02 May 2010
Less pain, less blood and a quicker recovery – these reasons make minimally invasive surgery (MIS) one of the most important developments in modern surgery. Yet, when MIS, or keyhole surgery as it’s more commonly known, first emerged in the late 1980s, it was greeted with mixed feelings.
Unlike open surgery in which a huge (5-10cm) cut is made for observation and the removal of abnormal growths or tumours, MIS typically involves the use of devices and instruments inserted through tiny openings (usually about 1cm) and controlled remotely to perform surgery.
“[MIS] was feasible but it took time for safety issues to be addressed, methods to be refined and for surgeons to adapt. Once these were sorted out by the 1990s, it began to be used increasingly across the different medical disciplines,” said Professor London Lucien Ooi, Chairman, Division of Surgery, Singapore General Hospital (SGH).
In the past, surgeons had to go to great lengths to explain the advantages of MIS when trying to persuade patients to opt for such surgery. “But now, we need to persuade them to go for conventional surgery when they are not fit for MIS!” said Associate Professor Bernard Chern, Head and Senior Consultant, Department of Obstetrics and Gynaecology, Minimally Invasive Surgery Unit at KK Women’s and Children’s Hospital (KKH).
Gynaecological surgeons were among the first to make wide use of this new tool – also known as laparoscopic surgery – for scanning the womb and fallopian tubes.
Building on MIS
The turning point for MIS came in 1989, when SGH pioneered the first keyhole procedure for gall bladder surgery in Southeast Asia. It led to greater awareness of what this intricate surgery could do, and greater acceptance followed.
Numerous conditions that would have required open surgery in the past, including cardiac; colorectal; gastrointestinal; ear, nose and throat; gynaecological; neurological; orthopaedic and thoracic; are now being treated using keyhole methods. With continual refinement and adaptationof the technique, the list of conditions suited for MIS will only grow. “[Adapted] MIS enables surgeons to explore other forms of surgery such as natural orifice surgery (NOS), where diseased organs and tissues, or even tumours, are removed through various natural orifices like the mouth, anus and vagina although such procedures are still in developmental infancy,” said Prof Ooi.
Less painful procedures
In keyhole surgery, three to four incisions are necessary, one for a laparoscope – a telescopic device for viewing internal cavities – and the others for specially designed surgical instruments. The future will possibly see all these instruments fitted via a single incision through a specially designed port – a concept that has recently been tried and tested here.
Last September, Assoc Prof Chern led a team of surgeons in undertaking the world’s first single-port surgery on a 34-year-old woman with a rare ectopic pregnancy, a complication that occurs when a fertilised egg implants itself on the outer wall of the uterus. The entire operation was carried out using specially designed instruments inserted through a single incision, or port, at the navel. The same incision was also used to retrieve the removed tissue. Assoc Prof Chern said that because of the large size of the ectopic pregnancy, conventional surgery could have led to the loss of the entire uterus. To preserve the woman’s ability to bear children, doctors opted for this method, which also left no visible scars. Assoc Prof Chern said: “Patients have reported less pain and are pleasantly surprised to have only a tiny and barely visible cut on their belly buttons. For surgeons though, there are some challenges.”
With several incisions in the conventional MIS approach, surgeons don’t have to deal with problems associated with orientation. But through a single port, they have to adapt to working with restricted movements. Surgeons operating through a single incision rely on curved instruments to achieve a 3D operating effect, which requires adjusting how they visualise the body and the procedure. “It’s like using a left-hand drive in the morning and then shifting to a right-hand drive later that day,” said Assoc Prof Chern. “[Single-port surgery is] not likely to completely replace conventional MIS for all procedures, but in time, who knows?”
Send in the robots
The use of robots to aid surgery has further advanced MIS. SGH introduced robotassisted surgery in 2003 – the first in Singapore – when it acquired the da Vinci Surgical System. The system combines robotics, special miniature instruments and computer-enhanced technology to enhance the skills of an experienced surgeon to perform keyhole surgery.
The latest, more advanced da Vinci Si Surgical System arrived in April. It allows surgeons to operate with greater dexterity and precision, and even enables two related procedures to be performed simultaneously by two surgeons from different specialities. “Ultimately, our patients will benefit from more precise surgery and much-improved outcomes. Robotics is definitely the surgical platform of the future,” said Prof Ooi.
Surgeons at KKH are also hoping to provide greater benefits to patients by combining the latest surgical techniques with robotic technology. “More surgeries can and will be done by single incision,” said Assoc Prof Chern. “And hopefully, we will see an increased marrying of single incision and robotic surgery, which would mean even less post-surgery discomfort and faster recovery for our patients.”
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