BIG SURGERIES, SMALL INCISIONS

Sure, the doctors were alert, but they were also very relaxed. Most stood around, looking at the monitor, where the insides of the patient8217;s heart could be seen magnified several hundredfold. Others lounged about, talking, joking and even attending to the occasional phone call. Some even laughingly offered to take off their masks for the benefit of our photographer.

Part of the ease was probably because this was a 8216;8216;robotic surgery8217;8217;, perhaps the ultimate in high precision, minimally invasive procedures. Still, the man in the hot seat, in this case the 8216;8216;console8217;8217;, from where he conducted the operation, Dr Yugal Kumar Mishra, managed to keep a running commentary going for our benefit.

But isn8217;t a beating-heart bypass surgery a very complicated procedure that requires extreme concentration? 8216;8216;This is simple,8217;8217; Mishra laughs, rubbing his hands in excitement. He could talk. After all, this was perhaps the 351st 8212; or was it the 352nd 8212; robotic surgery presided over by the man who took over as the director of cardiovascular surgery after Dr Naresh Trehan. The patient, he explains, will be up and about in around 10 days, compared to the 30-45 days in an ordinary surgery, where the chest has to be completely opened.

That is the beauty of the 8216;8216;minimally invasive8217;8217; procedures, where instead of incisions of five inches and more, all the work is done by instruments inserted into the body through three or four half-inch cuts. Result: The trauma is reduced to a fraction, the recovery is faster and even the pain is much less.

8216;8216;Only three places in India have the facility of robotic surgery,8217;8217; one of his teammates proudly says, 8216;8216;including the All India Institute of Medical Sciences8217;8217;. Part of the reason is that the medical community is divided over the necessity of the

Rs 12-crore instrument. Most agree that a robotic surgery is only essential for really complicated and time consuming processes, like removal of a cancerous prostrate gland, in which a 10-hour procedure can be reduced to two hours.

The essential instrument in minimally invasive surgery is the scope, explains Dr Arun Prasad, Senior Consultant of Apollo Surgical Centre8217;s Minimal Access Surgery. Also known as endoscope, this is a thin rod-like instrument, mounted with a tiny video camera and a powerful light, which functions like a telescope, projecting the magnified interior view of the body onto monitors.

The rest of the instruments include the usual scissors, forceps and the rest, about 2 to 3 mm in size, also mounted on thin rods, which are inserted into body through hollow rods called canulae, which hold the half-inch incisions open.

The technique is not new. Dr Jacobeus performed the first visual examination of abdominal organs in 1910. But in 1987, Phillip Mouret performed the first such operation in France.

Laparoscopic cholescystectomy, or removal of the gall bladder through laparoscopy translated from Greek, laparoscopy means examination of the abdomen through a scope became popular only in the 1980s. And in the 1990s, in view of its advantages, surgeons started using the minimal invasive procedure for the spine and other parts of the body. In India, Tempton Udwalia of Mumbai8217;s Hinduja Hospital is accepted a pioneer by most.

Currently, this process is applied for diagnostic and therapeutic processes in the brain, heart, organs in the chest and abdominal cavity, reproductive and genito-urinary organs and even some orthopaedic problems. 8216;8216;It can be used for removal of fluids, tumours and cysts, glands like prostrate and thyroid, organs like gall bladder, appendix, spleen, kidneys, uterus and even spinal discs,8217;8217; says Prasad.

8216;8216;When applied to the brain and spinal cord though,8217;8217; points out Dr D V Rajkumar, Consultant Neurosurgeon, Wockhardt hospitals, Bangalore, 8216;8216;the word we use is not minimally invasive. It is minimal access.8217;8217;

The reason being that the idea is not only to invade in minimum, but access only the portion required. In conventional open surgeries of the spine, where, for example, a damaged disc has to be removed, not only a 6 to 7 inch incision is required, it is also necessary to dislodge the muscle mass that holds the spine in place and strengthens it. 8216;8216;Thereafter, even though the wounds heal, the area remains weakened and may in future give rise to further complications,8217;8217; he says.

In fact, so small can be in the incision and so reduced the trauma, some operations can be done under local anesthesia, says Dr Vikas Gupte, Consultant Neurosurgeon, Wockhardt Mumbai, who is one of the few doctors in India to have conducted 8216;8216;slipped disc surgery in the awake state8217;8217;. In some cases, such incisions can be closed by a single stitch, says Dr Gupte, a specialist in Percutaneous Endoscopic Cervical/Lumbar Discectomy. Similar is the case of the brain.

8216;8216;Years ago, a tumour removal involved opening up a considerable portion of the skull,8217;8217; says Dr Rajendra Prasad, Senior Consultant, Neurosurgery and Spinal Surgery, Apollo, whose father too, had been a neurosurgeon. 8216;8216;Today, we can zero-in on the exact area and operate using the smallest possible incision, using only local anesthesia in some cases.8217;8217;

The process is hugely aided by 8216;8216;neuronavigation8217;8217;, where a CT scan is reformatted into a three-dimensional image to give the exact location of the affected area. 8216;8216;This is so specific that we could extract a bullet from the head of a man and in another case, accommodated the wishes of a 10-yr-old girl, who insisted on not shaving her head fully,8217;8217; adds Prasad.

Elsewhere, doctors have confined the incision to the eyebrows, where they can be effectively concealed, says Dr Deepu Banerji, Consultant neurosurgeon, Wockhardt Hospitals, Mumbai. And some brain tumours are even being accessed and extracted through the nose in what is called 8216;8216;trans-nasal tumour extraction8217;8217; in medical parlance.

The process, which has been in use in India and abroad since the mid-90s, has perhaps given rise to other ideas.

8216;8216;The more sophisticated version of the surgery that has been developed lately is the Natural Orifice Transluminal Endoscopic Surgery, also known as NOTES,8217;8217; says Dr Arun Prasad.

In this, instead of the half-inch incisions in the visible regions of the body, surgeons use the natural orifices like mouth, anus and even the vagina to access the internal organs. Hysterectomies have been traditionally done in the minimally invasive process through the vagina, but in NOTES, the surgeons have started accessing organs in the abdominal cavity.

The process is yet to gain currency and current research in the US at Columbia University in March and University of California, San Diego in September and has been confined to a few human trials. Reports of a successful laparoscopic surgery through vagina at the University Louis Pasteur in Strasbourg, France had hit the headlines also in September.

The biggest advantage of the minimal invasive surgery, according to Dr Arun Prasad, however, is the collaboration between different disciplines, that is of immense help to the patient.

8216;8216;For example, earlier due to the limitations of different diagnostic techniques, some symptoms could have been suspected to be due to a gastroenterological disorder, but was actually a gynaecological problem. There was no way of pinning it down. But now, if during the operation, I find the internal organs in order and suspect the problem lies elsewhere, I can call a gynaecologist and get it solved on the spot.8217;8217;

Moreover, in cases where a patient requires more than one operation at a time, like a hysterectomy and gall bladder excision, it would have meant two different sets of operation. But now, both operations can be done at one go through the same set of incisions by a gastroenterologist and a gynaecologist. Likewise, gastroenterological and thoracic problems, can too be fixed at once through the collaboration of surgeons from different disciplines. And such collaborations, he says, are only bound to increase.

For Paediatric gastroenterologist Dr Anupam Sibal of Apollo hospitals, minimal invasive surgery means a whole new realm of relief.

8216;8216;Operations on children can be difficult both for the child and the parent. Not only is it difficult to keep the patients quietly in bed for days in hospitals, looking after a sick child for a long post-operative period can be a trauma for the parents,8217;8217; he says. Minimal invasive surgery for kids ensure that in most cases, the hospital stay for children can be minimised to even a day. And the post-op period can be significantly shorter.

So what is the future of minimal access/invasive surgery?

For Dr Arun Prasad, not only does it mean more collaborations, but smaller incisions too as the surgical instruments become smaller. 8216;8216;Currently we have instruments of a diameter of 10 millimeter. But already instruments of 3 millimeter diameter are available and used. Though, because they are delicate, they cannot be used for too many procedures,8217;8217; he says.

Dr Rajkumar agrees. 8216;8216;Earlier we used to say 8216;big surgeons use big incisions8217;. Now it is 8216;big surgeons use small incisions8217;. Incisions used to be measured in inches. Now it is in centimeters and millimeters. I believe we are looking at a time where there would be no incisions at all. The various non-invasive techniques using gamma rays and X-Rays that are already used to arrest and shrink the smaller brain tumours, will be modified to eliminate surgery largely.8217;8217;