RobertWood Johnson ■ MEDICINE 23RobertWood Johnson ■ MEDICINE 23

RevolutionSurgeryThat’s Minimizing Everything but Results

By Lynda RudolphPHOTOS BY JOHN EMERSON

AIN

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The benefits are substantial. Shorterhospital stays. Less pain. Fewer andsmaller incisions. Less scarring. Re-duced blood loss. Faster healing andrecovery. For physicians, it’s a newfrontier — one that offers better accessto human anatomy. For patients, it’s arevelation — in some cases, cuttingrecovery time in half. For watchdogsof operational costs, it’s a panacea —the numbers of procedures are up;readmissions and complications aredown.

It seems as though we wentovernight from nine-inch incisions to those that are barely visible to the human eye. But when and where didthe MIS revolution actually begin?

Where It All Started

The origins of minimally inva-sive surgery date back morethan 200 years, to the same

year when Thomas Jefferson was

reelected president. In 1804, a devicecalled the Lichtleiter (light conductor)was introduced in Frankfurt, Germany,by Philipp Bozzini. It was a light-guidedinstrument that served as a primitiveendoscope. But it wasn’t until 1981that the first laparoscopic appendec-tomy was performed by Kurt Semm, apioneer of modern laparoscopic sur-gery. Today, the number of minimallyinvasive surgical applications is mind-boggling.

“Twenty years ago, there was verylittle minimally invasive surgery beingperformed. Today, the majority of sur-geries have some minimally invasive orremote access application,” says AlanM. Graham, MD, professor and inter-im chair, Department of Surgery, chief,vascular surgery at Robert WoodJohnson University Hospital (RWJUH),and medical director for clinical prac-tice operations and planning, RobertWood Johnson Medical Group.

Minimally invasive surgery is char-acterized as surgical procedures thatrequire incisions of no more than one-eighth to one-quarter of an inch. Theprocedural list is endless. Arthroscopy.Endovascular aneurysm repair. Mitralvalve repair. Hysterectomy. Uterinefibroid removal. Tubular microdisceto-my. Percutaneous nephrostomy. Atrialseptal defect repair. Mohs micrograph-ic surgery. Thyroidectomy. Urethralsuspension. Hip arthroplasty. Video-assisted thoracic surgery.

Traditional “open” surgery is going the way of the dinosaur. Heart valve repairs, brain

tumor resections, and other complex procedures that were formerly the territory of

open surgery are now being performed using minimally invasive surgery, or MIS. The

buzz about it is everywhere: on the lips and in the minds of not just clinicians but patients as well.

Even advocates of health care reform love it.

“Twenty years ago, there was very little minimally invasive surgery being performed. Today, the majority of surgeries have some minimally invasive or remote access application,” says Alan M. Graham, MD, professor and interim chair, Department of Surgery, chief, vascular surgery at Robert Wood Johnson University Hospital (RWJUH), and medical director for clinical practiceoperations and planning, Robert Wood Johnson Medical Group.

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MIS Applications Are Burgeoning Locally

Adrian Balica, MD, assistantprofessor of obstetrics, gyne-cology, and reproductive

sciences and director, MinimallyInvasive Gynecologic Surgery Pro-gram, is using minimally invasiveprocedures for women who sufferfrom gynecologic conditions. Singleport laparoscopic surgery (SILS) forhysterectomy, ovarian cystectomy,and uterine conservation procedures,such as endometrial ablation, usingradio frequency are commonplace.“Robotic surgery is a new tool we’veadded,” says Dr. Balica. “With themagnification built into the robotictechnology, I can actually see capil-laries that aren’t visible to the nakedeye.”

In the case of rectal surgeries,unlike the national trend, in whichonly 10 percent are done using mini-mally invasive methods, surgeons atRWJUH are using robotic surgery forthe rectum in nearly half the cases,with significant success. Since theneed for large incisions is eliminated,nerve damage that affects bladderfunction is avoided, so outcomes forpatients are much improved overthose following open surgery.

Along with rectal robotic surgicalexpertise, Craig Rezac, MD, assistantprofessor of surgery and director,Colorectal Surgery Program, is one of

Adrian Balica, MD, assistant professor ofobstetrics, gynecology, and reproductivesciences and director, Minimally Invasive

Gynecologic Surgery Program, is usingminimally invasive procedures for womenwho suffer from gynecologic conditions.

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the pioneers of transanal endoscopicmicrosurgery (TEM). He performedthe first procedure in the state fouryears ago and is developing theRobotic Colorectal Surgery Programat RWJMS and RWJUH. The TEM

procedure is a minimally invasiveapproach that provides magnifiedvision and superior optics for remov-ing tumors throughout the rectum,allowing surgeons to take out rectallesions that would have been consid-ered inoperable.

Isaac Yi Kim, MD, PhD, associateprofessor of surgery and chief, sectionof urologic oncology, at The CancerInstitute of New Jersey, completed his1,000th robotic prostatectomy inOctober 2012. Dr. Kim developed a

new approach known as the athermalintrafascial robotic (AIR) prostatecto-my. This radically different way toenter the tissue planes — around theprostate rather than through theendopelvic fascia — has resulted inreduced trauma to the nerves thatcontrol erections.

Gamma Knife Perfexion is currentlybeing used for brain cancer and to treatarteriovenous malformation (AVM),pain disorders, and tremor. GammaKnife Perfexion is the specialty of

Craig Rezac, MD, assistant professor of surgeryand director, Colorectal Surgery Program, is one ofthe pioneers of transanal endoscopic microsurgery.He performed the first procedure in the state fouryears ago and is developing the Robotic Colorectal

Surgery Program at RWJMS and RWJUH.

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Shabbar F. Danish, MD ’01, assistantprofessor of neurosurgery, director,stereotactic and functional neuro-surgery, and director, Gamma KnifeCenter at RWJUH. It’s the only radio-surgery tool that has been developedspecifically for use on the brain.

Dr. Danish and his team are usinglasers to treat brain tumors that havebeen inoperable with traditional sur-gical methods. They also use it totreat epilepsy. Having recentlyreached the 50-procedure milestone,they perform more of these types oflaser procedures than anyone else inthe country. Laser ablation has beenused on other parts of the anatomyfor years, but it has been employed totreat epilepsy only since 2010.

In the procedure, surgeons threada fiber-optic cable through a smallhole in the skull and, using imageguidance, carefully maneuver it towhere the brain lesion is located.Then they initiate the laser ablationto burn out the targeted tissue that isat the origination point of the epilep-sy. “I think laser procedures aregoing to revolutionize epilepsy treat-ment, because we can achieve thesame outcomes without opening thehead,” says Dr. Danish.

The implantation of deep brainstimulation (DBS) devices to treatmovement disorders is another wayin which MIS has transformed neuro-surgery. These devices deliver electri-cal pulses to stimulate the brain, tar-geting specific areas that will result in better control of the disabling

Isaac Yi Kim, MD, PhD, right, associate professor of surgery and chief, section of

urologic oncology, at The Cancer Institute ofNew Jersey, completed his 1,000th robotic

prostatectomy in October 2012.

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movements of Parkinson’s disease andsimilar conditions.

We may currently seem to take thisrevolution for granted. But, as Dr.Danish points out, “Five years ago,some of this technology didn’t exist.”

“The trend is moving toward mini-mally invasive,” says Dr. Graham.“The technology is evolving, andremarkable results are possible.”

“Just look at the numbers,” addsDr. Kim. “They are rising dramatical-ly each year.”

But the future is about more than

increasing numbers of existing MISprocedures. It’s also about innovations.“Within the next year, we expect to seesingle port laparoscopic surgery, usinga new robotic device, which meansonly one small incision will be needed,”says Dr. Kim. There’s a new applica-tion for partial nephrectomies as well,which involves injecting dye into thekidney to determine where the canceris located, effectively “staining” thecancer cell. The fluorescent-dyedtumor lights up, providing a real-timeassessment to reduce the likelihood ofleaving any cancerous tissue behind.

Minimally Invasive Surgery as a Major Attraction

MIS training and educationare required as part of thecurriculum qualifications

for residents. In 2005, the ResidencyReview Committee of the Accredita-tion Council for Graduate MedicalEducation revised the laparoscopicand endoscopic minimum case require-ments for graduates of surgical residen-cies. These requirements include 60basic laparoscopic surgeries, 25 advanc-ed laparoscopic surgeries, 35 upperendoscopies, and 50 colonoscopies.

“Medical residents are now lookingfor programs that can provide the kindof procedural experience they need,”says Dr. Rezac. “There are minimumrequirements for procedures neededfor residents to sit for their boards.”

Becoming a leader in the operatingroom affects physician recruitment aswell. “The dynamic physicians we’reafter are looking for a state-of-the-artenvironment,” says Dr. Graham.

And patients are coming into physi-cians’ offices armed with their ownresearch that they’ve done on theInternet. “They come in with a list ofwhat they’re looking for,” says Dr.Graham. “They’re going to go some-place else if we don’t have it.”

MIS has become so essential to med-ical practice that complete centers arebeing established around it. “We feelit’s so critical to patient care that weare establishing a Minimally InvasiveCenter at RWJMS and RWJUH,” saysDr. Graham. The center — alreadyrobust and newsworthy — will inviteall the specialties to be housed underone virtual roof. “This brings togetherour extensive collective of resources,creating a central hub of informationand innovation people in New Jerseycan turn to,” Dr. Graham concludes.

MIS is just the beginning of howsurgery is being reinvented. It notonly sets the bar for procedural inno-vations in place today; it holds thepromise of things to come.

Shabbar F. Danish, MD ’01, assistant professor of neurosurgery, director,

stereotactic and functional neurosurgery,and director, Gamma Knife Center at

RWJUH, and his team are using lasers to treat brain tumors that have beeninoperable with traditional surgical

methods.

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