of the NOTES surgery.

    Hybrid NOTES Surgery:

    In some of the laparoscopic surgeries, we have to take an incision to remove the organ (Esp. when the organ is large) which has been excised laparoscopically e.g. Lap. Spleenectomy, Lap Hemi / Total Colectomy , Lap Pancreatectomy, Lap Liver resection etc. In case, of a female patient such retrieval of the organ can be done through incision in the natural orifices like the rectum and vagina thereby avoiding large incisions over the exposed part of the body.

    In Nutshell: So to conclude, Minimal invasive surgery MIS is making rapid in stride in almost all the fields of surgery. Technology is advancing day by day and is helping the surgeons to perform surgeries through smaller and smaller incisions with lesser and lesser morbidity. Those days are not far when almost most of the surgeries would be done without any incisions over the exposed body.