Finding Balance through Innovation

Top 10 Innovations for 2009

#7 LESS and NOTES Applications

Minimally-invasive laparoscopic surgical approaches have been tried over the years in an effort to improve a variety of standard urological and gynecological surgeries. We now have two emerging innovations-LESS and NOTES-that allow doctors to perform surgeries with a minimum of cutting and virtually no scars. Pain levels are significantly reduced as well with these scarless surgeries, allowing patients to get home and back to activities of daily living much quicker.

Laparoscopy (from the Greek words lapara, or flank, and skopion, a means of viewing something) is a surgical procedure in which small (1-2 cm) incisions are made and plastic tubes (trocars) are inserted through them to keep the channel open so that tools-including surgical instruments and the viewing telescope (laparoscope) with its minicamera- can be inserted. When the abdomen is inflated with carbon dioxide, organs can be pushed out of the way for access and better vision, allowing the surgeon to work while watching an external video monitor. The tools can be manipulated to make necessary repairs, just as if the abdomen had been cut open the old-fashioned way, but without the surgeon's hands ever entering the patient's abdomen.

LESS (laparoendoscopic single-site surgery) takes laparoscopic surgery to an entirely new level by reducing the process to a small cut in the belly button. "LESS is performed through a single incision in the patient's navel," explains Inderbir S. Gill, M.D., Chairman of Urology at the Cleveland Clinic, and a pioneer who recently performed LESS live-donor nephrectomies in nine consecutive kidney donors for kidney transplantation. "All aspects of kidney harvesting were completed though the navel. Instead of a visible six-inch scar and a six-week recovery period, patients recovered within two weeks and had a tiny scar hidden by their belly button."

Because it only uses one port with multiple channels for the surgeon to simultaneously pass various surgical instruments, LESS may also reduce complications that might occur after traditional open and even laparoscopic abdominal surgery. "My patients report less discomfort and have faster recoveries compared to those undergoing traditional laparoscopy," Dr. Gill says.

NOTES (natural orifice transluminal endoscopic surgery) bypasses normal laparoscopic incisions altogether. Instead, the surgeon gets to an appendix, prostate, kidney, or gallbladder through one of the body's natural cavities, such as the mouth, vagina, or colon. "Being able to perform major surgery inside the abdomen and chest through natural orifices is a very intriguing concept," reports Dr. Gill. "Potential advantages of this would be the ability to have scar-free and, hopefully, pain-free surgery. This is what has caught the imagination of the public."

Many people react with fear when given the news about their metastatic cancer, others with anger, and some with a sense of utter hopelessness. When breast, colorectal, or prostate cancer becomes metastatic, it immediately raises numerous concerns and important, questions. What is the best therapy? How do I make the treatment choice? Should I consider joining a clinical trial?

Many recurrent cancer treatment choices are based on how the disease is progressing. To determine this, doctors look for signs, which are traditionally provided by imaging or tumor marker tests at certain points during therapy.

Now there is another option: use of a new technology to measure circulating tumor cells (CTCs) in a sample of blood to aid in the early detection of rogue cancer cells in patients with recurrent cancer. This is a different kind of test that can help people learn how their therapy is working much sooner. The technology allows patients to monitor their progress at any point along their treatment course, and guides the doctor in adjusting therapy as needed.

CTCs are cancer cells that have broken away from an existing tumor cell and have entered the bloodstream. The presence of these cells in the blood can provide valuable insight into the progression of the cancer. Clinical studies of patients with metastatic cancers of the breast, colon/rectum, or prostate have reported that the monitoring and detection of CTCs can actually predict whether a patient's prognosis is more or less favorable.

This blood test captures, identifies, and counts CTCs in a tube of blood. Using a predetermined cutoff number-5 CTCs for metastatic breast and prostate cancer; 3 CTCs for metastatic colorectal cancer-the test can specifically predict a patient's probable outcome. "This technology has enormous promise," says Daniel F. Hayes, M.D., Clinical Director of the Breast Oncology Program at the University of Michigan Comprehensive Cancer Center in Ann Arbor. "I regularly use it in my clinic. In the end, the benefit of this technology is that it will give us a snapshot of what cancer is doing right now without having to biopsy the patient. That is the real hope and excitement that this test offers."