Portal de Periódicos da CAPES

The Electric Kool‐Aid Acid Test: an allegory of surgical progress

2010; Wiley; Volume: 106; Issue: 6b Linguagem: Inglês

10.1111/j.1464-410x.2010.09664.x

1464-410X

Amin S. Herati, Mohamed A. Atalla, Louis R. Kavoussi,

Minimally Invasive Surgical Techniques

In 1968 Tom Wolfe [1] published The Electric Kool-Aid Acid Test, a chronicle of the experiences and revelations of a group of individuals delving into the psychedelic drug culture of the era. The novel describes a group known as the ‘Merry Pranksters’ who, whilst driving around the USA in a bus, subjected unknowing candidates to Kool-Aid laced with LSD. Candidates either passed (had a positive experience) or failed (had a negative experience) the acid test. This text not only gave portraiture of the hippie movement, but also an understanding into the workings of a creative cultural revolution. Ideology such as creating a better planet, world peace and universal love set the course for societal changes where the medium was newly discovered psychotropic medications. Although never achieving nirvana, and after repeated evasion of the enforcers of the status quo, ‘the Cops’, many important cultural and political changes were spawned. Unfortunately, the dangers associated with drug use, free love and disregard of societal rules left some casualties along the way. Surgical innovation echoes much of the same process as portrayed in Tom Wolfe’s novel. The continuing ideology driving change is the goal of creating absolute surgical cure with no disruption to what God has created. The individuals who have championed this approach have been dubbed ‘minimally invasive surgeons’, a term that has slowly gained acceptance in mainstream surgical practice. The psychedelic agent is technology that comes in a variety of forms that are initially applied in what can be perceived as an unconventional manner. Consider the urologist who stood up at a podium at a national meeting and injected his penis and paraded through the audience demonstrating the efficacy of cavernous injection therapy. Some developments are pulled from technology available outside the field of medicine. Ralph Clayman went on a run and noticed his Patagonia running shorts were the ideal material for an entrapment sac. He promptly had his secretary sew them into the first morcellating sac for laparoscopic nephrectomy. The creativity and innovation of pioneers in the field who accept risk help propel surgical evolution. We must be very wary, however, that there have been bad surgical ‘trips’ that ultimately failed the acid test. Anecdotal tales of tumour growing out of trocar sites and division of the aorta abound. Balloon dilatfation of the prostate was touted as the panacea for treating BPH. US Food and Drug Administration approval was rapid and significant capital outlay occurred to support programmes that ultimately proved useless. Progress requires risk and different situations require variable levels of risk. However, with success, perceived risk decreases and once-deviant approaches are embraced by the mainstream. For example, although initially scorned, endourology has successfully replaced open stone surgery of the urinary tract. This was subsequently followed by the emergence of laparoscopy, which over time has been demonstrated as an equally efficacious and safe contender for urological surgery. To gain a glimpse of the future of minimally invasive surgery, this paper summarizes the past and present. Understanding what has gone before allows us to really think about what it took to align all the stars that led to the innovation. Imagine using early twentieth-century endoscopic technology to perform the first TURP. Who was the patient and what was the outcome? What was it like trying to convince a patient to sit in a bathtub while an energy blast is shot at the kidney? Based on what has come before us, we will extrapolate into the future. Although the first records of endoscopy date back to the works of Hippocrates and the use of his anal speculum, Phillip Bozzini is considered by many to be the pioneer of endoscopy. In 1805, Bozzini created the first endoscope capable of looking into the urethra, rectum and pharynx. The ‘Lichtleiter’, or light conductor, was a funnel-shaped hollow tube covered by paper and leather, which housed an eyepiece at one end and attached at the other end a variety of cannulae that could be introduced into the natural orifice. The tube was illuminated by an internal candle, allowing Bozzini to peer inside the human body [2]. Bozzini’s first introduction of the Lichtleiter to the public, however, was met with scepticism and ridicule. Although Bozzini was censured by the Medical Faculty of Vienna for ‘undue curiosity’, his cystoscope had piqued the interest of Desormeaux of France. In 1853, he modified Bozzini’s cystoscope to include a gazogene lamp that used a mixture of alcohol and turpentine, a concentrating mirror, and a genitourinary speculum that created a more concentrated focus of light [3,4]. Later that year, Desormeaux performed the first true natural orifice transluminal endoscopic surgery when he resected a papilloma from the urethra [5]. However, the light of Desormeaux’s scope was insufficient for full visualization of body cavities, and the need for better lighting directed subsequent advances. The next breakthrough in operative lighting came in 1867, when a young German dentist named Julius Bruck introduced internal illumination and electro-endoscopy using an electrically heated platinum wire [6]. The heat from the wire loops, though, resulted in thermal injury to adjacent mucosa. Bruck therefore created a water-cooled apparatus that circulated cold water in small tubes surrounding the heated wire [6]. However, his device was too bulky for urethral insertion, forcing him to depend on light transmitted from the vagina or rectum into the bladder for indirect illumination, naming this ‘diaphanoscopy’. Although Bruck’s urethroscope provided a poor source of light, his novel attempt paved the way for improved internal illumination. Justus Schramm-Vogelsang of Dresden applied the same procedure in 1875 for diagnostic transillumination of female pelvic organs using what he called a diaphanoscope [7]. Working under Schramm-Vogelsang was a young assistant named Max Nitze, who realized that good visualization was crucial to diagnosing urological pathologies. After devoting much of his work to endoscopic illumination of the bladder, Nitze managed to concentrate the light emitted from the incandescent platinum wire at the distal end of the scope. To address magnification, it dawned on Nitze after peering through a dusty eyepiece of his microscope that he could magnify the field of view using a multi-lens optical system. By combining these two concepts, Nitze introduced the first cystoscope in 1877 [7]. Only two years later, the technology necessary to further advance illumination came to fruition with Thomas Edison’s invention of the electric light bulb. In collaboration with Joseph Leiter, Nitze used this invention to develop the first rigid endoscope with an incandescent bulb at one end. In addition to improving visualization by increasing transmitted light, this endoscope boasted an enlarged optical system, providing a larger field of vision, and reduced iatrogenic thermal damage to tissues once caused by the heated platinum loops [7]. The incandescent bulb, however, was far from perfect, as it continued to cause burns from the heat dissipated from the bulb. By the end of the nineteenth century, the cystoscope had become a simple and inexpensive tool used to peer into the natural orifice of the urinary tract. The concept of closed diagnostic inspection of the abdominal cavity was first conceived by a Petrograd gynaecologist named Dimitri Ott, who introduced ventroscopy for inspection of the abdominal cavity [5]. However, it was George Kelling, a surgeon from Dresden, who received credit for performing the first laparoscopy in 1901. With his attention focused on gastrointestinal bleeds into the peritoneum, Kelling postulated that the tamponade effect of pneumoperitoneum with a sufficiently high pressure would have better outcomes than a laparotomy. Kelling tested this by introducing a Nitze cystoscope into the abdominal wall of a dog. He termed his method ‘celioscopy’, but celioscopy was not applied to humans until 1910 [8,9]. Meanwhile, Bertram Bernheim [10] of Johns Hopkins University performed the first laparoscopic procedure in the USA in 1911 using a proctoscope and no insufflation to inspect the liver and stomach of a jaundiced patient. Although internists and gynaecologists quickly embraced laparoscopy as a diagnostic modality, general surgeons and urologists were late to see its potential as a future therapeutic tool. Over the next 20 years, much of the change that occurred in the realm of laparoscopy involved refinement of equipment used in access and insufflation techniques. In 1918, Otto Goetze modified the insufflation needle to include an automatic spring for gas insufflation, but trocar incompetence allowed insufflation gas to escape constantly [5]. To maintain insufflation, Stone [11] developed a new trocar fitted with a rubber gasket, preventing leakage of gas around the trocar. At around the same time, Zollikofer recommended using carbon dioxide rather than previously used gases for insufflation, recognizing that carbon dioxide was readily absorbed by the body, carried a decreased risk of air embolism and was less combustible than oxygen [5,12]. Insufflation would later be refined by Janos Verres, who in 1938 derived a needle with a sharp edge and a spring-loaded central blunt tip. Insufflation later became safer with the advent of an electronically controlled unit for insufflation and maintenance of pneumoperitoneum [13]. In 1933 laparoscopy made its debut as a therapeutic intervention by Fevers, who divided abdominal adhesions with unipolar electrocautery. Eight years later, Power and Barnes [14] expanded the applications of laparoscopy in humans by performing the first laparoscopic tubal ligation with electrocautery. Another important milestone in the advancement of laparoscopy came in 1952 when a group of Frenchmen developed a method of enhanced light transmission along a quartz rod, replacing the need for the incandescent light bulb and precluding the risk of burns and electrical injury caused by the hot tip of the endoscope [8]. Hopkins and Kapany simultaneously introduced fibre optics, which was not incorporated into laparoscopy until 1965 by Frangenheim [5]. In the late 1960s, scepticism about laparoscopy arose with reports of higher incidence of complications [12]. Further innovations continued, however, with Kurt Semm contributing an automatic insufflation apparatus, endocoagulation, tissue morcellation and a suction–irrigation system, sustaining the momentum of laparoscopic intervention [15]. In 1982, Semm [16] went on to perform the first laparoscopic appendicectomy. This was closely followed by the first laparoscopic cholecystectomy in 1985 by Erich Muhe [17], who used a modified galloscope. It was not until Dubois et al. [18] and Reddick and Olsen [19] published their series that laparoscopic cholecystectomy emerged as the gold standard approach for gall bladder removal and subsequently became the poster child of laparoscopic surgery success stories. The next major breakthrough in laparoscopic technology came in 1985 with the advent of a computer chip television camera. The camera allowed laparoscopic procedures to be performed with better ergonomics, enhanced operating team participation and accelerated transfer of technical skills to aspiring observers [5,8,12]. One of the first urological procedures to undergo near complete transformation into the realm of minimally invasive surgery was the surgical treatment of urinary tract stones. Before the early 1980s, patients with urolithiasis underwent large incisions and remained hospitalized for one to two weeks, in tremendous pain [20]. However, in the late 1970s, Fernström and Johansson [21] auspiciously discovered that stones could be extracted through nephrostomy tube tracts under direct radiographic control. In 1986, Snyder and Smith [22] published their experience with percutaneous stone extraction and validated its superiority over open nephrolithotomy. With the exception of rare select cases, almost all patients with stone disease requiring intervention now enjoy the benefits of a minimally invasive approach to stone extraction. Similarly, interventions for BPH have been revolutionized by an incisionless approach through transurethral resection. TURP emerged as a result of a series of inventions in the 1920s and 1930s. The combination of the cystoscope, the incandescent lamp, the fenestrated tube, the vacuum tube and the tungsten loop culminated in McCarthy’s addition of a foroblique lens system in 1932 to make TURP one of the oldest minimally invasive techniques still in use today [23]. In the 1970s, fibreoptic lighting, along with the Hopkins rod lens wide-angled system, significantly improved visualization for TURP and all other endourological approaches [24]. Despite a rapidly growing body of evidence to support laparoscopy’s role in general surgery by the late 1980s, laparoscopy had limited applications in urology until the early 1990s. Its earliest applications were limited to diagnostic manoeuvres by Cortesi et al. [25] in 1976 and Eshghi et al.’s [26] laparoscopic visualization of a stone extraction in 1985, but tremendous changes occurred in urological laparoscopy over the next two years. At the forefront of change were Schuessler et al. in 1991, when they staged prostate cancer with laparoscopic pelvic lymphadenectomy, helping establish laparoscopy as a promising tool in the treatment of urological disorders [27]. Clayman et al. [28] subsequently performed the first laparoscopic nephrectomy in 1991. Shortly thereafter, a steady stream of reports of new procedures emerged, each more complex than its predecessor. For instance, since originally reported by Schuessler et al. [29] in 1997, laparoscopic radical prostatectomy has not only gained worldwide acceptance but is being performed today with robotic assistance at hundreds of medical centres [30]. The incorporation of robotics in minimally invasive surgery has developed along several avenues over the last three decades. Two systems used a master–slave model in which the surgeon controlled the robotic apparatus. The Zeus robotic system (Computer Motion, Goleta, CA, USA) was closely followed by the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) from experimental to clinical use with great utility [31]. With a prototype initially developed for combat casualty care, the da Vinci is the result of an evolved system boasting seven degrees of motion and three-dimensional binocular view enhancing depth perception. The system has been embraced by the urological community and public alike with applications spearheaded by robotic-assisted prostatectomy. Although studies have not found a difference in functional or oncological outcomes between robot-assisted and laparoscopic surgeries, robot-assisted surgeries have been shown to have a shorter learning curve and better ergonomics than their laparoscopic alternatives [31]. The true benefit of robot assistance remains to be elucidated. From modest diagnostic manoeuvres, laparoscopy has transformed into a procedure capable of handling complex ablative and reconstructive procedures. With increasing technology and refined techniques, urological laparoscopy continued to challenge the open incision for extirpative, ablative and reconstructive procedures [32]. As equipment and technology advanced, so did the surgeons’ skills and their quest for the least invasive approach and technique. The ideology of surgery has not changed: society is seeking cure with no disruption to normal function. New technology will continue to be developed as older modalities are applied in unconventional ways. We will see continued miniaturization of instruments, improved optics and true robotic devices. Two evolutionary approaches of traditional endoscopy are natural orifice transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS). As a natural extension of the concept of scarless surgery, LESS, or keyhole surgery, obviates the creation of an external abdominal scar by making an incision at the umbilicus [33]. The first reported application of LESS in a human involved an appendicectomy performed in 1994 by Inoue et al. [34]. The first urological application was reported in 2007, when Raman et al. [35] performed single port nephrectomy in three human patients. Despite using articulating laparoscopic instruments, Raman struggled with colliding instruments both internally and externally. In a case-control study by the same group [36], the superiority of single port nephrectomy over conventional laparoscopy was limited to a mere subjective cosmetic advantage. The rationale with NOTES is that no incision will result in less pain and the ultimate in cosmesis. NOTES was initially developed as a hybrid model of laparoscopy and endoscopy. The approach uses natural orifices such as the mouth, anus, urethra and vagina to obtain intraperitoneal access for surgical intervention. Although it is still in the infancy of its experimental development as an abdominal procedure, urologists have pioneered the art of natural orifice endoscopic intervention with transurethral approaches to the urinary tract. NOTES offers the potential of eliminating incisional scars, abdominal wall hernias and wound infections. NOTES also promises to eliminate ‘external’ postoperative pain and reduce the need for postoperative analgesia with its inherent adverse effects [37]. In 2002, Gettman et al. [38] published the first experimental application of NOTES when they performed a transvaginal nephrectomy in a porcine model. They achieved this using a combination of rigid and flexible laparoscopes and a cystoscope. Lima et al. [39] evaluated the bladder as a potential portal for NOTES in 2006. NOTES has also been successfully applied to a variety of general surgical and gynaecological procedures. Yet, the benefits of NOTES as a surgical procedure have been primarily conjectural, and further comparative studies are needed before it can become an established means of surgical intervention. Moreover, before NOTES can become a practical clinical tool, a more stable operating platform will need to be developed and instruments specific for NOTES need to be designed [40]. Several developments have been made in the creation of novel operative approaches. Park et al. [40] devised a magnet anchoring and guidance system (MAGS), which can be used to actively control an intra-abdominal camera and multiple working instruments. Using a series of magnets placed intra-abdominally and a matching series on the overlying skin, the position of the instruments and camera can be modified easily using external magnets. Zeltser et al. [41] successfully used MAGS during a laparoscopic nephrectomy performed in a porcine model. Another operative platform, also in its experimental phase, is the TransPort Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA). This flexible device is capable of passing through a trocar and locking into a rigid conformation once it has reached its target location [42]. With its four working channels, the platform is capable of holding a laparoscope and three additional devices. Clayman et al. [43] successfully used the TransPort Multi-Lumen Operating Platform in a combined transvaginal and single port nephrectomy, although this platform may also have utility in NOTES. The authors encountered some limitations in the use of the novel platform, however, such as difficulty in providing traction, equipment slippage, visual field interference by the instruments and lack of triangulation. Paralleling the developments of LESS and NOTES, robotic surgical technology has also gained traction in its path towards making science fiction a reality. While existing devices merely serve as master–slave platforms, strides in technology will allow true robots to be applied in minimally invasive surgery. Kanagaratnam et al. [44] describe a novel operating system that represents the middle ground between master–slave platforms and an autonomous system. They used a robotic control system equipped with real-time ultrasonographic probes capable of three-dimensional reconstruction of cardiac anatomy to manipulate a steerable guide catheter to ablate aberrant conduction pathways causing atrial fibrillation in a series of 10 patients. Advances continue in the refinement of robotic vision and haptic senses, and the development of novel diagnostic capabilities. However, much research is needed to develop a truly autonomous system. We predict autonomous robots and nanotechnology will someday replace the surgeon in the operative treatment of various pathologies. Innovators and risk takers have always been and will always be needed to advance surgery. These include physicians as well as patients all with variable motivations for taking a chance. There are individuals who accidentally end up on the innovation bus, while others strive to be on no matter what the cost. Antagonists in the form of authority and peers play an important role to assure that innovation is not misplaced. Serendipity, greed, altruism and idealism from all sides contribute to progress. Prospective randomized trials are one means to deem new approaches efficacious and safe, but not the only way. Anecdotal experience and ‘series’ can be valuable, but are also not the only way. Which new technology will pass the acid test and get us one step closer to the sought after nirvana? The future cannot be predicted, but experience tells us that surgery will continue to be an evolving technology, making its way towards extinction. We must always remember that patients – not the ‘Merry Pranksters’ and not ‘the Cops’– will drive the bus that defines the ultimate standard of care. None declared.