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Vital Signs

Incisionless surgery: Not a sci-fi movie anymore

Imagine having surgery that didn't entail a single cut through the skin—not even the small ones made as portals for laparoscopic procedures. Instead, a little robot would enter the mouth, zoom down the esophagus to the stomach, and exit through the stomach wall to other internal organs—like the appendix or gallbladder—and repair or even remove them.

Dr. Richard Rothstein, section chief of gastroenterology and hepatology at DHMC, is testing the world's only robot that might be able to do just that. The robot's flexible arms are attached to an endoscope—a tiny, flexible tube with a light and a camera lens—that's been outfitted with surgical accessories. Rothstein demonstrates the system, sitting at a computer console where he views images being broadcast from inside his research model. He uses two joystick-like devices to control the robot's movements and can adjust the robot's "hands" to mimic the precise movements of human wrists, arms, and elbows.

"The idea would be to effortlessly recreate what you would try to do with your hands inside a very small space at the tip of the instruments," Rothstein explains. He already uses endoscopy to perform diagnostic as well as therapeutic procedures, such as removing polyps and tumors in the stomach; treating gastroesophageal reflux disease; and removing precancerous cells from the intestinal tract.

The idea of incisionless surgery originated with endoscopy researchers in Japan, who began removing large stomach tumors through the mouth. In the process, they would sometimes puncture the stomach wall—without apparent ill effect.

"We don't like . . . to perforate anything," says Rothstein. But the Japanese experience "led to a whole new thought process about the future of surgery . . . in the sense that we no longer needed to make incisions on the surface of the body. We could make an incision inside the stomach, go out into the peritoneal cavity, and now you have access to the appendix, gallbladder, the fallopian tubes, the liver, even the uterus, ovaries, [and] other organs."

As Rothstein worked on perfecting incisionless surgery techniques, he realized it might be possible to use surgical robots to assist in these complex procedures. About two and a half years ago, he began working with a Norwood, Mass., company that had developed a portable robot for laparoscopy—operations performed using a fiberoptic device inserted through a tiny incision in the abdomen. He thought the robot would work for endoscopy as well—operations using a fiberoptic device inserted through a natural opening in the body, such as the esophagus—especially incisionless procedures.

System: Robots aren't new to medicine. For instance, the daVinci robotic surgical system is used at some medical centers to assist surgeons performing laparoscopic procedures. But that robot has rigid arms, while Rothstein's has flexible arms better suited to endoscopic, incisionless procedures. And robots also assist in peripheral activities, like the pair of voice-activated robots in DHMC's laparoscopic surgery suites. One can guide a camera inside the patient, while the other can turn lights on and off and send images from inside the patient to a desktop computer.

Although incisionless surgery in humans has not yet been approved in the United States, it is already being used in India. A surgeon there has performed several appendectomies through the stomach wall.

Rothstein hopes "his" robot and techniques will be approved for use in humans in the U.S. within a few years. It might even be possible to use the system to do incisionless gastric bypasses on people who want to lose 20 to 40 pounds, he says. So far, such procedures have been done only on people who are very obese.

Robotic-controlled incisionless surgery would have several benefits. Patients would have no external scarring and so would tend to recover faster than from invasive surgery. In addition, robots can filter out fatigue-induced tremors in a doctor's hands and include safety features such as reading a patient's ID bracelet to be sure the correct patient undergoes surgery. And robots would allow a surgeon to operate in a remote location. Few people realize that a robot did a trans-Atlantic colonoscopy in September 2001; the surgeon was in New York City, and the patient was in France. But news of that advance was overshadowed by the tragic events of September 11.

Stages: Within the next five to ten years, "we're going to be able to do bigger operations through smaller incisions, or no incisions, if you do what Rothstein does," predicts Dr. Joseph Rosen, a DMS plastic surgeon and futurist who helped the military develop one of the first surgical robots. Rosen envisions that, one day, people will be able to swallow multiple robots that would clump together, perform an operation, disengage, and then be excreted. That may be a way off, however. "All of this is new and exciting but still in its very early stages," Rothstein says.

Mark P. Lawley

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