A laparoscopic robotic surgery machine.
The process of minimally invasive surgery has been augmented by specialized tools for decades. For example, TransEnterix of Durham, North Carolina received U.S Food and Drug Administration approval in October 2009 for its SPIDER Surgical System using ﬂexible instruments and one incision in the navel area instead of several. allowing quicker healing for patients. Dr. Richard Stac of Duke University developed the procecss.
In recent years, electronic tools have been developed to aid surgeons. Some of the features include:
- Visual magniﬁcation - use of a large viewing screen improves visibility
- Stabilization -- Electromechanical damping of vibrations. due to machinery or shaky human hands
- Simulators — use of specialized virtual reality training tools to improve physicians’ proficiency in surgery
- Reduced number of incisions
Robotic surgery has been touted as a solution to underdeveloped nations. whereby a single central hospital can operate several remote machines at distant locations. The potential for robotic surgery has had Strong military interest as well, with the intention of providing mobile medical care while keeping trained doctors safe from battle.
Natural orifice trattslumenal endoscopic surgery
Natural oriﬁce transluminal endoscopic surgery (NOTES) is an experimental surgical technique whereby "scarless" abdominal operations can be performed with an endoscope passed through a natural oriﬁce (mouth, urethra, anus, etc.) then through an internal incision in the stomach, vagina. bladder or colon, thus avoiding any external incisions or scars.
Stale of Research
This technique has been used for diagnostic and therapeutic procedures in animal models, including transgastric (through the stomach) organ removal. Most recently. the transvesical and the transcolonic approaches have been advocated by some researchers as being more suited to access upper abdominal structures that are often more difficult to work with using u transgastric approach. In this sequence, a group from Portugal used transgastric and transvesical combined approach to increase the feasibility of moderately complex procedures such as cholecystectomy. NOTES was originally described in animals by researchers at Johns Hopkins University (Dr. Anthony Kalloo et al.), and was recently used for transgastric appendectomy in humans in India (by Drs. G.V. Rao and N. Reddy). On June 25 2007 Swanstrorm and colleagues reported the ﬁrst human transgastric cholecystectomy. Totally transvaginal cholecystectomy has been described in experimental model without using laparoscopic assistance. In late 2008 surgeons from Johns Hopkins School of Medicine removed a healthy kidney from a woman donor using NOTES. The surgery was called transvaginal donor kidney extraction
The transvaginal access to NOTES seems to be the most safe and feasible for clinical Application.In early March 2007. the NOTES Research Group in Rio de Janeiro, Brazil, lead by Dr. Ricardo Zorron, performed the ﬁrst series of transvaginal NOTES cholecystectomy in four patients, based in previous experimental studies. With fewer potential complications, the procedure has a disadvantage of being possible only in women.
Proponents and researchers in this ﬁeld recognize the potential of this technique to revolutionize the ﬁeld of minimally invasive surgery by eliminating abdominal incisions. NOTES could be the next major paradigm shift in surgery, just as laparoscopy was the major paradigm shift during the 1980s and 1990s. Potential advantages include lower anesthesia requirements; faster recovery and shorter hospital stays; avoidance of the potential complications of transabdominal wound infections (e.g. hernias); less immunosuppresion; better postoperative pulmonary and diaphragmantic function; and the potential for "scarless" abdominal surgery. Critics challenge the safety and advantages of this technique in the face of effective minimally invasive surgical options such as laparoscopic surgery.
Unlike Laparoseopy, which was treated with much disdain as a passing fad by most nationally recognized academic institutions, NOTES is being embraced by several Universities nationally. The general impression is that NOTES, or a derivative of its technology will be accepted as the newest frontier in minimally invasive surgery. As of today non-Bariatric Minimally Invasive Surgery fellowships offer the best opportunity to train in this new approach. However, a systematized training modeI,in order to translate these procedures to the clinical practice in a safe way, is needed.