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Small is beautiful and very useful

(05 Aug 2008)
An Irish firm is behind a major breakthough in the field of minimally-invasive surgery, writes Conor Pope
TODAY'S MEDICAL inventions can make even the recent past look primitive. It is inevitable that a time will come when even the greatest surgeons operating today will be held up alongside the worst class of leech-wielding sawbones of past centuries, as darkly comic illustrations of how brutally and bloodily unsophisticated medicine once was.
That day may have come just a little closer with the news that a device, invented by a small medical engineering company based in Bray, Co Wicklow, has been used to perform major abdominal surgeries through a single incision in the patient's navel, dramatically reducing pain, recovery times and scarring.
For more than 15 years, the cutting edge of minimally-invasive surgery has been keyhole or laparoscopic surgeries. Such procedures see a number of incisions being made in the abdomen, through which various pieces of high-tech equipment including fibre optic cameras are inserted, allowing a range of increasingly complex surgical operations to take place.
The Triport, invented by Bray-based Advanced Surgical Concepts (ASC), is being hailed as a significant breakthrough by doctors at some of the world's most prestigious medical centres. It allows surgeons to perform the laparoscopic procedures through just a single incision, and it hit the headlines in the US last month when doctors in the Cleveland Clinic used it to remove a healthy kidney from a donor before successfully transplanting it into his father.
The process was filmed and broadcast on NBC's Today Show . The footage shows a three-quarter inch incision being made in the interior of the donor's belly button, after which a tube-like port with several round entry points for a camera and other tools is inserted. The abdomen was then inflated with carbon dioxide to give the surgeons room to manoeuvre, and the fist-sized kidney was freed from connecting tissue, wrapped in a plastic bag and removed through the navel.
It was a remarkably bloodless procedure, at least from the viewer's perspective, and the impressively upbeat donor was able to leave the hospital less than 48 hours after the surgery.
Instead of the foot-long abdominal scar that is common following kidney removal surgery, his incision was almost completely obscured by the natural contour of the navel. To date only a handful of kidney donors have undergone the procedure but Dr Inderbir Gill, who performed the surgery, is confident the technique could make donations more palatable by dramatically reducing recovery time.
Details of the recovery of the first four patients are carried in this month's issue of the American Journal of Urology and the numbers look impressive. Using the new procedure, patients have a recovery time of less than a month, compared with more than three months for donors who undergo the standard laparoscopic procedure using between four and six "keyhole" incisions.
According to Gill, donors can expect to return to work in around 17 days, as opposed to 51 days with the traditional procedure, and they need pain medication for fewer than four days compared with 26 days for patients who undergo other laparoscopic procedures.
"This represents an advance for the field of surgery in general," says Gill. He predicts that navel entry would be used increasingly for major abdominal surgery in a "nearly scar-free" way. "Will this decrease the disincentive to donation? I think the answer is yes," Gill says.
In addition to kidney transplants, surgeons have used the Triport to complete other single incision laparoscopic procedures, including cholecystectomies (gall bladder removal), hysterectomies, prostatectomies, and appendectomies - more than 300 all told.
"It is probably one of the most exciting things I have ever worked on for sure," says Frank Bonadio, the chief executive and founder of Advanced Surgical Concepts. Speaking to The Irish Times last week he said donor surgeries were "a bit trickier to do" and will probably be largely confined to the big medical centres including the John Hopkins, the Mayo Clinic and the Cleveland Clinic in the US and a small number of other centres in other countries.
He believes the device will be more commonly used for the removal of the gall bladder and hysterectomies, two very commonly done laparoscopic operations, which he says are "much more straightforward".
"These are early days. We have done about 10 hysterectomies and the patients are ready to go home that day but they usually stay a night in the hospital," he says. "The simpler procedures seem to be very translatable and surgeons have got the hang of it very quickly."
ASC became the first people in the world to do single port surgery in May of last year, when Bonadio went to India to work in conjunction with two Mumbai doctors.
He recalls that the doctors, two brothers, weren't aware the device had never been used before. "I was just so happy after we did our first appendectomy and then two cases later we took out a gall bladder and then I told them 'You know, you're the first people in the world to do this'. They got very excited."
Just one such surgery has been performed in Ireland, when a surgeon in Beaumont performed a gall bladder removal earlier this year.
ASC has a fairly hands-on role in the process, and apart from developing the equipment, it also instructs the chosen surgeons in how to use it. "The idea of going through a single port has been around for some time, it's just developing the device that makes it work and that is what we have done," Bonadio explains.
While inevitably most of the procedures have been carried out on already sick people, the donor surgeries are even more interesting for ASC, because the patient is a healthy person "so you really have a good baseline to gauge the pain associated with the operation and we're just not seeing it. They take paracetamol for a couple of days and it's finished, it's over".
"We're getting a huge amount of attention from medical people who want to be using this, but patients are going to drive it as well," he says. The attention which has been spawned by mainstream media coverage in the US has been almost overwhelming for ASC, which is largely an RD and production company.
It doesn't yet have any significant level of distribution and marketing in place, so the company "can't even come close to dealing with the hundreds of surgeons" who have contacted it in recent months.
If this breakthrough device really takes off, as it looks set to do, would the company, which employs just eight people, not be worth tens if not hundreds of millions of euro?
"Well, it's never that simple," suggests Bonadio who sidesteps anything as vulgar as hard cash. "These are the early days. The laparoscopic market is so vast, there are three or four million procedures done per annum - if even 10 per cent converted to this, it would be a large amount and it could be more than that. We just don't know yet," he says. "This whole thing will evolve, and our intention is to hold on to it."
© 2008 The Irish Times
This article appears in the print edition of the Irish Time

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