During the past two decades, three technologies have introduced drastic changes in the way pioneers in surgery meet the needs of some of their more unique patients. At the top of the list is anesthesiology. Most of the major surgical advancements in recent years would not have been possible without modern techniques in this medical specialty. Anesthesiologists today must consider many more issues than they did before the 1960's, which introduced the modern era of anesthesiology. Second on the list is minimally invasive surgery, such as laparoscopic or “keyhole” surgery. Surgeons have realized the need to overcome problems of space and inaccessibility while achieving a unique surgical solution. Finally, the most modern technological developments have been in the field of robotics, an amazing new approach that affords the surgeon ground-breaking techniques in solving patients' unique problems by enlisting the help of robots, imagery and computer technology.
Much of the success in surgical advancement is due to the efforts in the field of anesthesiology. Where once chloroform and ether were the principle tools of anesthesiologists, more advanced techniques and medications are available to suit the particular circumstances of patients and procedures. Today over half of the surgical procedures performed are classified as day surgery, requiring limited time in the hospital and limited use of general anesthesia in which case the patient was put into a deep, controlled sleep. More often, anesthesiologists employ the injection of medications, either at the surgical site or through intravenous routes so that the patient is either awake throughout the procedure or in a “light” sleep. Recovery time is usually much quicker and hospital stays are much shorter as a result.
In the Delivery Room, expectant mothers are afforded a much broader range of anesthesia than before. At one time, mothers in labor relied only on inhalants, such as ether or chloroform. This resulted in “sleepy babies” and was far more dangerous for mother and child than local injections. Today medications can be delivered through epidural routes, which are less dangerous for the mother and child, less painful for the mother and often controlled by the patient herself.
In the Operating Room, anesthesiologists have at hand much more sophisticated tools, which enable them to monitor, not only the vital signs of their patients, including pulse, blood pressure and respiration, but also levels of carbon dioxide and oxygen in the blood and most important, the status of the total delivery system of anesthesia. With more sophisticated anesthesia have come more advanced surgical procedures requiring smaller incisions and less invasive techniques that offer the patient less pain and a better chance of shorter recovery and hospital stay.
Minimally Invasive Surgery
Often referred to as “Keyhole Surgery,” these procedures require much smaller incisions, thus affording the patient a less painful recovery and less chance of infection. While the procedures themselves are not particularly new, the technological developments during the past two decades have been impressive. Early in the development of laparosopic surgery, where a laparoscope is used to view the surgical site through an opening in the abdomen, the instruments were rigid and cumbersome. The surgeon was required to hold the scope up to his eye throughout the surgical procedure. This precluded more complex procedures requiring both hands. In 1982, with the development of the computer chip, a tiny television camera could be attached to a flexible scope. An image of the surgical site could then be projected on a monitor and thus the surgeon's hands could be free to carry out more complex procedures. Laparoscopic surgery is used increasingly today as a means to reduce the shock of surgery and to minimize exposure of the patient to infection. One history-making case in Kuala Lumpur in 2011 highlights the technological advancements and benefits of this revolutionary procedure.
On October 24, 2011, Dr. Dayang Anita Abdul Aziz performed surgery on a 14 day old infant to remove 95 percent of his pancreas, making this the first surgery of its kind in the world for patients under the age of 30 days. The patient's pancreas was producing excess insulin causing the blood glucose to drop, resulting in a hypoglycemic state. If not controlled, this could result in brain damage or death. The patient was not only unique because of his age, but also he did not respond to any medications that would reduce his insulin output. The only choice left was surgery, and in this case, the best choice was laparoscopic, or keyhole surgery.
Dr. Dayang began by inserting a small laparoscopic camera through the child’s navel so that she could view the pancreas on a high definition screen. She then inserted the necessary surgical instruments through a small incision, less than 3mm in length, on either side of the abdomen. With the help of the high definition images, she proceeded to cut the pancreas into small pieces, removing each piece one at a time. She describes the procedure as being like “building a ship in a bottle with tiny tweezers.”
The procedure took over two and one half hours and was a total success. The patient has since gone back home. “He is doing so well,” says Dr. Dayang, “that he will not need any follow up treatment until he is four months old.”
Laparo-Endoscopic Single-Site Surgery, or the LESS Approach, developed by Olympus, represents a significant technological advancement in laparoscopic procedures and affords the surgeon greater flexibility and accuracy in making surgical repairs. The Triport, also developed by Olympus, is a multi-channel single port that was specially developed for single-site surgery. According to Olympus reports, it allows up to four instruments to be passed into the abdomen simultaneously through one small, 10 to 25mm incision that is usually made in the umbilicus, or navel. This technology replaces formerly used trocars. The combination of the LESS System and the TriPort gives surgeons much more flexibility and precision during the laparoscopic procedure. A valuable extension to minimally invasive surgery is the technology of robotic assisted surgery.
Often, surgeons require the help of robotic technology to perform procedures in very tight places. Even with modern laparoscopic techniques the range of motion is so limited that it is extremely difficult to reach, turn and otherwise function. Robotic systems afford an increased range of motion, enabling the surgeon to rotate 360 degrees when necessary to accomplish a task. Robotic systems, such as the da Vinci Surgical System, also allow surgeons to operate in much less invasive ways during laparoscopic surgery, with more precision and better visualization than standard keyhole surgery. Even with this capability, surgeons still long for a more realistic tactile sensation while using robotic systems during their more delicate procedures. They would like to receive tactile feedback as if they were touching the instruments and feel the pressure of the tissues being handled. Thanks to a new technology involving HAPTICS, tactile feedback is close on the horizon of technological developments. At Johns Hopkins University, researchers are developing Haptic systems that will give surgeons the tactile feedback they need to perform more delicate procedures as if they were using their own hands. This is perhaps the closest surgeons will come to “feeling” the tissues beneath their hands as they perform minimally invasive procedures in a confined space.