Worlds of David Darling > Children's
Encyclopedia of Science > Health Revolution > 2. Operating on a Small
THE HEALTH REVOLUTION:
Surgery and Medicine in the Twenty-first Century
a book in the Beyond 2000 series by David Darling
2. Operating on a Small Scale
Until quite recently most operations followed a similar pattern. The surgeon
would make a generous incision through a patient's skin with a sharp instrument
called a scalpel and then hold the cut open with separating tools called
retractors. Next the surgeon would pinch off severed blood vessels with
forceps, and, if necessary, saw through bone to reach the problem area.
Some operations must still be carried out in this way. But now the emphasis
in surgery has shifted to doing as little damage to the patient as possible.
This type of surgery is known as MINIMUM-INTERVENTION surgery and, among
other techniques, involves passing instruments into the body through very
small incisions and using new devices such as surgical lasers to avoid making
|Surgeons remove a patient's gallbladder through
a tiny incision, using a laser beam and other minimal-intervention
techniques. The operation is viewed on a TV monitor.
A View Through the Keyhole
Operating through cuts that may be only an inch or so across has given rise
to the name KEYHOLE SURGERY. An instrument called an ENDOSCOPE enables surgeons
to see what they are doing through such narrow openings.
The first endoscope, said to have been invented by Phillipe Bozzini of Frankfurt,
Germany, in 1806, was just a narrow, rigid tube down which a light could
be shone. With it, a doctor would have been able, for instance, to get a
rather murky view of the inside of a patient's throat or stomach.
But endoscopes have been improved a great deal since those early days. Now
they are made from optical fibers – fine, flexible strands of special
glass or plastic along which light can travel for long distances and even
around bends. Light is shone down one bundle of optical fibers, and the
surgeon sees through another bundle, which is equipped with a strong lens.
Also running down the length of the endoscope are control wires that allow
the surgeon to guide and maneuver the instrument from outside the patient's
body. Light traveling along the fiber-optic bundles relays a picture to
a viewing device held in front of the surgeon or onto a video screen, enabling
the surgeon and others to watch what is happening.
Surgery in a Tight Spot
In addition to giving an amazingly clear view of the inside of the body,
an endoscope can also carry instruments to perform certain types of operations.
Because of the limited space within the endoscope's tube, however, none
of these instruments can be more than about 3 millimeters in diameter, and
all must be long and flexible. Examples include tiny cutting devices and
forceps to cut away, grip, and pull away unwanted tissue (some of which
may be analyzed in the laboratory); minute electrodes through which an electric
current can be passed to seal blood vessels; and small balloons that can
be used to open stuck heart valves.
|Inside an endoscope. With fine, flexible
tubes, the surgeon can see around bends. Light travels down one bundle
of optical fibers, and the surgeon views through another bundle. Wires
control the instruments from outside the body. Pipes carry air and
Laser beams can also be directed down optical fibers in an endoscope to
control bleeding, make bloodless cuts through tissue (since the heat from
the laser immediately seals the wound), and destroy tumors and other growths
inside the body.
Smaller even than the openings made during keyhole surgery are those used
in another new technique, called PERCUTANEOUS SURGERY. Percutaneous
simply means "through the skin." It involves making a tiny hole through
the patient's skin and muscle with a needle just 1 millimeter across. Using
a series of wider tubes, the surgeon temporary stretches the hole until
it is a few millimeters across. During this procedure, instead of muscles
and other tissues of the body being cut, they are just gently forced apart.
Since hardly any blood is lost by a patient, no blood transfusions are needed,
and no wounds that require stitches are left behind. The patient recovers
almost immediately and may be able to leave the hospital less than a day
after the operation.
Unlike the flexible tools used with ordinary endoscopes, percutaneous instruments
are rigid. They are often merely modified or scaled-down versions of standard
surgical instruments. Many were originally designed for operating on the
|Small-scale Surgery on the Spine
Slipped disks in the back are now routinely treated by percutaneous
surgery. A disk is a doughnut-shaped piece of cartilage (a tough,
gristly substance) that fits between the bones in a person's spine
and acts like the suspension system of a car. Fluid surrounding each
disk also serves to absorb shock waves that travel up the spine when
a person moves around. Disks do not actually "slip." The cartilage
simply gets worn and, as a result, may protrude from the spine and
push painfully against a nerve ending. In the past the treatment for
this condition involved a major operation followed by a length stay
in hospital. But now the treatment can be carried out under a local
anesthetic. Probing with a needle 1 millimeter in diameter, the surgeon
locates the damaged cartilage. Then the surgeon begins to slip a series
of larger tubes over the needle to open a gap 3 millimeters to 7.5
millimeters across. Miniature retractors are pushed down the final
tube to pull the nerve endings out of the way, and tiny burs are used
to grind away any bone that may be trapping the nerve. Next a very
small cutting tool is inserted into the cartilage to slice into it.
Finally, a minute screw-shaped device is inserted into the spinal
column to drain off fluid and relieve pressure. This causes the bones
on either side of the disk to come together and fuse, leaving the
patient a little shorter but no longer in pain.
Today, if a person's arm, leg, fingers, or toes are accidentally cut off,
they can sometimes be reattached and made to work again, thanks to advances
in surgery. Simply reattaching an arm or leg is relatively easy, but reconnected
numerous tiny severed blood vessels and nerves to restore full use of the
limb calls for incredibly delicate techniques. These techniques are known
as MICROSURGERY because they must be carried out while the surgeon looks
at the work area through a special surgical microscope that magnifies about
|Two surgeons use an operating microscope
and fine instruments to reconnect a patient's severed blood vessels
Al least eight stitches are needed to ensure a blood-tight connection between
two sections of a severed blood vessel. The nylon thread used is narrower
than a human hair and is attached to a fine needle 3 millimeters long, made
of the metal titanium. Although titanium costs much more than steel, it
is the only material that can be worked to a fine enough point.
The idea of a robot carrying out a delicate operation may sound terrifying,
but the time is fast approaching when robots will take their place in the
operating room alongside human surgeons. In fact, a robot has already successfully
performed surgery on an animal. In 1990, a ten-year-old sheepdog called
Snook had its hip replaced at the University of California. A single-armed
robot, programmed with the exact shape and size of the bone, used a rotary
cutter to carve a cavity in the dog's thigh bone and then fitted with an
At first, robots that take part in operations on people will be used mainly
for tasks that are simple but tedious for humans to perform. For instance,
during keyhole surgery a miniature camera often has to be held for long
periods by a junior doctor while the surgeon carries out the procedure.
In the future robots will be used in such circumstances to handle the camera,
freeing human assistants for more complex jobs.
|This hand-held robot arm with a probe is
used to accurately locate brain tumors. CAT scan data of a patient's
brain is fed into the robot's computer to create a three-dimensional
image of the brain and tumor on a TV monitor. When the tip of the
probe is moved on the patient's brain, the exact position of the tumor
can be found while visualizing it on the screen.
Robots will also play an increasingly important role in operations that
demand a high level of accuracy. In a typical future setup, the surgeon
may not operate directly on the patient. Instead, sensory devices will track
the movements of the surgeon and send signals to a detector unit. This unit,
in turn, will control a motor attached to a robot holding a scalpel or other
surgical tool so that the robot copies the surgeon's movements exactly.
The equipment could also be arranged so that fairly large movements by the
surgeon's hands are turned into smaller, more delicate actions by the robot.
|Robot-assisted surgery. More and more operations
in the future will be carried out by robots under the guidance of
Entering Inner Space
Even more amazing developments early in the next century could result in
surgeons being outfitted more like astronauts and doctors. Work is going
on to create a space-age helmet for surgeons that will display the interior
of the patient's body. Wearing the helmet, the surgeon will have the impression
of being inside the patient's heart or stomach or whatever else the operation
site may be.
Special gloves equipped with electronic sensing gear will detect all movements
of the surgeon's hands and transmit the movements to a miniature robot carrying
tiny instruments inside the patient. With such equipment it would not even
be necessary for the surgeon to be present in the operating room. He or
she could perform an operation remotely over a telephone line. This would
allow a surgeon to operate on patients in different hospitals – even
in different countries – from just once central location.