The New Trend in MISC XIV IKABI Congress, Jakarta 10-12 July 2003 Guest Lecture THE LATEST

TREND IN MINIMALLY INVASIVE SURGERY Davide LOMANTO, M.D., Ph.D Director of Minimally Invasive Surgical Centre MISC, Department of Surgery National University of Singapore email: surdl@[Link] The substantial developments in surgery, over the last century with the advent of antiseptic substance, anesthetic agents, antibiotics, surgical nutrition, and organ transplantation, havent modified the basic tools of surgery and even the surgical techniques has remained basically unchanged. Moreover, in the last decades, the invasiveness has been the focus of surgical practice gaining the momentum especially because of the better outcome in term of post-operative pain, fewer complications and quicker return to functional activity. The starting change has come with the advent of the laparoscopic surgery and, because of the rapid acceptance and success of such operation like laparoscopic cholecystectomy, over the last ten years a revolution has taken place in general surgery. Since then, a variety of surgical operations in all the surgical specialty have used endo/laparoscopic techniques. The modern era of laparoscopic surgery was ushered in when a miniature video camera was attached to the eyepiece of the laparoscope, which allowed multiple observers to view an operative field from the same vantage point but mainly when many large series were reported in the literature high lightening the main advantages of the laparoscopic approach over traditional open surgery (as reduced postoperative pain, shorter hospital stays, periods of disability and cost-effective for hospitals and patients). But also the news and media quickly portrayed laparoscopic surgery, with its small incisions, as a panacea inventing different name as key-hole surgery, minimally invasive, bandaid or Nintendo surgery so the success among the patients was great and the number of cases and surgeons experience grew supported by the development of new high-tech instrumentation and devices. But during the years, laparoscopic surgery was limited by a number of factors, as: twodimensional vision: the control of the surgical field by an assistant. The laparoscopic port acts as a fulcrum that restricts the freedom of movement of the instruments and instruments are straight without articulated movements like human wrist. Moreover, the instruments utilized, do not

provide any tactile or force feedback. Nevertheless, the number of operations grew, surgeons became skilled over the limitation imposed by laparoscopy and along the years this gap was almost recovered. All these new high-technology equipments also made some changes to Hospital design, OT have to be redrawn according to the new devices but also the surgical training programmes have to be re-organized. Together with technological development new approach come-out. The size of ports used to access the abdominal cavity has decreased over time from 10 mm to 2 mm. The 2-mm ports, called needlescopic ports, have proven to be feasible, safe, and effective when an enlarged port is not required for extraction of a specimen. Benefits include less postoperative pain and improved wound cosmesis. The use of hand-assisted ports, in which a hand is inserted into the peritoneum to assist the performance of the surgical procedure, allows for tactile assessment by the surgeon. This different surgical approach is particularly advantageous when a larger incision is needed to remove the surgical specimen like donor nephrectomy, splenectomy or gastric surgery or for cases that are too complex or take too long to be managed with the total laparoscopic technique. The application of the minimally invasive procedure to more complex surgeries will require the new technology and techniques. In general surgery, techniques such as hand-assisted laparoscopy attempt to bridge the gap between open and completely endoscopic procedures. Other possibilities include developing new ways to perform conventional surgical tasks as a way to adapt these procedures to an endoscopic or less invasive surgical approach. Inanimate trainers or simulators are being used as teaching tools to improve surgeon performance, and the use of self-retaining retractors enables the surgeon to use fewer assistants in the operating room. Recently, robotic-assisted surgery is being used. Robotic arms allow the surgeons for finer control and remote presence and provide a computerized interface between the patient and the surgeon. Two robotic systems are now in the market: Zeus (Computer Motion, USA) and DaVinci (Intuitive Surgical, USA). These systems provide enhanced dexterity, motion scaling, articulation, 3-dimensional vision and, the potential for telesurgery. Conversely, they do not allow for tactile or haptic sensation, and actually the number of cases and surgical application of robotic-assisted surgery are slightly increasing, mainly due to the high investment and running costs of the devices while the initial benefit are undoubtful. But also new applications must be developed and the full ranges of robotic application are still to be implemented. The initial concept of robotics in surgery involved operating at a remote site from the surgeon. The ability to transpose surgical and technical expertise from one site to a distant site (i.e: proctorship, assisting developing country or remote area like ) was thought to expand surgical application. Although simple surgical procedures have been performed remotely, there are some difficulties for an extensive clinical use because of expense, transmission delay, and medical and legal issues. Application of telepresence surgery in the foreseeable future will probably be limited to telementoring rather than to remote manipulation. Telementoring will allow the surgeon to teach or proctor performance of an advanced or new technique at a remote site using real-time teleobservation and monitoring. However, a robotic development in the area of software

simulation and virtual reality could be expected but also surgical operation and manoeuvres that need dexterity enhancement and motion microscaling will need the robotic assistance. Other possible roles for computer and robotic assistance in surgery include voice control over surgical manipulators and information manipulators. At present, technology exists to give the surgeon voice control over virtually all operating room equipment including electrocautery, operating table position, laparoscopic movement-control, lighting, and telephone. Future developments promise the overlay of additional data to the operative field, including 3-dimensional magnetic resonance imaging reconstructions and physiologic data acquisition especially for pre-operative virtual simulation. In conclusion, efforts are now focused on those techniques that facilitate the more complex tasks by minimally invasive approaches. Other aspects are the clear role of audio-visual telementoring in future training concepts and of telemanipulation/telesurgery. New technological concepts promote the development of hand-held mechanical manipulators used in combination with mono-tasking computerized robots like AESOP, resulting in a significant cost reduction. Advancements in microchip and wireless technology may allow the development of microrobots for completing surgical procedures, and magnetically controlled implants that can be navigated remotely. The technological innovations in surgery are only beginning, the future will be very attractive, the potential is enormous, and the path is minimal.

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LOPEZ, MARY CRIS O.