Health care innovation, including ones in the field of minimally invasive surgery
(MIS), can be defined as a dynamic and continuous process involving the introduction
of a new technology or technique that initiates a change in practice.[1] There have been constant innovations to improve MIS since its emergence in the early
1980s, although the basic concepts have changed little. They include technological
innovations in instruments used, such as laparoscopic instruments and sutures or MIS-associated
technology, such as surgical robotics, image guidance systems, natural orifice transluminal
endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS).
There are distinct patterns of growth, development, and innovations in MIS since the
early 1980s represented by the number of patent applications and literature publications,
with each of these patterns containing technologies with unique characteristics.[2] The first growth pattern was in relation to novel surgical instruments and sutures
to complement MIS. This growth shows a peak in the mid-1990s and then again in the
mid-2000s. The peak in the 1990s was mainly in relation to basic laparoscopic instruments
when the concept was introduced, and steps are taken to popularize.[1] A new growth spurt with instruments was seen again in the mid-2000s as the laparoscopic
procedures became well established and widely used necessitating more ergonomics instruments.
The second growth phase noted is with regards to surgical robotics and image guidance.
Their growth shows gradual and exponential patterns starting in the mid-1990s throughout
2000, and beyond.[2] The reason for this growth pattern is probably multifactorial. These technologies,
in spite of numerous complex engineering challenges, have demonstrated continued development
to keep up with the clinical demand. Continued development of robotic technology resulted
in third generation surgical robots. These technologies also serve to expand the practice
of MIS rather than just providing necessary tools for the MIS. This is evident in
increased usage of robotics in various operations, sometimes even acting as a complementary
technology for an existing method, such as SILS.
The latest and the third growth phase was noted in the late 2000s in relation to NOTES
and SILS with its inception in the mid-2000s, peaking soon after that. Although the
popularity of NOTES plateaued in late 2000, SILS has continued to receive interest.
The reason for this plateau with NOTES is partly due to dwindling of innovation and
interest in the technique, and partly due to the profound difference between innovators
and adopters. Conversely, SILS may likely have a brighter future owing to easier access
to technology and instrumentation, specialist to mainstream practice, and possibly
with increasing popularity of robotics, which may complement SILS.[2]
One of the biggest advances in MIS in the last decade is in the field of robotic surgery.
Robotics was introduced for surgery in civilian hospitals in the early 1990s, although
it was initially used in the military environment performing surgeries in the 1970s.[3] Robotics combined with computer science has been able to augment surgeon's skills
to achieve greatly improved accuracy and precision in complex surgery. Ever improving
technology in optics and computer science has introduced virtual reality (VR) and
three dimensional (3D) to operating rooms.[4]
[5] This allows for the development of patient-specific models enabling planning and
practice of complex surgery on VR platform before performing the actual surgery. The
3D virtual model improves the mental representation of anatomical details, which could
be underestimated with two-dimensional visualization platform that is more commonly
used currently in operating suites.
Robotic surgery has evolved immensely since the initial operating room version Zeus
(Computer Motion). Newer models of surgical robots, Da Vinci (Intuitive Surgical),
feature compact mobile platforms, multiple operating arms, and superior surgeon's
console equipped with surgeon- piloted stereotactic 3D immersive and ergonomic handles
intuitive to human hand movements providing improved dexterity. Other robotic platforms
have been approved and are in various stages of development and introduction to the
surgical market. They claimed to produce small robotic platforms with better maneuverability,
more user-friendly in constricted spaces, provide force feedback and eye tracking
capabilities. The eye tracking technology works with the aid of a camera mounted on
an eyewear, which could track the surgeons' eye movements and move the scope inside
the patient accordingly. Some of the examples are Amadeus Composer (Titan Medical
Inc.) from Canada and TELELAP Alf-X (TransEnterix) from Italy.[3]
The application of robotic surgery potentially is much wider than just restricted
to operating theater where the robot is physically located. The current platform enables
remote access enabling telesurgery, without the need for the surgeon to be present
physically in the operating theater. One such event was a surgical operation performed
in Strasbourg (France) by surgeons in New York (United States), which became a milestone
in global telesurgery.[6]
[7] Furthermore robotic surgery experiments have been performed in a weightless environment.[8]
[9]
[10] Considering the current quality and speed of web-based transmission of signals,
it would make remote surgery on any facility orbiting the earth, such as international
space station, possible. Currently, it would require more advanced telecommunication
for surgeries at a distance further from the moon.[11]
The role of robotic surgery compared with laparoscopic surgery is debatable, mainly
due to high cost and equivocal surgical outcome. In spite of that robotic surgery
remained appealing to health care organizations and surgeons with a passion for cutting-edge
technology. Astronomical cost while a disadvantage may change with improved platforms
that are easier and quicker to set up, which improves further with experience, and
lower cost with vanishing monopoly in the production of surgical robots.
Robotic surgery in the peritoneal cavity has been investigated fairly extensively,
and the technology has proven to be of benefit in selected operations. Robots have
been used in colorectal surgery for over 10 years.[12] A systematic review concluded that robotic surgery had a reduced rate of conversion
rate to open in rectal surgery. However, no difference was found in duration of surgery,
morbidity, and oncological outcomes in either rectal or colonic surgery.[13] When it comes to upper gastrointestinal surgery, especially oncological surgeries,
such as gastrectomy and esophagectomy, there is very little benefit in the usage of
robots over laparoscopic surgery.[14]
[15]
[16] On the other hand, some definite benefit has been shown in benign upper gastrointestinal
surgeries where precision is of utmost importance, such as Heller myotomy where it
reduces perforation rates.[17] In the field of bariatric surgery, robots aid in reducing the steep learning curve
in Roux-en-Y gastric bypass (RYGBP) by making intracorporeal suturing easier and eliminates
the use of staplers, potentially proving to be cost-effective compared with laparoscopic
RYGBP.[18]
[19]
In hepatobiliary surgery, robotic surgeries have not demonstrated a clear superiority
compared with laparoscopic surgery.[20] However, there is some evidence that it may be useful in achieving higher rates
of radical R0 resection in pancreatic cancers.[21] Currently, there is a paucity of experience regarding liver resection to draw any
major conclusions.[22]
Another significant innovation in the last decade is NOTES, described by some as perhaps
the most significant innovation in surgery since Phillipe Mouret of France performed
the first laparoscopic cholecystectomy in 1987.[23] Although, it was Kalloo et al in 2004 that brought the technique into the spotlight.[24] It appears to be a stepwise progression from endoscopic mucosal resection before
anyone dared to breach the muscular layer intentionally. This novel technique was
a result of a harmonious union between gastroenterologists and surgeons in America
in early 2000. Since then several NOTES procedures have been performed using mainly
stomach, rectum, and vagina as the portal of entry into the peritoneal cavity. NOTES
was also the first “scar less,” surgical technique introduced to the public and their
perception, initially at least, was in favor of this technique.[25]
There are several barriers to NOTES. Some of them include difficulty in the closure
of enterotomy, anastomotic techniques, spatial orientation, long learning curve, lack
of triangulation of instruments, control of hemorrhage, and prevention of the transluminal
spread of infection. At the same time, there are advantages associated with NOTES.
They include no scars, less external pain, lower cost, an alternative to the laparoscopic
procedure in a patient not suitable for laparoscopy and it even could act as a complementary
technology to laparoscopic surgery and avoid major resections.
Unfortunately, over the last decade NOTES encountered more problems than solutions
that the industries are still trying to correct. Therefore it has hit a plateau in
its popularity, and usage.[2] Comparable results were noticed in the first nonrandomized trial to be published
comparing diagnostic laparoscopy and transgastric peritoneoscopy after careful selection
of patients.[26] This study demonstrated the usefulness of NOTES while testing its specific aspects
but does not improve the safety of NOTES in general.
While the closure of an enterotomy remains a huge issue, access and triangulation
are fundamental to the success of MIS. Some surgeons have endeavored to address these
issues. Combining laparoscopy with NOTES has been suggested and trialed to improve
insufflation, orientation, retraction, instrument navigation, and solid organ manipulation.[27] Another novel technique: dual access NOTES has been proposed and tested to improved
handling, orientation, and maneuverability (e.g., rectal and gastric).[28]
[29] However, dual access doubles the risk of contamination, infection, and luminal closure
difficulties. Various companies engineered different devices address problems associated
with the closure of enterotomy. They range from simple endoscopic dexeclips used to
close enterotomies as large as 4 cm to purse string applicators used to close gastric
incisions and g-prox (USGI Medical) tissue grasper.[30]
[31]
[32] Some have only been used in animal models.
Developments in VR, stereoscopic 3D cameras, and augmented reality (AR) camera are
some of the areas worth following in the years to come. Conventional cameras are two-dimensional
and lack depth perception. At present da Vinci robotic camera has 3D visualization
capability but extending that technology to the laparoscopic camera has had its challenges.
Although Olympus has introduced a video-assisted camera capable of 3D visualization,
it lacks the resolution that robotic 3D camera provides. Some research groups have
reported developing AR visualization for laparoscopic cameras.[33]
[34] Here, the preoperative images are registered in a stationary format, which is then
superimposed on the available intraoperative images from the laparoscopic camera.
However, the surgeon normally constantly manipulates the tissues and organs, in reality,
making the abovementioned model less useful. Upcoming technologies claim that they
could reconstruct preoperative images in real-time according to patient's body shape.[35]
Another technology worth mentioning is a laparoscopic ultrasound (LUS), which is two-dimensional
with the images displayed on a separate monitor that unfortunately forces the surgeons
to take their eyes off the organ or laparoscopic screen. With the combination of LUS
and AR technology in a stereoscopic 3D camera one can now view the organ that is subjected
to ultrasound and its abnormalities in real-time directly on the organ itself and
make surgical decisions for accurate dissection with precise movements, so that resection
margins are kept to minimum but sufficient and safeguarding the surrounding structures
that may not be visible in 2D view.[36]
