THE doctor sits in a darkened corner of an operating room about 10 feet from where his patient lies on a gurney. Members of his surgical team stand around the room's periphery, staring at several large, flat-screen video monitors hanging from the ceiling.
On screen is a colon, shiny and pink. The patient himself is barely visible, shrouded in surgical sheets and dwarfed by a refrigerator-sized, four-armed robot positioned over his body.
He almost appears to be alone, even adrift, with a team of physicians and nurses trying to reach him from afar.
In reality, surgeon Alessio Pigazzi and his team at City of Hope are getting the best possible view and access. The robot's arms hold slender surgical instruments, a tiny camera and a light, all threaded through dime-sized openings in the abdomen. The monitors reveal a bright, nearly bloodless landscape, magnified 10 times.
Using hand controls and foot pedals, Pigazzi commands the robot from a console, sliding the instruments into the tight confines of the rectum where a cancerous tumor sits -- a space nearly impossible to see without the technology at his disposal. "There it is," he announces.
This is 21st century surgery -- with little blood loss, rapid healing and minimal scarring -- and it's quickly replacing surgery in which scalpels (in, hopefully, steady hands) slice long, bloody incisions through the body. In this dynamic movement, doctors aim to fix the body without hurting it.
"People will soon look back at any large incision as barbaric and archaic," says Dr. Paul A. Wetter, chairman of the Society of Laparoendoscopic Surgeons and a professor emeritus of gynecology at the University of Miami.
In only the last few years, minimally invasive surgery has evolved from a popular technique used for the simplest of abdominal surgeries -- such as a gallbladder removal or hernia repair -- to a method that can treat even life-threatening diseases such as cancer, heart problems and emphysema.
An increasing number of these surgeries are augmented with sophisticated computer and imaging technology -- such as robots. Such techniques elevate ordinary doctor skills to the super-human level by providing magnified, high-definition images and by preventing mistakes, such as cutting into the wrong tissue.
Some doctors are even taking the first tentative steps toward operating without incisions, using the body's natural openings -- the nose, mouth and anus -- to gain access to its inner workings.
Think of it as surgery without scars.
"Anything you can think of is now fair game," says Dr. Gary H. Hoffman, a clinical attending surgeon at Cedars-Sinai Medical Center. "It's to the point now where surgeons know no boundaries and are boldly trying to do all kinds of things."
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Evolving procedure
The first minimally invasive surgery, a gallbladder removal, was performed by surgeons in France in 1987. Today, as many as 90% of gallbladder surgeries are laparoscopic (minimally invasive surgery performed through the abdomen).
In these non-robot-assisted surgeries, several dime-sized openings are made in the abdomen for the insertion of a tiny camera, fiber-optic light and instruments for cutting and cauterizing tissue. The surgeon manipulates the instruments from outside the body while watching his or her movements on a monitor.
Most patients undergo the procedure as outpatients. They are back at work within a few days and can return to normal physical activities shortly thereafter. In contrast, traditional gallbladder removal involves several days in the hospital, much more pain and four to six weeks of recovery.
Now hernia repair, appendectomy, even gastric bypass are also routinely performed with only small incisions in the abdomen. These operations have proved to be but the first step in the evolution of minimally invasive surgery.
"This first stage is sort of like where the first automobiles were," Wetter says. "They were made with bicycle parts. Modern vehicles are nothing like that. We're moving into a new phase in which instruments are designed with minimally invasive surgery in mind instead of taking big instruments used in open surgery and just miniaturizing them."
Some physicians are using minimally invasive techniques in spinal fusion surgery (which traditionally requires a 6-inch incision in the back). Others are using the methods to reduce lung capacity in emphysema patients, to remove part of the bowel in people with Crohn's disease, to replace faulty heart valves and to repair aortic aneurisms. (Open cardiac surgery typically requires a lengthy incision through the chest and the splitting of the chest bone to expose the heart.)
Still other surgeons are repairing the anus or intestines in infants with birth defects, removing women's ovaries or uterus without opening the abdomen, and removing kidneys from live donors while saving them significant pain and time spent recuperating.
