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Quest for the Perfect Crime

The tools of minimally invasive surgery are becoming smaller and stealthier.

By Charles Slack // Spring 2006
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Surgical tools

John Offenbach

To reach deep within the twisting confines of the digestive tract, surgeons thread flexible tools such as (left to right) an IT knife, Coagrasper, triangle tip knife, hook knife and Hot Claw through their endoscopes to grasp and snip tissue. For natural orifice surgery to succeed on humans, surgeons will need even smaller and more flexible instruments, possibly including voice-activated controls and tiny robots.

Surgeons targeting organs in the abdominal cavity rely on stealth and subterfuge to sneak past the body’s complicated network designed to recognize and attack all invaders. First using endoscopes, then laparoscopes (and maybe someday the new instruments of natural orifice surgery), they make ever smaller incisions and employ less invasive equipment—inching toward surgery’s age-old goal to leave no trace at all.

Endoscopy

In 1853 the French surgeon Antoine Jean Desormeaux used a “Lichtleiter” to look inside patients. The device used lenses and mirrors and was lit by a turpentine-and- alcohol-burning lamp outside the body. In the early 1900s, lightbulbs allowed physicians to insert the light source into a patient, through the mouth or anus. The introduction of fiber optics (which transmit light and pictures around curves) in the 1950s and ‘60s made it possible for surgeons to peer deep inside the stomach and intestines.

Today, sophisticated probes, cameras and monitors enable physicians to diagnose and treat such gastrointestinal problems as tumors and bowel disease. Still, most endoscopy is confined to the digestive tract.

Laparoscopy

In the early twentieth century, physicians began using small scopes to diagnose liver disease and other ailments. But it was not until the 1980s that minimally invasive laparoscopic surgery made its great advance, when surgeons began inserting instruments (including digital cameras that produced clear, real-time images) through small incisions in the abdominal wall. Laparoscopic gallbladder removal, first performed in 1987, is now routine.

Because incisions are small, laparoscopy patients experience significantly less pain than they would with open abdominal surgery. Hospital stays have dropped from several nights to overnight for many procedures, and recovery is swift.

Natural Orifice Surgery

During the late 1990s, Anthony N. Kalloo of Johns Hopkins came up with the idea of inserting an endoscope through the mouth or anus and cutting a hole in the stomach or colon to reach other organs that required surgery. Initial trials on pigs show successful recovery from surgery performed on gallbladders, ovaries and other organs. But the tests also highlight the need for further advances such as better tools and improved methods for closing the stomach hole.

If human trials (beginning in two to five years) succeed, NOTES could be used for many procedures now done laparoscopically. Benefits for patients may include no external scarring, less pain and faster recovery than with current techniques.

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Down the Hatch

scarless surgery

A new opening could lead surgeons past endoscopy and laparoscopy to a procedure that leaves no scars.

A New Step in Scarless Surgery

Years ahead of schedule, doctors perform on humans a surgery that involves reaching internal organs via the mouth or other natural orifices.

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