The Tiniest Revolution Minimally Invasive Methods Changing World of Surgery by Gina Shaw Five years ago, if you wanted to donate a kidney to save the life of your sister or your cousin or your best friend, you faced the prospect of major surgery. After the operation, you could expect to spend about a week in the hospital, and then you’d be out of work for several weeks while you recovered. This gift of life was a painful and difficult process, often much worse for the donor of the kidney than for the recipient. But a new, minimally invasive surgical technique called laparoscopic nephrectomy, developed by surgeons at Johns Hopkins Hospital, has changed all that. Since pioneering doctors Louis Kavoussi and Lloyd Ratner performed the first such operation at Hopkins in 1995, the procedure has become increasingly popular. "Here at Hopkins, we’ve done over 400, and I’d say easily over half the transplant programs in the country offer this," said Kavoussi, chief of Urology at Johns Hopkins-Bayview Medical Center. More and more, surgery doesn’t mean large incisions and major invasion into the body. Instead, advances in laparoscopic technology and robotic control of instruments mean that surgeons can perform gall bladder surgery, heart surgery and even complex neurological operations through tiny holes sometimes no bigger than the size of a penny. "There’s going to be less and less open surgery being done over time," said Kavoussi. For example, about 95 percent of gall bladder removals are now done using minimally invasive techniques. Although this is a comparatively simple surgery, more and more complex operations are also being performed this way, thanks to tools such as endoscopes (long, flexible thin tubes that can be advanced through the body), microscopic catheters and ultrasound probes, miniature video cameras and robotic arms. Laparoscopic nephrectomy involves four small incisions—two about the size of a pencil eraser, one penny-sized and a fourth "bikini incision" about two inches long—instead of the previous large incision that went halfway around the donor’s flank. The benefits: less pain, shorter hospital time, shorter recovery time and a much smaller scar. Instead of a week in the hospital and several weeks at home recovering, patients are in the hospital for only a couple of days. "They get back to their normal activities about a month earlier than they would with open surgery," Kavoussi said. "Plus, from a cosmetic standpoint, a lot of donors are younger, healthier people, and a smaller incision makes a difference in terms of things like bathing suits." In fact, Kavoussi and his colleague Ratner originally developed the technique at a patient’s request. One day, a man approached them about donating a kidney to his sister—and insisted that he wanted to do it laparoscopically. "I told him that it had never been done before," Kavoussi recalled. "He pulled out references on laparoscopic nephrectomies done with tumors and other cases, and says ‘I know you’ve done it for these cases, why can’t you do it now?’" The surgeons agreed to try it, but warned the man that there was a good chance he’d have to have invasive surgery. Their predictions were wrong. "We did it, and he did very well. We saw immediately post-operatively how well he was doing by comparison to our other open-surgery patients." Although no national studies have examined whether or not the availability of this much less stressful surgery has encouraged more people to donate kidneys, Kavoussi believes it has. "At our institution and other institutions where laparoscopic nephrectomy is being offered, there’s been a marked increase in the number of living kidney donors. There’s even been an increase in anonymous stranger donations—people who have heard of the technique and want to do this for someone," he said. At the University of Maryland Medical Center, when they began using laparoscopic nephrectomies, the rate of live-donor transplants climbed from 25 percent to 40 percent in just four years. ‘Saving Brains from the Inside’ < br> Can you imagine a surgeon operating on your brain through a tiny cut in your groin? That’s what happens in endovascular neurosurgery, a minimally invasive technique in which doctors thread microscopic catheters through a vein in the groin all the way up to the blood vessels of the brain and spinal cord. Using this technique, they can treat life-threatening conditions like cerebral aneurysms—the bulging or ballooning of an artery in the brain—without having to make incisions and open the neck, skull or back. At the Center for Neurointerventional and Neuroendovascular Therapy (CNNET), established in early 2000 at the University of Pittsburgh Medical Center, surgeons use endovascular techniques to treat aneurysms and to perform a number of other types of brain and spinal cord surgery. Dr. Michael Horowitz, associate professor of neurological surgery and radiology and co-director of the CNNET, described the typical endovascular aneurysm repair this way: "Instead of having to open someone’s head and put a clip across the aneurysm to seal it off, we can advance a catheter through the groin into the brain and into the aneurysm. Through that catheter, we insert platinum coils to seal the aneurysms off." As with the minimally invasive kidney removal, patients benefit in a number of ways. The surgery is much less painful, and the risk of complications that arise from surgical infections—particularly a worry when opening up the skull or spinal cord—is greatly reduced. "It allows for less brain retraction, and the complication and morbidity/mortality rates have been shown to be lower in a number of studies. With an unruptured aneurysm, the patient can go home the next day, and they’re back at work the day after," Horowitz said. "For a ruptured aneurysm, you’re at the whim of how bad your rupture was." More and more hospitals are using the minimally invasive coiling technique to treat aneurysms; the U.S. Food and Drug Administration in 1996 approved it. "Five years ago, probably fewer than 10 percent of aneurysms here at Pitt were treated with coils. Now we use the technique in up to 70 percent of cases, and the rate is probably about 15 to 20 percent across the U.S.," Horowitz said. The surgery has become even more popular in Europe, with about 90 percent of brain aneurysms treated with coils in Scandinavia and about 70 percent in France. Horowitz predicts that these numbers will continue to climb as technology advances. "The aneurysm has to be amenable to be coiled—that means that its shape has to be acceptable. But the great thing is that there are new devices coming out every couple of months that let us treat aneurysms we couldn’t treat just a couple of months ago." From the Heart to the Brain Another exciting advance in minimally invasive neurosurgery, Horowitz said, is a technique called intracranial stenting. Many people with heart disease, such as Vice President Dick Cheney, have had stents (small stainless steel tubes) inserted into the arteries of their hearts to keep them open and prevent a heart attack. Now, smaller and more flexible stents have become available that allow neurosurgeons to treat potential blockages in the blood vessels of the brain in the same way. "We use coronary stents to treat narrowing of the blood vessels in the brain, opening up those narrowed areas and increasing blood flow," Horowitz said. This type of stenting can help to prevent cerebral thrombosis, one of the most common types of stroke. "It’s a huge growth area to be able to treat vascular disease just by going through the groin," Horowitz said. He pointed to the exponential growth in the number of patients receiving coronary stents rather than going through much more complicated open-heart surgery and predicted that over time intracranial stenting will grow at the same rate if not more quickly. "It can be safer. It’s less invasive. The recovery time’s less, and it’s less expensive. Who wouldn’t rather just have somebody make a little nick in their groin rather than undergo a big surgical procedure?" Doctors are also treating a variety of cancers with minimally invasive techniques, using endoscopes to extract tumors from the esophagus, cut out cancerous lung tissue, and remove a cancerous prostate without extensive nerve damage. At Henry Ford Hospital in Detroit, for example, surgeons at the Vattikuti Urology Institute routinely remove cancerous prostates using only tiny incisions in the abdomen. Laparoscopic prostatectomy, an operation first performed by Dr. George Ferzli at Staten Island University Hospital in 1997, allows patients to go home from the hospital within 24 hours and return to work in two weeks instead of six. New Technologies, Next Steps The availability of new technologies means that minimally invasive surgeries will probably continue to replace the old-style, open-incision type of operation for more and more diseases and conditions. The surgeons at Henry Ford perform their prostate cancer operations using da Vinci, a high-tech new system developed by a California company called Intuitive Surgical. Da Vinci lets the surgeon operate on a patient while sitting comfortably beside him at a computer terminal. Like a player at a video game, the surgeon sees a 3-D image of the surgical field and uses specialized grips to manipulate instrument handles—movements that the computer translates to the instruments within the patient’s body. European surgeons in countries such as Germany, Belgium, France and Italy also use the system, first approved by the FDA in July 2000. Another surgical robot system, dubbed Zeus by its creators, California’s Computer Motion, just received FDA clearance in October 2001. Zeus, which increases surgeon precision and dexterity in endoscopic and laparoscopic surgeries, has been used in simple operations such as gall bladder removal as well as complex reconstructive surgeries such as endoscopic beating heart coronary artery bypass. In September, a woman in Strasbourg, France, had her gall bladder removed using Zeus—with her surgeons nearly 4,000 miles away in New York City. The 68-year-old woman was out of the hospital two days later and returned to her normal daily routine by the following week. What’s next for minimally invasive surgery? Many experts agree that surgeons are limited only by how fast engineers can turn out new, micro-size tools for them to use. "It’s a field that’s only limited by engineering," Horowitz said. The next big endovascular tool, he predicted, will be better stents. He also expects that surgeons will soon be routinely fixing aneurysms with acrylics, instead of inserting coils. And not next year, but very soon, he predicts doctors will be able to treat endovascular problems with genetic modification. "I think we’re going to be putting devices in that are able to genetically modify the vasculature. For example, we might put something in an aneurysm and make it heal itself by turning on the genes that heal damaged tissue," he said. "We could be inserting genetic tissue up through blood vessels into areas that have had strokes. I think we’re going to be putting in materials that make tumors more sensitive to radiation. All of this will be done without major surgery, with shorter recovery times, and with greater effectiveness for the patient." Ultimately, Hopkins’s 17 Kavoussi predicted that at least some operations will evolve toward completely incisionless surgery. "We’ll be able to get rid of small liver or k idney tumors by inserting a needle using a CT or MRI scan and literally cooking those tumors in the body." In Austria, scientists are now testing a system called HIFU, for high-intensity focused ultrasound. "It’s a fine zone of heat, up to 90 degrees Centigrade, that can burn away cancerous tissue without burning the skin or intervening tissue," Kavoussi said. Robotics—such as da Vinci, Zeus and other technologies now in development—will also improve surgeons’ ability to operate using smaller and smaller incisions. "One of the reasons we make bigger incisions is that our hands are a certain size," said Kavoussi. "These robots can function as our hands and do very sophisticated procedures." Gina Shaw is the medical writer for The Washington Diplomat.