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Last year, when 47-year-old San Diego resident Linda Qua had her gall bladder removed, her doctor took it out through her vagina as part of a clinical trial for a procedure known as “natural orifice surgery,” or NOTES (Natural Orifice Translumenal Endoscopic Surgery), in which surgeons operate through the mouth, vagina, or even rectum, eliminating the need for a large incision.
After an episode of severe abdominal pain, an ultrasound revealed what Qua calls “a big ol’ honkin’ gallstone,” about the size of a marble. When she was put in touch with Dr. Santiago Horgan, a professor of surgery and director of minimally invasive surgery at the University of California San Diego Medical Center, who told her about NOTES, she was sold. She had undergone surgery in her teens for scoliosis and was not too keen on the idea of being cut open again: her back surgery had necessitated a 24-inch incision, which took four painful weeks to recover from. Given the chance to avoid another such incision, she took it.
In fact, it is the incision itself, not what goes on inside the body, that so often makes surgical recovery a horrendous experience for patients. Qua entered the trial and underwent a surgery that took less than two hours. In it, Dr. Horgan made a small internal incision at the top of her vagina, through which he con- ducted the operation. Because the operation is still in its trial stage, a tiny external incision in Qua’s belly button was also made for the camera placement, but this incision was negligible from Qua’s point of view, and will be phased out over time. “It’s so neat,” Qua says of the belly button incision. “You can’t even tell where [it] was.” And as for the pain? “Seven days later, exactly to the day—no pain. I could touch it, mush it, squish it—no pain.” There was no internal pain, either, and a reduced risk of infection because the operation was conducted inside of her body’s own sterile environment. Being part of a clinical trial wasn’t scary; on the contrary, Qua received extra personal attention from her doctors. In turn, she kept a journal of her experience for them.
Dr. Horgan, the most experienced NOTES doctor with 46 completed cases at the time of this writing, is part of NOSCAR, the Natural Orifice Surgery Consortium for Assessment and Research, and says NOSCAR believes all natural orifice surgeries should be under clinical trial at present. Even though all devices used in NOTES surgeries are FDA-approved, and trials are reviewed for patient welfare by the university’s internal review board, Dr. Horgan strongly cautions that the procedures are not ready for widespread use. “We are testing the waters and asking ourselves, does this make sense to push forward?” So far they think it does. He adds, “We need more technology. One thing is to say UCSD can do it, another is to say anybody can do it.” NOTES procedures performed at UCSD through the mouth and vagina are gall bladder removals (called cholecystectomies) and appendectomies, as well as an obesity surgery called a sleeve gastrectomy, which has been performed via the vagina. “Earlier this year, when we removed an appendix through the mouth, I was truly amazed! [These advances] represent a radical change in the way we do surgery,” he says.
And radical changes are in the works all the time, though the general public may not be aware of it.
Laparoscopy (known as “closed” surgery), which be- came widespread in the 1990s, is routine in many pro- cedures, although many patients are still pleasantly surprised by not being cut open from sternum to pubis.
Laparoscopy (known as “closed” surgery), which became widespread in the 1990s, is routine in many procedures, although many patients are still pleas- antly surprised by not being cut open from sternum to pubis. TV programs like Grey’s Anatomy frequently show surgery as big and bloody, with surgeons up to their gloved wrists in handfuls of bright-red gore, yet many standard surgical procedures are carried out by a surgeon viewing his or her own work via video, and the only thing getting bloody is a small length of the instrument. During laparoscopic surgery, the surgeon makes a few tiny incisions—about the size of a pea—through which to place a fiber optic cable for light, a camera lens system that hooks up to a video screen, and surgical instruments. Then the surgeon ma- nipulates the instruments while viewing his or her work on a video screen.
That’s not all. Dr. Maria Bell, a Gynecologic Oncologist practicing at Sanford Clinic Women’s Health in Sioux Falls, South Dakota, regularly uses a robot to perform closed surgeries like hysterectomies. The robot, a da Vinci Surgical System manufactured by Intuitive Surgical of Sunnyville, California, is not an android like Star Wars’ C3PO. Instead, picture a laparoscopic setup, but the surgeon controls the instruments from a console a few feet away. Dr. Bell, who’s been using the robot for four years, emphasizes that it’s not a robot performing surgery but a doctor controlling the robot, and lists several advantages of using it. “First of all, the instruments articulate like the human wrist does—more, actually,” giving the surgeon greater dexterity for turning, twisting, incising, and suturing, “and there’s a camera for the left eye and one for the right eye, so it’s 3-D, which is very important when dissecting delicate tissues . . . I can see everything and look around. For surgeons, it’s more ergonomic; you’re not standing at a table looking down.”
Perhaps one of the greatest patient advantages to robotic surgery is the ability to attach miniscule instruments—say, a fingernail-sized scalpel—to the robotic arms, and then magnify the image on the screen, allowing surgeons to perform “microsurgeries” in a kind of Inner Space reality, cutting only necessary tissue and leaving other structures intact, like the blood vessels and nerves surrounding the prostate that control sexual function. The result? Many patients can resume a normal sex life after a recovery made even quicker by tiny incisions instead of the six-inch scar of the past.
Before robotics, recovery from a hysterectomy with a standard ten- to twelve- inch incision could take four to six weeks, but the robotic surgery that Brenda Gordon underwent in 2006 to remove her cancer-ridden endometrium—along with her uterus, ovaries, cervix, and fallopian tubes—left her feeling what she describes as “mild discomfort,” but no pain. She also reports feeling a strong level of energy because she didn’t lose much blood during the surgery, as is typical in open surgeries. Her procedure, which was performed by Dr. John Boggess of the University of North Carolina in Chapel Hill using a da Vinci robot, permitted her to get back to her normal activities, including mile-long walks in the woods near her home, within a matter of days. In Gordon’s case a quick recovery was particularly important, because the radiation and chemotherapy she underwent a few weeks later would take all of her body’s strength and reserves to endure.
Dr. Horgan, the natural orifice surgeon at UCSD, gives a great deal of credit for surgical advancement to the field of biomedical engineering, which has fueled invention of new devices used for closed surgeries. “Now we are seeing that we have focus groups of engineers dedicated to bringing new technology to medicine,” he says. Returning the praise is Dr. Michael Neuman, Professor and Chair of the Department of Biomedical Engineering at Michigan Technological University in Houghton, Michigan, and editor-in-chief of Engineering in Medicine and Biology magazine, who credits success to bright minds from many different backgrounds coming together in his field. “Biomedical engineering looks at a problem and asks the question, is there a better way for doing this? [In many cases] along came someone who said, we don’t have to do it this way. Let’s reduce trauma to the patient.”
Projects in the works in the field of biomedical engineering are: the implantation of an artificial heart and trials of a visual prosthesis that can give very limited sight for certain types of blindness. Like Dr. Horgan, Dr. Neuman cautions that devices and procedures under clinical trial are not cause for proclaiming victory from the rooftops. “The type of sight the visual prosthesis gives is very limited . . . no one’s going to be able to read with that.” Still, it could help some blind people be more mobile and independent.
Though techniques like laparoscopy, which is nearly twenty years old, continue to amaze us, there are new developments all the time. According to cancer survivor Brenda Gordon, that’s an important reason to do your own research, choose a doctor you’re confident in, and ask about your treatment options, because something better just might be available. “You really, really have to take your health care into your own hands,” she emphasizes. “I can’t say that enough.”
The robotic surgical team at Sanford USD Medical Center.
