Non-invasion of the body stature: SLS predicts surgery sea change

Paul Wetter, one of the first surgeons to do minimally invasive laparoscopies during the 1980s, said the further refinement of the procedure – in which “the instrument itself is like a needle” – represents only the middle stage in the development of how surgeries will soon be done: with no incision at all.

“We don’t know exactly what we’re going to have, but we know where it’s all headed,” said Wetter, chairman of the Society of Laparoendoscopic Surgeons (SLS). Ordinary people are walking around with supercomputers in the form of cell phones, and nanotechnology has made huge strides. “Those two things are colliding,” he said. “Even five years ago, no one really imagined that you could do surgery with something the size of a needle. We’re at the cusp of some pretty amazing things,” due to make themselves known in the next decade, he predicted.

“We helped train a lot of the general surgeons when they started to remove gall bladders with small incisions,” Wetter told Medical Device Daily. “It was probably one of the biggest breakthroughs of the last century. Now we’re heading toward a whole new set of instruments” in mini-laparoscopy, which does not need a trocar through which to use operative tools, as in the traditional approach. Instead, the needle-like instrument “just goes through the skin, and when it’s removed there’s almost no pain or discomfort or scarring involved.”

Today, “most hospitals are [still] using trocars, big devices of 5-10 millimeters,” Wetter said. “At SLS, we’re starting to train people” in the new method, and “within the next two years, you’re going to start to see more of this around the country.” But there’s more to come, he said, likening the situation to the first moon launch. Aerospace engineers “already knew how to do that for quite a number of years before” a man walked on the moon’s surface, but nuts-and-bolts work had to be done, he noted. “We’re at the stage now where a lot of the nanotechnology is understood, and the ability to scan the body. People are starting to put things together so they can get to the next step.”

Wetter described that next step as using “different types of energy that are controlled from outside the body to remove tissue or ablate tissue.” It’s already available in such applications as focused ultrasound, which “sees some lesion and can focus and destroy that lesion with heat,” he said. “Obviously, this is not for every type of thing. We’re at the beginning stages.” Another example is Accuray’s (Sunnyvale, California) non-invasive robotic radiosurgery system branded CyberKnife, which takes on cancerous and non-cancerous tumors anywhere in the body, including the prostate, lung, brain, spine, liver, pancreas and kidney, delivering beams of high-dose radiation extreme accuracy.

These, too, will be refined, Wetter said, “with all the new miniaturization that’s happening.” The 30 vacuum tubes and 200 parts that once made up a television can now be fitted into a chip the size of a pencil eraser, and the same tiny precision has arrived in medicine, he said, along with “the ability to use computers to digitize and focus things precisely, and the imaging of the human body” that’s clearer than ever. “We’ll be able deliver different forms of energy from outside [the body] to inside, without an incision to do a lot of things we’re doing now” by cutting, he said.

“The military is working on it, the microchip industry, aviation – these things are going to come together in this future of surgery without any incision,” Wetter said. Magnetic resonance imaging-guided surgery, though a step in the right direction, still puts small instruments through openings in skin.

“Laparoscopy itself started for only diagnosis, to look at things,” Wetter pointed out. “Someone figured out how to make a special loop so you could remove the appendix. That went on for a couple of years, and someone figured out how you could make smaller instruments and remove the gall bladder.” Next came hysterectomies, and then colon cancer. “Now they’re using it for so many different things,” he said. “It’s the same sort of progression” in the CyberKnife and focused ultrasound methods.

Pledging to advance the cause is SLS, “a multi-specialty society,” Wetter said. “A lot of really innovative and neat things happen where different disciplines meet. That’s a rare thing in medicine these days. There’s not much of this cross-pollination. At SLS we have three or four disciplines within surgery that are part of the group – general surgeons, gynecologists, urologists, robotic surgeons, and other people who use small instrumentation” and who meet every year to swap ideas, he said. Late last year in Orlando, Florida, SLS conducted one of the first courses anywhere on how to do mini-laparoscopy.

The organization publishes a peer-reviewed, open-access, multidisciplinary journal begun in January 1997, available in print and online. IngentaConnect, which tracks 15,000 scientific publications, pegged the Journal of the Society of Laparoendoscopic Surgeons among the top 100 downloads eight times within two years, “a monumental achievement for a specialty society journal,” boasts the SLS website.

“It’s really hard to tell” where, therapeutically, the first benefit will show from new ways of working at a level “where it’s actually the molecules that can be rearranged in certain ways” purely by energy directed from outside the body, Wetter said. “There are hundreds of different areas that it could come in. The ultimate of minimally invasive is non-invasive. Eventually, it will be.”

Source: The Medical Device Daily