Surgery without cutting the skin

The quest to minimise surgical invasiveness has led to the development of a new technique called flexible transgastric peritoneoscopy (FTP). After laparoscopy, could this be the next big step in minimally invasive surgery? Isabel Lesto reports.

Flexible transgastric peritoneoscopy, or FTP, is a new surgical procedure that requires no abdominal incisions and leaves no scars.

The technique, which allows surgeons to repair abdominal organs in the peritoneal cavity such as the intestines, liver, pancreas, gallbladder and uterus, has not yet been performed on humans in clinical trials, but laboratory studies on animals have produced successful results and indicate the procedure is safe.

FTP involves inserting an endoscope – a flexible minitelescope – and surgical tools through the mouth and into the stomach. After puncturing the stomach wall and the peritoneum – the thin membrane surrounding the stomach – surgeons are able to see and repair any of the abdominal organs in the peritoneal cavity.

Where FTP differs from laparoscopy is the path it takes to reach this cavity. FTP involves entering the cavity from inside the body, leaving the abdominal wall intact. Laparoscopy involves entering the peritoneal cavity from the outside of the body through a tiny abdominal incision. Using a small, lighted instrument, surgeons are able to perform laparoscopy for diagnosis, perform biopsy or surgery.

Leading the way in FTP research is Dr Anthony Kalloo, associate professor of medicine and director of gastrointestinal endoscopy at The Johns Hopkins Hospital, Baltimore, US. Dr Kalloo is lead author of a report describing the new procedure and believes FTP may dramatically change the way surgery is practiced. In a study published in the July issue of Gastrointestinal Endoscopy, Dr Kalloo described how he and his team from Johns Hopkins

were able to safely explore the peritoneal cavity and perform liver biopsies on pigs under general anaesthetic. Most of the research was carried out by Dr Kalloo and colleagues from an international think-tank of gastroenterologists from five universities, called the Apollo Group. The operations themselves were performed by Dr Kalloo and colleagues from Johns Hopkins. After washing the stomach with an antibacterial solution to prevent infection, a small incision was made into the stomach to allow access to the eritoneal cavity.

The cavity was then filled with air to increase the visibility of the organs, biopsy samples were taken from the liver and the incision was sealed with clips. The pigs were monitored for 14 days afterwards and showed no signs of serious infection or other complications. The surgical site healed completely. Pending publication are results from two more successful procedures performed in the laboratory. The first is gastrojejunostomy, the surgical formation of a passage between the stomach and jejunum, a procedure normally performed in patients who have cancer blocking the stomach but also used in the management of obesity. The second is tubal ligation, a common procedure used to induce sterility. “We were able to perform this quickly in the pigs with rapid recovery and short surgical time. Technically, this was very simple to do,” says Dr Kalloo.

 He explained the reason FTP has not been performed in the past is because, done incorrectly, it could lead to infection and even death. “If you ask a regular surgeon or physician about making a hole in the stomach and looking into the peritoneal cavity they will tell you ‘that’s crazy’. And the reason they will tell you that is because of the dreaded complication of peritonitis,” Dr Kalloo says, adding: “The results of our studies show that careful preparation and monitoring can turn a potentially fatal situation into a better and safe
surgical technique.”

During the past four years, the Apollo Group has developed techniques and devices to overcome such problems. Crucial to the procedure is a suturing device that will allow surgeons to close incisions. “We are awaiting refinement of the device. Once that is done we will be able to get going,” says Dr Kalloo, who hopes to start clinical trials on humans within a year.

Patients most likely to benefit from FTP are those who have gastric cancer or blockage of their gastric outlet, and those considered
poor surgical candidates for either laparoscopic or standard surgery.

“We expect, although we don’t know for sure, that because there are no incisions in the abdomen wall or musculature, and the
lining of the stomach repairs faster than skin, recovery would be faster,” says Dr Kalloo. Patients could leave soon after surgery instead of staying in a hospital overnight. “We anticipate the recovery may be in hours and not in days.” Additionally he believes FTP would probably leave less scar tissue, which is one of the complications of regular surgery, because surgeons would be cutting through less tissue.

And from a cosmetic standpoint FTP would be perfect, he says. No incision on the abdominal wall means no scar.

For surgeons performing operations on obese patients, FTP could also prove beneficial. “In obese patients a surgeon faces the
challenge of cutting across large layers of fat. FTP could become a tremendous advantage for procedures such as tubal ligation and
gastric bypass surgeries because we could avoid incisions on the expansive abdominal wall,” explains Dr Kalloo.

Besides surgery, the procedure could be used for diagnosis. If a patient has abdominal pain or suspected cancer and the imaging tests are negative, the surgeon could quickly explore the peritoneal cavity using FTP. It could also be used to diagnose other conditions such as endometriosis.

“When you pass into the peritoneal cavity it’s a straight shot to the pelvis, so you would be able to see the endometrial tissue. You’d be able to diagnose and probably do therapy,” says Dr Kalloo.

He believes FTP is the logical next step to minimal invasiveness. “The way traditional surgery was done for over a hundred years was to make long, painful incisions into the abdominal wall to enter the peritoneal cavity. It took us nearly 100 years for any significant change in terms of minimally invasiveness and to learn the technique of laparoscopy.

“The question you have to ask yourself is: how do you think surgery should evolve in the future? If you think about it, you have to say the next step is not to do any incisions at all in the abdominal wall.”

Reactions from the medical community are mixed and, says Dr Kalloo, were initially very negative because people felt he was doing something associated with severe complications. “But that actually inspired me because even when laparoscopic surgery first came around, there were many, many fears and now we’re doing it as a routine
part of surgery.

“Quite often any significant or incremental change is difficult for people to accept. The American writer James Baldwin has a great quote I use. He says: ‘The future is like heaven, everyone exalts it but noone wants to go there.’”

Not everyone is convinced about the benefits of FTP. Sir Ara Darzi, clinical professor of Surgery, Anaesthetics and Intensive Care at Imperial College’s Faculty of Medicine, London, says FTP is “a novel, technical innovation that has no clinical application”.

He argues that if a cavity or an organ that requires surgery is directly accessible through an orifice such as the mouth, it makes sense to approach it from the inside of the
body. “But why make an incision in the stomach wall to get to the peritoneal cavity which you can access easily from the outside using keyhole laparoscopy?”

As for the benefits of FTP on obese patients, Sir Darzi argues: “Obese patients also have tougher stomachs so cutting through the wall could prove just as difficult.” Dr Kallo believes laparoscopy and regular surgery will always be around, but maintains there will be a certain group of patients where FTP will make a “tremendous difference”.

“Even though laparoscopy is less invasive, regular surgery still exists because some indications are just not amenable to the laparoscopic approach. I’m sure that’s going to be the same with FTP.”

Tom Dehn, consultant surgeon and council member of the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALS) says: “The association is interested in exploring any technique in which minimally invasive surgery is employed. We await with interest the details of which procedures can be performed by FTP and whether this technique has sustained advantages over laparoscopic surgery in the form of patient recovery, anaesthetic requirements and recovery times.”

Meanwhile, at the time of going to press it was announced that Sir Darzi has received the Hamdan Award for Medical Research Excellence in the category of Minimally Invasive Surgery. The awards were announced on 19 October by Hamad Abdel Rahman Al Midfa, UAE Minister of Health and the award’s chairman..

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