Modern Surgery—Minimally Invasive and Maximally Restorative
New, state-of-the-art technological advances have redefined surgery in the 21st century, and a new surgical paradigm has evolved. The three basic tenets of modern day surgery are minimally invasive, organ sparing and maximally restoring. According to Fabrizio Michelassi, M.D., Chairman of Surgery and the Lewis Atterbury Stimson Professor of Surgery at Weill Cornell Medical College and Surgeon-in-Chief at NewYork-Presbyterian Hospital-Weill Cornell Medical Center, “Modern surgery is minimally invasive, and that speaks to the approach, but has also become more organ-saving and maximally restoring. Thirty years ago, a patient with a tumor of the leg would undergo an amputation. Today, with minimally invasive and maximally saving procedures, the leg is preserved. There has been an evolution of surgery approaches from just removing to curing without destroying.”
A very high percentage of the gastrointestinal surgeries done at the New-York Presbyterian Hospital are performed using minimally invasive techniques, a trend which distinguishes Weill Cornell’s gastrointestinal surgery program from most other institutions nationwide. “The reason the majority of colorectal surgeries performed at Weill Cornell are done using minimally invasive techniques can be attributed to the leadership of Dr. Jeffrey Milsom, who is internationally recognized as one of the pioneers in developing laparoscopic procedures for colorectal procedures in the early 90s,” said Dr. Michelassi. “Dr. Milsom, who is chief of colorectal surgery, and his team, Dr. Toyooki Sonoda, Dr. Sang Lee and Dr. Sharon Stein, all have incredible expertise and experience in minimally invasive approaches to a wide range of colorectal procedures, including colorectal cancer.”
Dr. Michelassi stressed the patient advantages of such surgeries—a shorter hospital stay, less pain, and a faster total recovery time. “I’ve been impressed by seeing patients when they come back to my office in the post-operative period, that 2 weeks after surgery, they feel like they are ready to go back to work. So it is evident that recovery is enhanced by the minimally invasive approach, but it’s also important to stress that we want to do surgery not only in a minimally invasive way, but also in a maximally restorative way.”
Over the past two decades, Dr. Michelassi has made a series of significant breakthroughs in the fields of inflammatory bowel disease and cancer by challenging assumptions about traditional surgical techniques. A procedure Dr. Michelassi devised for patients with advanced Crohn’s disease, the side-to-side strictureplasty, is one example of a maximally restoring surgery. Dr. Michelassi described the differences from the traditional approach. “When you have a Crohn’s patient with many strictures in the small bowel, historically surgeons have removed the entire segment of intestine with the strictures. As a visual example, let’s say you have a series of sausages—surgeons remove all the sausages and put together the two remaining ends. Now, in Crohn’s disease, the stricture is problematic, but in between the strictures, the intestine is just fine and works quite effectively. Surgeons have traditionally been removing strictures, but also very well-functioning intestine in between, so the side-to-side was the answer to the need of preserving viable, working intestine.”
This advance has helped Crohn’s patients, who often undergo many surgeries, to avoid short gut syndrome, where the intestine is no longer able to absorb nutrients. Side-to-side strictureplasty is both a bowel-saving and a maximally restoring procedure for the patient. Said Dr. Michelassi, “We don’t have to resect anything, we don’t have to remove any healthy sections of intestine. We just palliate the strictures points.” In addition to preserving more functional tissue, an exciting finding is that side-to-side strictureplasty seems to reverse the progression of Crohn’s disease. “Crohn’s disease is a chronic inflammation. In the course of examining patients who have had the procedure, I’ve discovered that at the site of the strictures, Crohn’s disease quiets down. We are currently conducting research to prove that side-to-side strictureplasty can restore function to the intestine, which would be a major advance in the surgical treatment of Crohn’s,” said Dr. Michelassi.
Dr. Michelassi has recently published a study describing the international experience with side-to-side strictureplasty in six different medical centers worldwide. “For a procedure to be widely accepted,” he said, “it needs to be reproducible, among other things. This year we published a paper demonstrating that other surgeons in other centers were able to achieve the same good short- and long-term results that I had achieved. By now, this procedure is for consumption—over 700 have already been performed. Any surgeon who deals with patients with Crohn’s disease should be adept at this procedure because you never know when you need to use it.”
Technological advances play an important role in modern surgery. Dr. Michelassi commented on how quickly and dramatically things have changed and continue to change. “When laparoscopic colon surgery started 15 years ago or so, it was like operating in the abdomen with chopsticks through a keyhole—not particularly easy. Since then many different instruments have been devised, and many more will come in the near future, allowing safer and easier procedures. For example, in the past, if a surgeon needed to obliterate a vessel before cutting it, you had to tie it in a conventional way. Today, new energy sources enable us to obliterate these vessels just by applying the tips of a forceps around it, cutting in a much safer and more expeditious way. Many innovative instruments are designed to be more ergonometric, so that it’s easier to perform surgery. Other advances, such as robotics, are an extension of that. It’s a new surgical platform, allowing a higher degree of freedom, safety, and precision.”
Surgery in the 21st century requires a complete picture of all relevant patient information, which is key in decision-making. At NewYork Presbyterian Hospital-Weill Cornell Medical Center, the new, “smart” operating rooms equipped with a “Wall of Knowledge,” give surgeons instant access to an unprecedented amount of vital information on the patient and the procedure. The surgical suites feature state-of-the-art technologies, including an array of flat-panel screens that display up-to-the-second information, vital signs, lab results, medical records, and even a real time view through the pathologist’s microscope.
“Some surgical advances are evolutionary, some are revolutionary,” noted Dr. Michelassi, “but the trend is for safer surgery. When the first thyroidectomy was done in the late 1800s there was a 40 percent mortality rate. Now, after a thyroidectomy, you go home the same day and mortalities are very, very rare and due to reasons other than the surgery. It has taken 100 years to get to this point, but in an evolutionary fashion, surgery has become much easier, much safer. In my opinion, the new laparoscopic techniques, the Wall of Knowledge, and the robotics all add up to a better surgical paradigm.”
The future trend of minimally invasive surgery will shortly include no incisions at all, and through the use of natural body openings, will result in scarless, painless surgery. Dr. Michelassi offered a glimpse into this possible new wave of the future. “NOTES means Natural Orifice Trans-Endoscopic Surgery, which is done using natural orifices, such as the mouth or rectum, to gain access inside the abdomen. For instance, let’s say you need to remove a gallbladder. Currently, we remove the organ through small incisions through the abdomen. Why not put a scope through the mouth, go down into the stomach, and make an opening in the wall of the stomach to arrive at the gall bladder and remove it through the mouth? We are at the very beginning of this revolution,” he explained.
NewYork- Presbyterian surgeons are the recognized pioneers of NOTES, having performed the first procedure in North America. Later this year, the Hospital will be holding an international conference on NOTES for physicians, to address the newest developments and to train surgeons in the NOTES techniques.
“Besides the cosmetic advantages of avoiding incisions—no scar—a big patient benefit could be decreased postoperative pain, and a faster return of intestinal function and resumption of normal life. It would mean much shorter hospital stays and a much quicker, painless recovery time,” Dr. Michelassi said. “ In order to perform NOTES surgery we need to devise a more advanced platform of instrumentation that at this point does not yet exist. Industry and surgeons together are involved in the development of a new generation of instruments designed for NOTES surgery. At our Hospital and some other centers around the world, NOTES surgery is already being performed, proving that it is feasible. However, much more needs to be conducted in controlled studies, proving it is advantageous and not associated with morbidity or mortality. In the next three to five years, all this work will be done and it will likely result, yet again, in another major advantage for the patient.”