Not evena scar

Among the innovative techniques in surgery, The most mind-bending is the natural orifice procedure

The doctor sits in a darkened corner of an operating room about 10 ft from the gurney where his patient lies. His surgical team is staring at several large, flat-screen video monitors hanging from the ceiling. On screen is a colon, shiny and pink. The patient is barely visible, shrouded in surgical sheets and dwarfed by a refrigerator-sized, four-armed robot positioned over his body.

But Dr Alessio Pigazzi and his surgery team at City of Hope in Los Angeles are getting the best view and access. The robot holds slender surgical instruments, a tiny camera and a light, all threaded through dime-sized openings in the abdomen. The monitors reveal a bright, nearly bloodless landscape, magnified 10 times. Using hand controls and foot pedals, Pigazzi controls the robot from a console, sliding the instruments into the tight confines of the rectum where a cancerous tumor sits8212;a space nearly impossible to see without the technology at his disposal. 8216;8216;There it is,8217;8217; he announces.

This is 21st-century surgery8212;little blood loss, rapid healing and minimal scarring8212;and it8217;s quickly replacing surgery in which scalpels slice long, bloody incisions through the body. 8216;8216;People will soon look back at any large incision as barbaric and archaic,8217;8217; says Dr Paul A. Wetter, chairman of the Society of Laparoendoscopic Surgeons and a professor emeritus of gynecology at the University of Miami.

In the last few years, minimally invasive surgery has evolved from a popular technique used for simple abdominal surgeries to a method that can treat life-threatening cancer, heart problems and emphysema. An increasing number of these surgeries are augmented with sophisticated computer and imaging technology such as robots. These techniques elevate ordinary doctor skills to the super-human level by providing magnified, high-definition images and by preventing mistakes, such as cutting into the wrong tissue.

Some doctors are even taking the first steps toward operating without incisions, using the body8217;s natural openings8212;nose, mouth and anus8212;to gain access to its inner workings. Think of it as surgery without scars.

Some physicians are using minimally invasive techniques in spinal fusion surgery which traditionally requires a 6-inch incision in the back. Others are using the methods to remove part of the bowel in people with Crohn8217;s disease, to replace faulty heart valves and to repair aortic aneurisms. Open cardiac surgery typically requires a lengthy incision through the chest and the splitting of the chest bone to expose the heart. Still other surgeons are repairing the anus or intestines in infants with birth defects, removing women8217;s ovaries or uterus without opening the abdomen, and removing kidneys from live donors while saving them significant pain and recovery time.

Compared with standard laparoscopy, robotic surgery allows doctors a magnified, three-dimensional view of the body, increases the surgeon8217;s dexterity and range of motion and removes hand tremors. Although the value of robots is hotly debated one doctor calls the robot 8216;8216;a fancy coat rack8217;8217;, more surgeons are turning to the technology for operations in areas of the body that are hard to reach and even harder to see, such as the pelvis.

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Robotic surgery may prove to be useful in gynecologic surgery, where laparoscopy has not caught on because of the time gynecological procedures tend to take. The sole robot approved for use in the United States, the Da Vinci Surgical System, was granted Food and Drug Administration approval for use in gynecological surgeries last year. Proponents of robotic surgery predict the technology will also spread because it8217;s easier for surgeons to learn compared with the training involved in laparoscopy. The advances don8217;t stop with robots.

The most mind-bending frontier is natural orifice surgery. Dr Amin Kassam of the University of Pittsburgh Medical Center, is among surgeons who are removing baseball-sized tumors through the nose. The traditional approach to removing brain- and skull-based tumors is a craniotomy. It requires surgeons to make a long incision across the forehead, then peel back the skin of the face and open the top of the skull with a saw. In endonasal surgery, however, Kassam threads a camera and specially designed surgical instruments through the soft nasal tissue and network of air cavities. He drills a hole the size of a thumbnail in the skull and enters the brain to reach the tumour. Large growths are broken into small pieces and pulled out, one by one, through the nose without disturbing surrounding brain tissue.

Surgeons also hope to eventually enter the body through the mouth or anus, extending flexible instruments far into human anatomy and leaving the external surfaces without a stitch. Doctors could make an incision in the stomach wall, for example, to gain access to the abdominal cavity. Such work is in the early stages, but researchers at Johns Hopkins University and elsewhere have done these types of operations on animals.

Shari Roan