France excels in minimally invasive surgery : N° 34, october 2012

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Mr Jacques Marescaux, President of the Institute of Research against Digestive Cancer, IRCAD-EITS

French experts are recognised worldwide for breaking new ground in the development and teaching of what are known as minimally invasive surgical techniques, particularly in transgastric surgery. The constant innovations in robotics and virtual techniques in operative practice are opening up new possibilities, such as surgical interventions that leave no visible scars.

Surgery has undergone a genuine revolution in recent years. The era of minimally invasive surgery devised by French surgeons has allowed the development of a considerable international market, especially in Japan, the United States, Latin America and China, but also in Spain, Germany and Italy. Transluminal surgery leaving no visible scar is a rapidly developing new concept.

“A new stage has been entered with transluminal surgery, using the body’s natural orifices and pathways. Performance is improving, with surgery that is less and less invasive,” explains Jacques Marescaux, Professor of Surgery at the Strasbourg University Hospital Institute (IHU) and President of the Institute of Research against Digestive Cancer, IRCAD-EITS. Unlike traditional surgery, minimally invasive surgery allows the surgeon to access the organs to be treated by making the smallest possible incisions, with Lilliputian instruments, using the natural pathways of the body (mouth, rectum, urethra, etc). “In 2007, we successfully carried out the first transvaginal resection of a gall bladder,” points out Professor Marescaux. The surgeons operated by controlling their movements via images transmitted on computer. Since then, around 50 operations of this kind have been carried out successfully in Professor Marescaux’s department.

Transgastric surgery is an experimental approach to surgery through natural orifices. The surgeon inserts a very flexible endoscope, equipped with a miniature camera, through one orifice. Then, by passing the long fine instrument through the stomach wall (transgastric route), he reaches the organ to be treated: the gall bladder, the spleen, the kidneys, the colon, the intestine or the suprarenal gland. This method requires the assistance of highly developed robotics. “Flexible robotics are developing rapidly. Thanks to new developments in computer science, the process will become semi-automatic. In France we have an institution, the Institute for Research in Computer Science and Applied Mathematics (INRIA), which has a team of 3,000 engineers who are among the most highly reputed in the world,” says Professor Marescaux.

A lot of research combining a robotic approach (highly manoeuvrable tools, etc.) and remote handling (including specialist software) is in progress, especially for guiding the clinician’s movements to a minute degree. The points that need improvement concern the physiological movements of the organs and the movements of the patient’s body (breathing, heartbeats, etc.).

“Many countries are interested in our experience and are seeking our help. Our school trains some 4,000 surgeons a year from 92 countries. We have a phenomenal breeding ground for creative people,” observes Professor Marescaux. Established in the same spirit as the IRCAD in Alsace, the centre at Changhua, named ASIA-IRCAD, was set up on the west coast of Taiwan in 2008. The market is immense, with around two million surgeons to be trained. Its reputation is international. It is the largest organisation in Asia for teaching minimally invasive surgery. In 2009, IRCAD also opened a unit in the state of São Paulo in Brazil. “The three centres work in partnership, both at a clinical level and in research and training. The transfer of skills and scientific knowledge is essential.”

The advantages offered by this cutting-edge surgery are many, because they allow both operations on more fragile patients, notably the elderly, and the treatment of more complex diseases, such as cancer. Other benefits are reduced post-operative pain and risks of complications, much more rapid healing, lighter anaesthesia and a shorter period of hospitalisation. Finally, in aesthetic terms, the absence of any visible scar. Providing the highest possible precision, the robot enables the surgeon to work faster and with greater concentration.

In this quest for ever less aggressive surgery, Professor Marescaux, who was responsible for performing the world’s first remote surgical procedure in 2001 with a surgeon in New York and a patient in Strasbourg, heralds a new revolution: the assistance of virtual reality. This involves building a 3D copy of the organ to be operated on, based on images of the patient obtained using a scanner or MRI (Magnetic Resonance Imaging). The surgeon is guided as though through a transparent body. It then becomes possible to simulate the procedure and repeat it in advance until an ideal operation is achieved, recorded on the computer.

By inventing hybrid surgery, the Strasbourg University Hospital Institute, a recently created organisation of excellence (there are six of them in France), may become the centre of the new surgical world. Equipped with futuristic endoscopy units, operation suites that are unique in the world, it should also lead to the creation of 2,000 jobs. Everything may become possible for the practitioner: planning the operative sequences and acting directly on the diseased organs, under immediate control. “It’s the surgery of the future,” says Professor Marescaux with enthusiasm.

Annik Bianchini

Websites Institut de Recherche contre les Cancers de l’Appareil Digestif (IRCAD) Institut National de Recherche en Informatique et Automatique (INRIA)

publie le 15/10/2012

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