Laparoendoscopic Gastrointestinal Surgeon at Sanford Health

Kashif Zuberi

Over the last 50 years, we have seen a dramatic change in the way procedures are being performed in both the outpatient and inpatient setting. Initially, patients feared facing medical procedures due to the maximally invasive nature of the art. Extended hospital stays and long durations of pain as well as increased rates of complications as compared to today’s standards, were the norm. The role of minimally invasive surgery encompasses many techniques and equipment that reduce post-procedural pain, hospital length of stay, and complications, which is a priority for the patient. When I mention minimally invasive surgery, I refer to a combination of video-assisted surgery using different forms of endoscopes. The advent of endoscopy changed how we learn and how we treat. Procedures that were deemed dangerous for the patient have become routine. Limiting access to the body, but maximizing exposure has, without a doubt, changed patient outcomes. Endoscopic surgery has grown to such an extent that almost all operations performed via the classic open method can now be done safely and efficiently with the proper training and equipment. Surgery evolved from open cases to laparoscopic/thoracoscopic cases to the use of surgical robotics.

Flexible endoscopy has also been increasingly utilized as a novel apparatus for minimal access surgery. Flexible endoscopy has evolved in the past 40 years to higher definition and variations for management of intraluminal and in some cases, extraluminal therapy with a variety of different configurations and view-points. It includes operating endoscopes with multiple channels, diagnostic endoscopes, side-viewing endoscopes, and specialized attachments to provide a therapeutic advantage. Besides this, endoscopes within endoscopes to evaluate ducts and smaller orifices within lumens of organs has virtually eliminated the need for open bird’s eye operations of the past.

Automated robotic instruments and platforms have been in the market for decades and will only improve over time, in the future. The list of procedures that have evolved in the last 20 years from improving precision and accuracy with these technologies has minimized morbidity and mortality in conditions both common and rare.

Surgical Robotics in the mainstream has essentially evolved through the DaVinci Surgical Robot by Intuitive Surgical. Predecessor robots from today’s standards were crude and primarily designed for a single operation or practice. It is not the case today with laserguided robotic features and integration of the operating table into the platform. Robotics in surgery is essentially the future projection of this profession. It provides a younger generation of surgeons who face the regulations of training, another method of performing surgery from a minimally invasive standpoint without a two-dimensional view or rigid instruments with limited mobility. Recent graduates have now trained with these technologies as a primary source of skill. Subsequently, we will see forward momentum with higher definition cameras and 3-dimensional as well as holographic projections that will change the way we practice medicine in the future.

Virtual reality devices are also being evaluated for their role and impact in pre-operative planning and identification of pitfalls to operative approaches. Threehundred- and-sixty-degree movement of holographic images in real-time or superimposed on patients is being evaluated and utilized at research centers in the United Kingdom. With the advancement of this technology, instrumentation has changed and continuously evolves to maximize our use of these platforms. We now combine these different platforms to provide a full inside and outside view from a reconstruction standpoint and management of complications immediately or within the peri-operative period, safely and efficiently.

The biggest pitfall with technology is cost and training. An increase in staff for seamless utilization of the equipment, additional knowledge of associated devices or instruments requires repetition to learn. Cost of unused or unnecessary opened equipment can add up. However, this should be short-lived with the experience alongside the cost of the equipment itself.

With all that said, it is inevitable that camera-based surgery, be it endoscopic or robotic, will be the expectation of the future patient. This progress of minimizing trauma to the body will maximize our ability to manage patient’s conditions safely and efficiently with the long term result of overall cost savings and best outcomes.