Laparoscopic General Surgery Instrumentation

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Dr. Larry Demco: "I’m Dr. Demco, reporting from the 4^th Annual Global Symposium on New Diagnostic Techniques from the SLS meeting in Miami. I’d like to interview Dr. Carlos Gracia, who is a general surgeon and a vascular surgeon who works out of Southern California and has a special interest in pursuing microscopic techniques and general surgery. Carlos, I was just wondering, can you give us a little overview of how you arrived from where you were with larger instruments, and why you changed to the microscopic instruments themselves?"

Dr. Carlos Gracia: "Sure Dr. Demco. We saw a significant change in outcomes in patients when we took the incisions away and went ahead and starting using traditional ¼-inch and ½-inch laparoscopic instrumentation. Probably around five years ago, we saw some interesting innovations with smaller instruments and smaller scopes that looked very promising. And finally, after looking at some pioneering work from Michelle Gunya and a couple of others about three years ago, it occurred to me that there may be some merit here, and by that time the technology had been evolving.

By the time I tried the smaller scopes and instruments on my first few cases, I realized right away that one could technically accomplish the same outcomes that I had been doing with the larger instruments. So really, over a matter of weeks, and probably within 20 to 30 cases in terms of a variety of different procedures like gallbladders, hernias, and some stomach and bowel surgery, we realized that we really could work as we were doing with the larger tools.

Although it was a little more difficult at first to continue with the smaller tools, we were able to stay motivated because the patients were showing us noticeably different outcomes. Patients that I was able to send home the day after surgery with the normal ¼-inch or ½-inch instruments always needed a little prodding to go home the next day. As I mentioned to other people, when we started doing them with the 1/8-inch or smaller instruments, they were now chasing me down in the hallways the next day, eager to go home. All the nurses and everyone else really noticed a dramatic change in how much better the patients did, which stands to reason due to the fact that we were just making smaller punctures with instruments now smaller than an 1/8 of an inch in size."

Dr. Larry Demco: "So what instruments are you currently using as your first choice instrument? Is it a 2-, 3-, 5-, or 10-mm?"

Dr. Carlos Gracia: "We have developed a strong preference for the 3-mm instruments. We sampled 2-mm’s and 3-mm’s, and unlike some of the diagnostic procedures, probably 2-mm or better since we’re doing more operative procedures that is actually doing resections, removal of organs, or reconstructions. We find that the 3-mm’s are a little bit more durable, and we’ve had excellent luck with the Karl Storz instruments because they’ve had the tensile strength and the jaw patterns that really work, as if you were holding a regular 5-mm instrument."

Dr. Larry Demco: "What procedures have you developed now, being a cardiovascular surgeon as well as a general surgeon? Can you list some of the procedures that you have done successfully using the 3-mm instruments that you are now recommending?"

Dr. Carlos Gracia: "We’ve been very successful in using it for all of the standard gastrointestinal operations. For example, we've worked with gall bladder resections, anti-reflux surgeries involving stomach reconstruction, colon and small bowel removals, appendectomies, removal of the spleen for various blood problems, and blood disorders. We’ve applied it to all of our other operations in terms of spinal fusion to expose the spine for the orthopedics doctors, and we’ve been using it with a whole host of other operations. We’ve been very aggressive in applying laparoscopy to vascular surgery, and with aortic surgery we’ve been able to use it in addition to the 5-mm and some 10-mm instruments that we still need to use in these procedures and which are still evolving. We’ve been able to use 3-mm’s in areas where we were previously using the 5-mm’s and the 10-mm’s."

Dr. Larry Demco: "I understand that you were one of the first to actually do a aortic bypass surgery, in its infancy. Can you tell us a little bit about laparoscopy in vascular surgeries, since this is a new frontier, and can you tell us the benefits to the patient?"

Dr. Carlos Gracia: "It’s a very exciting and significant area of growth because vascular surgery has been pretty much passed over by the minimally invasive surgical community over the last eight or nine years. The vascular surgeon’s only real minimally invasive tool has always been to go into the artery through a needle and a wire using balloons and cages and things to dilate from within. That works very well in some situations, but in a significant number of others, those things have high failure rates and you end up having to really do surgical reconstruction. So since 1994 and up to 1995, we’ve been developing techniques to be able to provide the same normal surgical reconstructions but without the typical 8-inch, 9-inch, or 10-inch incision that is usually accompanied by them. So in vascular surgery, there is tremendous growth for working with minimally invasive surgical techniques, particularly on the larger blood vessels, for both blockages and for aneurysms."

Dr. Larry Demco: "Myself, I’ve had an opportunity to work with robotics in vascular surgery. We’ve seen coronary artery bypass surgeries by remote robotics. Have you had any experience with this, and can you pass on some information on it, if so?"

Dr. Carlos Gracia: "Yes, I’ve been a big fan of robotics since the early 1990s. We started working with the original AESOP robot – which basically added a third arm to the surgeon to manipulate the scope – and saw that through its development with foot controls, eye tracking, and to its current control system, which is speech. I think robotics have a significant role in the growth of many of these things because they basically put a computer between the surgeon’s hand and the tip of the instrument.

As you mentioned, in cardiac surgery, the Zeus system offers tremendous advantages by enabling surgeons to do very, very fine maneuvers with the sutures that are, basically, the thinness of your hair. We can work with little blood vessels that are 1/8" in size to put them together without having to open up patients. So I think robotics clearly have a bright future in enabling more and more minimally invasive surgeries, especially in the cardiac field."

Dr. Larry Demco: "Do you see the day where bypass surgery can be done with only an overnight stay?"

Dr. Carlos Gracia: "Probably a 48-hour stay. I think we’re going to be very, very close to that. In fact, if you really look now at some of the minimally invasive, direct anastomosis that are being done through very small 2-inch river sections to get down to a single vessel of the heart, in some cases, these patients are already going home in 48 hours. Less than 72 hours is really remarkable. In the next decade or so, I think the age of outpatient cardiac surgery could definitely be on the horizon."

Dr. Larry Demco: "When I was using Zeus, it was interesting to see that we were able to operate as the heart beat, and the computer would compensate for that. Do you see an advantage in not stopping the heart in cardiovascular surgery while you’re repairing the artery? Is this a big advantage for the patient?"

Dr. Carlos Gracia: "I think by now it’s been pretty well demonstrated that not using bypass has tremendous advantages to the patients because it’s not only the significant part of the cost of the operation, but it also imparts for the most people the highest risk of complication. I think many surgeons have finally seen the light on that one and have adopted many new and innovative techniques that operate on a heart while it is still beating. So I think there’s a big advantage to that, and I think the technology is there to really begin to sort of cancel out the cardiac motion and make it look like you’re working on a stilled heart by using these computer interfaces. Again, this is not only between the surgeon’s hands and the end of the instrument, but also between the surgeon’s eyes and the monitor so that the surgeon has an even better target to work with on a stable platform. It seems to be very promising, the only exception being that certain types of heart surgeries, valves, and things are always going to need some kind of bypass. But for the routine blockages, which are clearly the vast majority of cases, there are some really great things happening for patients."

Dr. Larry Demco: "We’ve all heard about them opening up an artery by passing a balloon through the artery through a radiological procedure. Where do you see this junction with robotics and the outpatient, or 24- to 48-hour stay, using minimally invasive surgery over the next few years?"

Dr. Carlos Gracia: "There’s an interesting concept being unfolded on hybrid procedures where it’s not unusual to see disease in more than one artery of the heart. If it’s on the left side of the heart, or the main muscle of the heart, you don’t really necessarily want that failing in four to six months, and I think very few people would argue the fact that that would be best surgically bypassed. But instead of having to open up the whole chest and do several blood vessels at one time, the hybrid procedures are concepts that allow a cardiologist to dilate two or three other slightly less important blood vessels with balloons. The surgeon would then later that day go in and operate on the left side of the heart with one of these small little river section operations, and the patient could go home in 24 to 48 hours, basically after having his or her heart successfully revascularized."

Dr. Larry Demco: "So David Letterman is a dying breed, in the sense that he’s had an operation done in the traditional manner, and there are other things on the horizon. It would be interesting to see what he might say at this time, knowing this new information. We’d like to thank you for your input, and hopefully some of these views will open up the eyes of patients who are listening to this and some of the general practitioners and surgeons who are unaware that such techniques are available and are currently being practiced in the United States and the rest of the world. I’d like to thank you very much, Carlos, for your interview. We hope to see more of your progress not only here on the Internet, but also all over the world. Thank you very much."

Dr. Carlos Gracia: "Thank you, Larry."