Surgeons go to new lengths to avoid scarring
- From: Florida <demeter547opine@xxxxxxxxx>
- Date: 30 Apr 2007 09:35:29 -0700
Surgeons go to new lengths to avoid scarring
PITTSBURGH, Pennsylvania (AP) -- A 4-year-old boy lay on an operating
table in Pittsburgh a few weeks ago with a tumor that had eaten into
his brain and the base of his skull. Standard surgery would involve
cutting open his face, leaving an ugly scar and hindering his facial
growth as he matured.
But doctors at the University of Pittsburgh Medical Center knew a way
to avoid those devastating consequences. They removed much of the
tumor through the boy's nose.
Since then, doctors in New York and in France have announced they
removed gall bladders through the vaginas of two women. And doctors in
India say they have performed appendectomies through the mouth.
It's a startling concept and a little unpleasant to contemplate. But
researchers are exploring new ways to do surgery using slender
instruments through the body's natural openings, avoiding cutting
through the skin and muscle.
Many questions remain about that approach. But doctors say it holds
the promise of providing a faster recovery with less pain and no
visible scars. And in the brain, it can avoid a need for manipulating
tissue that could disturb brain and eye function.
For abdominal surgeries, going through the mouth, vagina or rectum
would avoid the need to cut through sensitive tissues. And deep inside
the body, where tissue doesn't feel lasting pain, the procedures
themselves might be less traumatic.
Some abdominal surgeries like bowel operations can require patients to
spend a week or more recovering at home. With the natural-opening
surgery, the theoretical hope is that "they really can go back to work
the next day," said Dr. David Rattner of Massachusetts General
Hospital.
"It would be like going to the dentist and getting a root canal,"
Rattner said. "It's not trivial, but it also isn't disabling."
Natural channels
Sometimes doctors even pass up one natural body opening for another.
On the same day they treated the 4-year-old, doctors in Pittsburgh
operated on neck vertebrae of an elderly man through his nose.
Usually, this operation would have been done through the mouth.
But going through the nose meant the patient could start eating right
away rather than waiting a few days. And he avoided the risks of a
feeding tube and a surgical hole in his throat to help him breathe,
said neurosurgeon Dr. Amin Kassam.
Doctors at the medical center first reached the spine through the nose
just two years ago, he said.
They have even removed brain tumors the size of baseballs through the
nose, nibbling at them and withdrawing pieces the size of popcorn
kernels.
However, entry through the nose isn't feasible for brain tumors in
some locations. That's why doctors had to remove the rest of the 4-
year-old's tumor another way, by going through the side of his skull.
They used an incision designed to hide behind his hairline.
The key to operating through body openings is specialized slender
instruments that can be inserted into the natural channels, along with
devices that provide light and a video camera lens at the site of the
surgery. Doctors watch their progress on video screens as they
manipulate the surgical instruments.
Sound familiar? It's much like laparoscopic surgery, which
revolutionized the operating room more than 15 years ago. For many
operations, long incisions have been replaced with three or four
holes, each maybe a quarter-inch to a half-inch wide. That has vastly
reduced pain and recovery time.
The natural-opening approach holds the promise of going a step beyond
that by eliminating the need for those punctures.
"Getting rid of them completely is going to be not an evolutionary
step, but a revolutionary step," said Dr. Marc Bessler of New York-
Presbyterian Hospital/Columbia University Medical Center.
He led the surgery in New York that detached and removed a woman's
gall bladder through her vagina. The team also inserted laparoscopic
instruments into two small incisions in her abdomen, using one
instrument to hold tissue out of the way.
A week after that surgery was announced, a French doctor said his team
had removed a woman's gall bladder through her vagina without any
abdominal incisions. Instead, the team pierced her abdomen with a
needle about a tenth of an inch wide. The needle was equipped with a
video camera system and also allowed doctors to inflate the abdomen to
create a working space.
The surgery, performed April 2 on a 30-year-old woman at University
Hospital of Strasbourg, was led by Dr. Jacques Marescaux of the
Institute for Research into Cancer of the Digestive System in
Strasbourg. In a written statement, Marescaux said the procedure left
no abdominal scar.
Meanwhile, surgeons have shown increasing interest in removing brain
tumors through the nose over the last five years or so, noted Dr. Gail
Rosseau, chief of surgery at the Neurologic-Orthopedic Institute of
Chicago.
"This is the dawn of this phase of neurosurgery," said Rosseau, a
spokeswoman for the American Association of Neurological Surgeons.
"This is exciting, it's new and it may well be better for our
patients. In fact, we hope it will be. But it does raise questions."
Cancers can come back if they're not completely removed, she noted.
It's too soon to tell whether attacking tumors through the nose leads
to a higher rate of cancer recurrence than going through the skull,
she said.
Risks still exist
Concerns like the risk of meningitis from spinal fluid leakage also
have to be addressed.
Today, most surgeons would go through the skull to remove baseball-
sized tumors, she said, "but a decade from now? I don't know."
As for abdominal surgery, a few procedures have been done in people,
but nearly all the research so far has been in animals. There are
still plenty of questions and barriers to overcome.
For example, Rattner said, new tools must be developed to perform this
kind of surgery. And while it makes sense that people would recover
faster from natural-opening surgery than laparoscopic procedures, that
hasn't been proven yet, Rattner said.
Then there's the basic question of just what abdominal procedures make
sense for a natural-opening approach. For women, Bessler believes the
gall bladder and appendix will be among those that will be removed
through the vagina.
Rattner questions whether a natural-opening approach for removing
those organs offers enough of an improvement over laparoscopy -- which
can get a patient back to work in four to seven days -- to make it
worthwhile.
He sees more potential for procedures that replace surgeries that can
keep a person out of work for weeks, like removing a kidney, adrenal
gland or a portion of the intestine. Or doing obesity surgery.
"It's not going to replace laparoscopic surgery, but it's going to
have a niche somewhere," Rattner said. "We're trying to figure out
where that niche is going to be."
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http://www.cnn.com/2007/HEALTH/04/29/scarless.surgery.ap/index.html
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