"The future of surgery is not about blood and guts; the future of surgery is about bits and bytes.”
/Dr. Richard Satava/

Sunday, August 24, 2008

The NOTES technique

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.” as wiki says. In fact this is a new and promising technology that extensively combines technology and medicine. The name was invented at Hopkins, when first used on animals by Dr. Kalloo., as a developed version of single port laparoscopy (also called single incision laparoscopic surgery - SILS). The first human operation was in June 2007, a transgastric cholecystectomy. (An excellent review on NOTES can be found here.)
NOTES provides numerous patient benefits, such as reduced pain, faster recovery, better cosmetic outcome (making it popular e.g. among models) and lower risk of infection. One of the great advantages is that theoretically no sterile environment is required, only sterile equipment. The single port entry means serious limitations in spatial motion beyond making laparoscopy manageable in obese patients, children or burnt patients. Hyper-redundant endoscopes must be used to achieve in-body navigation, and many surgeons are needed to manipulate these devices. (More videos are here.) Research labs all around the world are trying to provide an automated tool for NOTES. One example from Singapore uses a bigger endoscopic tube to introduce a two-armed manipulator to the surgical field. Similar devices have been developed at UGSI as well.
There are many other ways to promote this technology, such as combining it with real-time 3D visualization and augmented reality applications, such as the MUSTOF endoscope (Multi-Sensor-Time-Of-Flight) from Friedrich-Alexander-University, Germany, presented recently at a lab seminar.
NOTES today is still looking for the killer application that would best benefit from the development and justify the higher costs of the procedures. The main goals of the Natural Orifice Surgery Consortion for Assessment and Research (NOSCAR) working group are to solve the question of stability and navigation in the next five years while providing more advanced tools with the capability of triangulation, and additional features such as stapling and closing.

Wednesday, August 13, 2008

Bio-robotics lab at Stanford

Last week I visited the Bio-robotics lab belonging to Prof. Ken Salisbury at Stanford University, in Silicon valley. (This is equivalent of the JKS robotics group.). Even though the professor was out of town, I could talk to some of the folks and learnt many things. The group is rather small, approximately seven guys, all grad students. Most of them have finished the MS (which requires tremendous classes and project work at Stanford), and now focusing on research. They are all very self-sustaining and autonomous, finding their own projects, sometimes even forging some industrail cooperation behind. The actual lab area is located in the new James H. Clark Center, together with other interdisciplinary people, such as biochemists and genetic engineers. The majority of their projects focus on haptics, smaller scale robotics and robotics design. Having a decent machine shop, they can prepare the modells and the prototypes very quickly from wood. Different surgical human interfaces are also developed to better serve ergonomics and functionality. One of the interesting things I was introduced to is a haptic simulator for sinus surgery. (As I had some experience with our robot, if was great to play around with the realistic program.) Another promising area is the magnet guided endoscopy. They use external EM field to steer micro-endoscopes within the body. Many of the projects are run in cooperation with the Stanford MedSchool right next door.

Monday, August 4, 2008

Surgery for engineers II

On the last classes we were introduced to MIS laparoscopy. First we learned about the tools and the procedures, but more interestingly we moved to the OR afterwards to perform a laparoscopic cholecystectomy on a pig. The animal was already in anesthesia, we only had to make the incisions and insert the trocars. One could definitely see the MIS advantages compared to the previous week’s open procedure. We had some difficulties navigating around the smaller abdomen, but managed to end up in an uneventful surgery.
The other day we got introduced to many cutting edge research results of the new NOTES technique that aims to perform surgery without any scars, just getting into the cavity though the natural orifices. Our class got an hour and a half time with one of the two da Vincis at Hopkins, we could play on the test boards and setups provided by Intuitive Surgical. This was the first time that I used a robot with the original controller behind, it was really easy to handle, and the motions were very smooth. We also tried many other haptic simulators, suturing phantoms and training pads.
Finally, we were given an hour-long tour of the operating rooms. First, we visited the 24 ORs in the very old Blalock building, where they perform scheduled and emergency cases 24/7. Most interestingly, the major limitation is space here. All the rooms, the corners, the corridors are packed with the equipment instantly not in use. Dozens of C-arms, microscopes, anesthesia towers, Jackson tables (for spine operations) are piled up, leaving just enough place to navigate around with a patient on a bad. They have an extensive electronic system to manage all this. The newer building (Weinberg) was designed a lot wiser, leaving enough space for everything. The ORs are approximately 30-40m2, as much space is required for the technical equipments and their operators. Not rare to have 7-9 people in the OR at a case. A patient is billed 10USD/min for using the OR, and this does not include any of the equipment or the doctors’ fee. There are 14 more ORs in the hospital, but a major extension is on the way. By 2011, three new buildings will be added to the immense campus of Hopkins, providing 33 new ORs.