The evolution of surgery: robots

I realize this is well over a month old, and maybe some of you have seen it before, but I haven’t. It’s a fascinating look by surgeon and inventor Catherine Mohr at the history of surgery and how it has evolved over the centuries.

One thing that talks like this remind me is just how much surgery has evolved just in the short span of my career thus far, since I went to medical school in the mid-1980s. Indeed, I undertook my surgical training right in the middle of the laparoscopic revolution and experienced some of the disconnect that older surgeons must have experienced. You see, I went into the laboratory to work on my Ph.D. in 1990. A little more than three years later, in 1993, I came back to surgical training as a third year resident. In just that short a period of time, a cholecystectomy (gall bladder removal) had gone from being an case for a second year resident to scrub on that was done the old-fashioned way to all of them being done by laparoscopy. All the third year residents to whose class I now belonged knew how to use the camera and instruments. When I came out of the lab, I did not. I caught up, but the first few months back were very frustrating for me and, I’m sure, for any of the attending surgeons whom I assisted.

Since the 1990s, things have changed even more rapidly. Laparoscopy is used to do more and more procedures, some of which would have been unthinkable when I was a resident. Over the last three years or so, there has even been the development of so-called “natural orifice” surgery,” (natural orifice translumenal endoscopic surgery, or NOTES), in which even the tiny incisions used for laparoscopy are dispensed with and instruments introduced through the rectum, vagina, or stomach using endoscopic instruments. I have to admit, I don’t yet see the utility of NOTES, given that laparoscopy incisions are already quite small and introducing instruments through the esophagus, rectum, or vagina appears likely the risk of infection, namely because it’s impossible to completely sterilize the mouth, rectum, or vagina.

Still, I do sometimes look on in a bit of envy at my surgical colleagues in other fields. Comparatively speaking, breast surgery is still fairly low tech. True, even that low tech has evolved fairly rapidly in my career. When I was a medical student and early in my residency we still did quite a few mastectomies, and every woman got her axillary lymph nodes removed. Now, around 25% of women require a mastectomy, thanks to lumpectomy and radiation (not to mention neoadjuvant chemotherapy), and possibly even fewer require all of their lymph nodes removed, thanks to sentinel lymph node biopsy, the latter of which became standard of care within the last decade or so, almost as fast as laparoscopic cholecystectomy supplanted open cholecystectomy. Most women with breast cancer no longer need to lose a breast, and the rates of lymphedema from lymph node surgery are way down.

Still, sometimes I wish I could figure out a way to use the da Vinci robot to do a lumpectomy. It’s a silly thought, of course, but we surgeons do like our toys.