Chapter 13
Future Aspects of Laparoscopic Colorectal Surgery
Jeffrey W. Milsom, Bartholomäus Böhm, and Kiyokazu Nakajima
Ten years ago, the adoption of laparoscopic techniques into common- place use in the practice of colorectal surgery was uncertain. Today, most surgeons would agree that this fi eld is evolving rapidly, and some would say that minimally invasive surgery is only at its beginning. In this chapter, we will briefl y present some of the interesting develop- ments shaping the future development of the fi eld of laparoscopic colorectal surgery.
Surgical Energy
The ability to successfully transect tissues without bleeding has improved dramatically in the past decade. The biggest changes have occurred with the use of ultrasonic tools and of the bipolar electro- surgery devices which permit rapid cutting and coagulation of even large vessels.
Prediction: In the next decade, many further developments in energy devices will occur, permitting faster, safer, and less traumatic division of tissues. These new tools will allow more facile dissection of tissues, and this will extend the range and safety of current laparoscopic methods. Example: A rectal dissection without blood loss, and clean and quick dissection of the correct planes, minimizing also the poten- tial for nerve damage.
Computer-Assisted Instruments, Including Staplers and Endoscopes
Many of the decisions which only humans have made in the past will be made by computers. Current simple examples include the decision as to when the surgical tissue is safe to cut when the LigaSure bipolar instrument is used. A “beep” from the machine tells the surgeon that the impedance of the tissue is at a point that permits safe cutting of the tissue such that it will not bleed. An expansion of such decisions will be applied to stapling tools (“tissue is at the proper thickness to staple 408
and cut”) as is seen in the Powermedical stapling tools (New Hope, PA). All of their stapling devices are attached to a computer by a thick sterile cable, enabling feedback between computer and the human tissue. Another example of this type of interface will occur in the use of endoscopic tools in the operating room. Surgeons (and endoscopists) will increasingly rely on computer-acquired information to make deci- sions and treat patients.
Prediction: Surgical devices used in the human body will increasingly have interfaces with sophisticated monitoring equipment, which should allow for better judgment in the operating room (Is the tissue ischemic or not? Is this a malignant or benign process?), and more precise dis- section of tissues. This will mean LESS and LESS invasive surgery, because the surgeon will know much more about the environment in which he/she is working.
Biological Glues and Adhesives
The role of these agents in the treatment of surgical diseases is increas- ing. Glues such as Tisseel (Baxter Healthcare Corp., Deerfi eld, IL) and BioGlue (Cryolife, Kennesaw, GA), which are derivatives of fi brin, are in common use in multiple disciplines such as vascular, cardiac, and neurosurgery. There they are used to stop bleeding from pinpoint areas.
The companies manufacturing these products are exploring a wide array of clinical applications in the abdomen, and some areas, such as the cut edge of the liver, are ideal applications for an effective hemo- static agent. Cyanoacrylic glues also seem to be acceptable agents in the treatment of certain bleeding areas of the brain. There are countless possibilities for using such agents, especially if they can be inserted through laparoscopic applicators, or endoscopically.
Prediction: Biological glues and adhesives will expand dramatically over the next decade, and have the potential to challenge the suture and staple as a mainstay of tissue apposition. Laparoscopic and endo- scopic applications will soon be used to supplement these current methods.
Robotics
There is no fi eld of minimally invasive surgery that is more eagerly anticipated than the use of robotic tools. These tools have been shown to increase the precision of many surgical actions, including the sutur- ing of small vessels. For radical prostatectomy, the current com- mercially available robot (“Da Vinci”; Intuitive Surgery, Mountain View, CA) seems to afford some advantages compared with open pros- tatectomy. Again, some of this is attributable to the magnifi cation afforded by the stereoscopic laparoscope, and using the Da Vinci’s small graspers equipped with wrists is also helpful in performing the cystourethral anastomosis. The fi eld of laparoscopic colorectal surgery has not yet found applications mainly because of our needs to move
through multiple quadrants of the abdomen while performing a single operation, which the current Da Vinci does not readily permit. Also, the use of the small robotic arms within the abdominal cavity does not easily permit retraction of the small and large intestines, a major impediment.
Prediction: Robotics will continue to improve, and the merging of surgical therapy and robotics will result in many applications, although this evolution will occur slowly because of the tremendous amount of technology and expense involved in making this transformation.
Capsule endoscopy is a forerunner of such tools which may perform surgical actions, under guidance from a surgeon, or on their own (“seek and destroy missions”).
Other Technologies of Importance
Image processing (e.g., miniaturization, three-dimensional, HDTV), changes in the laparoscope function and design, and use of wireless technologies will transform how we procure images in the operating room and use them in the surgical treatment of patients. Photodocu- mentation is now easy to obtain during any operation, and most are high-quality, digital images. Along with commercial applications, surgery will experience further important improvements in these tech- nologies in the near future. Improvements in these images will acceler- ate our ability to transmit knowledge and teach new methods of minimally invasive surgery. This will lead to further progress in under- standing diseases and progress in the treatment of patients.
Telesurgery
This topic deserves a separate discussion, although it involves many different technologies, techniques, and educational concepts. From the earliest time of using the miniaturized cameras of the laparoscope, the transmittal of these images to remote locations (telesurgery) has been a fundamentally important part of the “laparoscopic revolution”
(Figure 13.1). This permitted many individuals to see, witness, and learn about new methods of performing surgery. For the fi rst time, many surgeons could witness an expert throughout a complex opera- tion, potentiating the learning experience of surgery.
The topic of telementoring deserves some mention. The possibility of an expert surgeon to observe, and render advice/teach actively during an operation which is some distance away from this expert, is likely to become an important part of the future of surgery (Figure 13.2). The possibilities of using such expert instruction from a distance means that new ideas and technologies could be quickly disseminated without the need for “on-site” instructions or labs, and it could also form a means of getting rapid operating room teleconsultations in remote areas, if the need arose, from a centralized source of expertise.
Figure 13.1. Telesurgery, now widely practiced, will expand in the future to permit more widespread dissemination of new ideas and technology.
A further source of expert help will combine telementoring with some of the emerging aspects of robotics, telepresence, and miniatur- ization of instruments. This means that the expert surgeon will be capable of entering the operating room as a “robotic” surgeon and performing surgical actions, assisting the team there (Figure 13.3). Even our uses of robotics will change, because robots may be expected to enter the body on their own, identify body structures, and make deci- sions with or without human directions (Figure 13.4). This scenario will challenge both our technological as well as ethical frontiers, and it is one that we must prepare for, because there is no doubt, at least among the editors of this book, that this will occur.
Figure 13.2. Telementoring, which involves direct instruction of a laparoscopic mentor interacting with a surgical team in real time, will expand the use of new methods and technologies.
Figure 13.3. Robotic-assisted surgery will permit surgical experts to DIRECTLY perform surgeries in remote locations, with the assistance of a local team.
Figure 13.4. A Minute robots themselves, under the guidance of surgical experts, may be expected to actively enter the scene of surgery in the future.
B Robots may also actively enter the scene of surgery to make complex deci- sions about cases on their own. This could be particularly important in battle- fi eld situations, where actual surgeons would be directing the robots from a
“safe” location.
A
B
Conclusions
The fi eld of laparoscopic colorectal surgery is squarely in the middle of the great technological changes that are occurring in surgery. The complexity of laparoscopic colorectal procedures has made it necessary to proceed slowly over the fi rst decade, but now many new tools are emerging that are going to improve on the effi ciencies and outcomes of patients requiring laparoscopic treatment of their colorectal diseases.
We have reviewed some of the important changes occurring, albeit briefl y, which are now upon us, and have also made some predictions.
The operating room of the future will be a highly complex environ- ment, fi lled with tools that will change the outcomes of patients in a dramatically positive way. The potential for improvements will depend on the cooperation of surgeons and the surgical industries to continue to innovate and work together.
