By Sara Wykes
Illustration by Leif Parsons
Seventy-five-year-old Joe Cherry woke up on a Friday at his home in Florida with a severe headache. By the end of the day, he was in the emergency room.
“I didn’t know much of anything for the next two or three days,” he says. Cherry’s son, Mike, a Stanford genetics professor who had flown out to be with his father, began feeding MRI images to Stanford Hospital physicians, including professor of neurosurgery Griff Harsh, MD, surgical director of the Stanford Pituitary Center, and associate professor of neurosurgery and medicine Laurence Katznelson, MD, the center’s medical director. What they saw was a tumor at the base of Cherry’s skull, below the pituitary gland. Nearby was a deposit of blood. Cherry’s eyesight was in jeopardy.
No surgeon goes near the brain without a keen awareness of what inadvertent damage can do. The pituitary is one of the body’s master control organs, surrounded by critical neurological structures. Drilling a hole into Cherry’s skull was out of the question. Instead, Cherry’s tumor would be reached and removed through his nose.
Yes, his nose. Increasingly, surgeons pipe brain tumors out nostrils, remove appendixes through patients’ mouths, and conduct gastric bypasses by way of the belly button. These surgeries seem weird and amazing — but probably won’t much longer. The popularity of surgeries via pre-existing openings and tiny incisions is rising, taking the trend begun decades ago toward minimal-access surgery to the ultimate extreme.
As with traditional minimal-access surgery, physicians use long tubular instruments called endoscopes to avoid cutting large incisions through skin, bone and muscle. The endoscopes allow physicians to slip tiny surgical tools in and out of the body; an attached camera transmits video images to a screen showing what’s happening inside.
The first endoscopic gallbladder removal, in 1987, started the trend. Now the technique is used for nearly all of the hundreds of thousands of gallbladder removals annually in the United States, as well as the majority of certain other common operations, including appendectomy, colon polyp removal and hernia repair, according to the Center for Minimally Invasive Surgery at the University of Minnesota. Soon minimal-access procedures will constitute as much as 65 percent of surgeries, the center projects.
The benefits of surgery without large incisions easily explain the increase in these procedures’ popularity over the last 30 years. Instead of a big scar, they leave a small one. Instead of lots of pain medication, there can be far less. Smaller incisions also reduce infection and speed recovery — there is literally less to heal and, overall, the body is less traumatized. Some procedures that once required hospitalization can now be done as day surgery, and patients can more quickly get back to their normal lives. When even one day in the hospital can cost several thousand dollars, avoiding stays can mean large savings.
Using natural orifices for surgery has another advantage — an internal incision instead of an external incision. Whatever scar is left behind will not be visible from the outside. Some physicians say that internal incisions heal more quickly than external. And, with some surgeries, like Cherry’s, entering the body through one of its existing openings is literally the only way to get in without life-altering damage.
Documenting how common this small-scale surgery has become depends on definitions. Endoscopic surgeries are performed by the hundreds of thousands each year. At least 90 percent of the average year’s 700,000 gallbladder removals were done with a laparoscope — an endoscope that enters the abdomen. Catheter access, which annually aids hundreds of stroke, tumor and cardiac patients, is available at major medical centers like Stanford. Within each of these groupings, however, are leading-edge procedures — like removing an appendix through the mouth or a gallbladder through the vagina — that are available at only a handful of facilities.
For patients like Cherry and many others, the microsurgical instruments developed for minimal-access surgery, combined with advanced imaging technology that gives physicians the assistance of real-time video as they work, have made life-saving surgeries possible. Stroke, aneurysms and skull base tumors can now be reached and treated effectively with a minimum of disruption, whether entry begins at the nose or the femoral artery, in the thigh. Physicians can send tools through the mouth to get to the voice box for a far more effective removal of tumors there. Other body openings physicians have begun using include the vagina, rectum and urethra. Stanford surgeon Sanjeev Dutta, MD, is pioneering another minimal-access avenue — traveling through the body underneath the skin.
The innovative use of access routes, in particular through the nose, is influencing how physicians work together, blurring traditional lines of territory and technique. When neurosurgeons Harsh and Katznelson operated on Cherry, a third surgeon was part of the team — rhinologist Peter Hwang, MD, director of the Stanford Sinus Center. Stanford neurosurgeon Robert Dodd, MD, PhD, often pairs with interventional radiologists to repair ruptured blood vessels in the brain, working through a barely visible incision in the leg. As a collaborative team, Harsh says, specialists in surgery, oncology, radiation, ophthalmology and otolaryngology can accomplish what they could not as individuals.
The demands of minimal-access surgery also have begun influencing hospital design. New hospitals will no longer have places called operating rooms. They will have a flexible hybrid called an interventional platform: a space with movable partitions that meets the standards for open incision surgery and has space to hold the equipment to allow both surgical and catheter interventions. The new hybrid room is large enough to hold collaborative teams of clinicians for procedures that combine both specialties. This spring, Stanford Hospital inaugurated its first hybrid, specially fitted for neurological diagnosis and treatment. Plans for a new Stanford Hospital building call for an entire floor of interventional platform space.
Enthusiasm for surgery via small incisions is so great that medical training, research, tools and hospital infrastructure are only now starting to catch up. Despite advances, the instruments for these surgeries are still not as small, strong or flexible as physicians say they should be — problems that programs like Stanford’s surgical innovations fellowship for surgical trainees are trying to solve. The program teaches surgeons how to invent and bring new surgical devices to market.
When neurosurgeon Harsh goes into narrow vessels or arteries to reach pituitary tumors, the two fine tips of the forceps tool must be equally narrow. And those fine tips are so delicate, he says, they can lose precision just by passing through the body. The tools’ maneuverability also needs improvement. Turning corners with a catheter in the human body is not like moving a stick through dry sand.
“Nobody taught me anatomy from that angle. I had to reorient myself.”
The early laparoscopic tools were like chopsticks, says Stanford’s chief of general surgery, Tom Krummel, MD, “long, straight sticks that couldn’t do very much.” The tools are better now but have a way to go. “Now what we have are relatively small in diameter — about the thickness of a swizzle stick — and they incorporate radio frequency, ultrasound and dividing tools. Until we get better tools — to suture, to grasp — we are limited in what we can do.” Some device manufacturers are interested in the next generation of minimal-access surgery’s special requirements, he says, “but the tool kit we need hasn’t yet materialized.”
Refining these tools may come far faster than surgeons can be trained, or retrained, with the special skills required to use them — and to compensate for the loss of big field view and tactile information. Data show that the more experienced a physician is in this type of procedure, the better the outcome.
For surgeons trained in open surgery, it’s a completely new view of anatomy. Dutta, an associate professor of surgery, does minimal-access neck surgery. “Nobody taught me anatomy from that angle. I had to reorient myself,” he says. “Even experienced surgeons can get lost.” Getting that training can be a challenge: While research hospitals like Stanford provide training in minimal-access surgery, opportunities for learning the techniques are not nearly as widespread as for traditional, open surgery.
The new techniques are also physically strenuous. With shoulders up and arms out, holding and maneuvering long instruments with eyes fixed on a video screen, sometimes for hours, surgeons are feeling the pain. A recent survey of its members by the Society of American Gastrointestinal and Endoscopic Surgeons found a stunning 86.9 percent reporting physical complaints attributed to minimal-access procedures.
The ultimate question is how well these minimal-access techniques stack up against open surgery. In fact, the shift toward more minimal-access surgeries is happening before researchers have gathered compelling evidence supporting their value. “The way technology is now,” says clinical associate professor of surgery James Lau, MD, a recent arrival to Stanford Hospital’s bariatric surgery program, “you get the process and the technology way before you get the literature.”
Very simply, Krummel says, “the risk increases as we make smaller and smaller holes for more complicated approaches, and we don’t yet have an adequate track record of success and safety.”
These new approaches are, after all, just another step in treatment evolution, says minimal-access surgery specialist John Morton, MD, and need to be carefully evaluated for appropriateness. “There is a continuum, from big to little to no incision,” says Morton, an associate professor of surgery. “Not every single approach is going to meet every single problem.”
Cherry never hesitated about his procedure to remove the pituitary tumor. Harsh explained the procedure to him in great detail, he says, “what they were going to do and how they were going to take the tumor out. I knew the nose was the direct route. Of course, I was very eager to get this thing out of my head and I had total confidence. I even asked another one of my doctors, Peter Hwang, ‘Why should I believe you can do this job? He said, ‘Because I’ve done thousands of others successfully.’”
Cherry had also expected pain. “You would think that when you have surgery and they go in and start cutting that you would have pain. I had no pain at all. Everything was a real success. I’ve just been doing terrific.”
His surgery, he says, “was a life saver.”
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At Stanford, teams of interventional radiologists, surgeons and other specialists in a range of disciplines are expanding the possibilities for surgery through small incisions — or by way of natural orifices.
A few examples:
• Stanford surgeon John Morton, MD, who has done minimal-access procedures for years using three or four small incisions, has begun using a single incision — in the belly button — for certain gastric bypass surgeries. The associate professor of surgery says it’s not easy to tie knots on the inside, but the payoff for patients is a quick recovery. Patients are often able to go home the next day and are up and about a few days later.
• Sanjeev Dutta, MD, is a Stanford and Lucile Packard Children’s Hospital surgeon who uses the armpit as an entrance point, making an incision just deep enough to let him slip tiny surgical tools under the skin to reach the neck. Once there, he can remove thyroid and parathyroid glands, cysts and other lesions. Dutta has also used the subcutaneous route to move from an incision in the scalp to a cyst on a patient’s forehead. Neck surgery in particular can leave some of the most stigmatizing scars, he says, “and if I can safely and effectively do things I need to do while addressing that kind of concern, I’m obligated to do that.”
• Stanford otolaryngology surgeon Jayakar Nayak, MD, PhD, calls the nose a central terminal that makes several areas accessible without the kind of long incisions down the side of the face once needed for procedures such as reducing eye pressure caused by the autoimmune disorder Graves’ disease. The new scope of transnasal surgery means treatment for a wider variety of tumors and infections. And even though the nose houses bacteria, incisions in its interior have proven to have a lower infection rate than any skin incision. He says the next destination by nasal entry could be the spine.