MINIREVIEW SERIES FOR THE 50TH
VOLUME
Development of endoscopic surgery for the minimally invasive
treatment of digestive and other diseases
Toshiharu Furukawa, Masahiko Watanabe, Soji Ozawa, Yoshihide Otani, Go Wakabayashi,
Yasuhide Morikawa, Minoru Tanabe, Hirotoshi Hasegawa, Yuko Kitagawa, Ken Hoshino, Motohide Shimazu,
Masakazu Ueda, Tetsuro Kubota and Masaki Kitajima
Department of Surgery, School of Medicine, Keio University, Tokyo, Japan(Received for publication on July 12, 2001)

Abstract. Minimally invasive surgery has rapidly changed the performance of surgical practice in awide range of surgical specialities in the last decade of the 20th century. The marked progress inendoscopic surgery has been conducted especially in general and digestive surgery. The Department ofSurgery, School of Medicine, Keio University has contributed to the development and establishment ofendoscopic surgery in every subspeciality of general and digestive surgery. Our achievements include
the development of original methods for laparoscopic wedge gastrectomy and endoscopic thyroidectomy, establishment of surgical techniques in endoscopic surgery for esophageal, gastric, colorectal
and hepatobiliary diseases, and the introduction of robotics and tele-communicative technologies toendoscopic surgery. (Keio J Med 50 (3): 167±174, September 2001)
Key words: endoscopic surgery, gastrointestinal surgery, thyroidectomy, master-slave manipulator,
tele-surgery

The pain, discomfort, and disability, or other morbidity occurring as a result of surgery are more frequently due to trauma involved in gaining access to thearea to perform the intended procedure rather thanfrom the procedure itself. For example, following acholecystectomy, the need for hospitalization is not related to the removal of the gallbladder but rather isnecessary because of pain from the trauma to the abdominal wall caused by the incision to gain access to thegallbladder.1 In comparison with open surgery, laparoscopic surgery results in less postoperative pain, shorter
hospitalization, more rapid return to the work force, abetter cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. Following the introduction of laparoscopic cholecystectomy by Mouret
in France, the use of the minimally invasive approachhas rapidly changed the performance of surgical procedures in a wide range of surgical specialities, including
general surgery, urology, gynecology, thoracic surgery,plastic surgery, and cardiac surgery.

The Department of Surgery, School of Medicine,
Keio University ®rst performed laparoscopic surgery in
1990, shortly after the primary success was reported in
the United States, and since that time, has continued
the development and establishment of laparoscopic surgery as one of the most advanced institutes worldwide.
Development of Laparoscopic Surgery
for Gastric Diseases
Laparoscopic wedge gastrectomy for early gastric cancer
The most typical achievement of our department was
the development of laparoscopic procedures for thetreatment of early gastric cancer.
Asymptomatic early gastric cancer, especially lesions
in which in®ltration is limited to the mucosa, have beenfrequently detected through a well-established screening program in Japan. The accuracy of the preoperative
diagnosis of the depth of cancerous in®ltration for

Reprint request to: Dr. Toshiharu Furukawa, Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjyuku-ku,
Tokyo 160-8582, Japan
167

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Furukawa T, et al: Development of endoscopic surgery

Fig. 1a A device to lift lesions termed the `lesion-lifting set'; a 2±3
cm metal rod with a ®ne wire at the center is introduced through theouter sheath into the stomach.

Fig. 1b The lesion is accurately lifted using the metal rod by pullingthe wire.

mucosal gastric cancer is as high as 90% by endoscopy
and endoscopic ultrasonography. Therefore, it is important to establish a minimally invasive therapy formucosal gastric cancer. Among 483 consecutive patientswith mucosal gastric cancers who underwent gastrectomy with lymph node dissection in our institution,
lymph node metastasis was found in only 10 (2.1%),
most of whom had large, depressed lesions with ulcers
or scar formation. There was no lymph node metastasis
when the diameter of the lesion was less than 25 mm.
Most mucosal gastric cancers can thus be curatively
treated by local resection of stomach tissue. To obtain
both a complete cure and minimal invasiveness, we
introduced an original laparoscopic treatment for earlygastric cancer since 1992.2 The technique was termed
the lesion-lifting method.
After laparoscopic exposure of the gastric wallaround a cancerous lesion, a small metal rod is introduced into the stomach at the vicinity of the lesion
through a catheter which pierces the abdominal walland the exposed gastric wall. While the cancerous lesionis accurately lifted up with the support of the metalrod (Figs. 1a & 1b), wedge resection of the stomach iscarried out using an endoscopic stapling device. This
procedure results in complete local resection of the lesion with a suf®cient surgical margin.3,4
We have successfully treated 111 patients with earlygastric cancer using the laparoscopic approach. There
have been two recurrences, both of which were mucosal
lesions found 2 years after the initial surgery, and weresuccessfully treated with gastrectomy and laser irrigation. All patients survived for 3 to 96 months. To date,
our method has been recognized as a curative andminimally invasive treatment for early gastric cancer,
and are applied worldwide.

Application to gastric submucosal tumors
Asymptomatic gastric tumors are frequently detected through screening programs, and include submucosal tumors as well as early gastric cancers. Unfortunately, it is often impossible to evaluate themalignant potential of the tumors based on the resultsof endoscopic biopsy, endoscopic ultrasonography, or
computed tomography. Even with EUS-guided aspiration biopsy, the tissue specimens are usually too small
to make a pathologic diagnosis. As it has been indicatedthat small leiomyosarcomas possess malignant potential, patients with a gastric SMT are treated by open
surgery. However, the treatment of malignant stromal
tumors including leiomyosarcomas is controversial. Of
the 28 patients with leiomyosarcoma who underwent
open surgery between 1984 and 1994 at our institute, nolymph node metastases were detected at the time ofoperation.5 Furthermore, there were no difference insurvival between systemic lymph node dissection andnondisection groups. Conversely, tumor size and histologic grade can be used to predict disease-free survival
after curative resection. Therefore, to make a pathologic diagnosis and to ensure the removal of the lesion,wedge resection for small leiomyosarcomas is the ®rst
line treatment of a gastric SMT. Thus, laparoscopic
wedge resection of the stomach, ®rst introduced for thetreatment of early gastric cancer at our institute, hasalso been applied to the treatment of SMTs of thestomach since 1993.6
Over 50 patients with SMTs of the stomach underwent laparoscopic wedge gastrectomy. The tumors
ranged from 8 to 60 mm in diameter. All surgical margins were clear. The average operative time was 131
minutes. Conversion to open surgery was needed inKeio J Med 2001; 50 (3): 167±174

only one patient with a tumor along the lesser curvatureof the mid-portion of the stomach because of obesity. Most of the patients began eating on the ®rst operative day and were discharged within 5 to 7 days.
Histopathological examination of the tumors showed
gastrointestinal stromal tumor, ectopic pancreas, leiomyosarcoma, schwannoma, carcinoid, leiomyoma, anin¯ammatory lesion caused by parasites, and cysts. No
recurrences were observed over the 5-year follow-up
period. It is suggested that laparoscopic wedge resection of the stomach for an SMT is a safe, curative, andminimally invasive procedure, if the patients are carefully selected.
Application of sentinel node navigation surgery tolaparoscopic gastrectomy
Curative resection for invasive gastric cancer should
include removal of the lymphatic drainage of the tumorbearing segment of the stomach. Gastrectomy with systematic lymph node dissection (D1 or D2) has been
considered as a standard procedure for the treatmentof early gastric cancer with potential for micro-lymph
node metastases. The frequency of lymph node involvement, however, is less than 15% in early gastriccancer, in which the depth of invasion is limited within
the submucosal layer.7 Simple wedge resection with asafe surgical margin should be suf®cient for curative
treatment for early gastric cancer without lymph nodemetastases. From this point of view, distal or total gastrectomy with lymphadenectomy, for patients withearly gastric cancer without lymph node metastases,
might be regarded as an excessive surgery. The dif®culty in the preoperative diagnosis of the micro-lymph
node involvement, however, is the reason why conventional gastrectomy with lymphadenectomy remains valid as a standard procedure.
The sentinel node concept is based upon the orderly
progression of tumor cells within the lymphatic system.
The ®rst draining node, called the sentinel node, is also
the ®rst to contain metastases. Identifying the sentinelnode can be accompanied by preoperative injection ofradioactive isotope-labeled colloidal albumin at the siteof the primary tumor and subsequent intraoperative useof a handheld gamma probe to localize radioactivity inthe lymph lesion. The technique can also be performed
with a vital blue dye which enables visualization of thelymphatics. Sentinel node biopsy has been performed inpatients with melanoma and those with breast cancer,
and the histological status of the sentinel node accurately predicted the lymph node status.
We introduced this technique to gastrointestinal
cancers to assess the extent of lymphadenectomy ineach patient since 1999.8 In a pilot study in open surgery, both of the detectable and predictive rates of169

sentinel nodes in patients with gastric cancer werehigher than 95%. Using this technique, our curative
laparoscopic proceure, which was originally developed
for the minimally invasive treatment of mucosal cancers, may be applicable to patients without lymph nodemetastases con®rmed by intraoperative sentinel nodebiopsy. We con®rmed the feasibility of laparoscopic
detection of sentinel nodes in early gastric cancer, using
the abdominal gamma probe in a preliminary study.
There are several issues to resolve for a clinical trial oflaparoscopic sentinel node navigation surgery of earlygastric cancer, such as the laparoscopic technique forradio-guided sentinel node detection, and the sensitivityof intraoperative pathologic examination of micrometastases in the sentinel nodes. However, we note that
it is worthwhile to continue evaluating this technique todetermine its role in a minimally invasive approach toearly gastric cancer.
Development of Endoscopic Surgery
for Thyroid Diseases
Postoperative cosmesis in the neck is often a major
concern of patients, particularly those undergoing thyroid surgery. Therefore, the performance of thyroidectomy without an operative scar in the neck is expected
to improve patient satisfaction. We developed an original technique for performing endoscopic thyroidectomy
using a breast approach and low pressure CO2 insuf¯ation into the subplatysmal space.9
The subcutaneous space in the breast area and subplatysmal space in the neck were bluntly dissected
through a 15-mm incision between the nipples, and CO 2
was insuf¯ated at 6 mmHg to create the operative
space. Three trocars were inserted at the breast (Fig. 2),
and dissection of the thyroid and division of the thyroid

Fig. 2 Scarless endoscopic thyroidectomy: breast approach for better
cosmesis.

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Furukawa T, et al: Development of endoscopic surgery

vessels and parenchyma were performed endoscopically using an ultrasonic-activated scalpel. Four hemithyroidectomy and one partial resection of the thyroidfor ®ve female patients with thyroid adenomas 5 to 7
cm in diameter were successfully performed using thisprocedure. There were no conversions to open surgery
or complications. No scars were apparent in the neck,and all patients were fully satis®ed with the cosmetic
results.
Development of Endoscopic Surgery
for Esophageal Diseases
The esophagus is anatomically hard to approach
because it is surrounded by important organs, namely
the trachea, bronchus, aorta, heart, lung, and so on.
General thoracic surgeons are required to perform safe
and sure operations on the esophagus. We also succeeded in the thoracoscopic or the laparoscopic treatment of esophageal diseases.10
Thoracoscopic surgery
The enucleation of an esophageal submucosal tumor,
the resection of a giant esophageal diverticulum, andthe resection of an esophagobronchial ®stula were successfully performed by a full thoracoscopic procedure.
Furthermore, patients with thoracic esophageal cancer
were also treated thoracoscopically. The mobilizationof the thoracic esophagus and the dissection of mediastinal lymph nodes were performed with better visualization.
Laparoscopic Heller and Dor operation for esophageal
achalasia
Laparoscopic Heller myotomy and Dor fundoplication (Heller and Dor operation) is now regarded as theoperation of the ®rst choice for esophageal achalasia. It
is indicated for patients who are resistant to medical
therapy with a calcium blocker, for example, or havepneumatic dilatation and with frequent aspiration atnight. Since it was reported that surgical treatment isbetter than pneumatic dilatation and since laparoscopic
surgery is less invasive, the indications for the laparoscopic Heller and Dor operation could include allachalasia patients resistant to medical therapy. We successfully performed the laparoscopic Heller and Doroperation on 22 patients, all of whom had an uneventful
postoperative course.11 Manometric evaluation, endoscopic examination, and 24-hour pH monitoring
showed good results. There are six important technicalpoints: 1) ¯exible laparoscopy; 2) pneumoperitoneum;3) gauze in the abdominal cavity to absorb blood; 4)

laparoscopic coagulating shears; 5) extra-corporeal
knot-tying technique; and 6) intracorporeal knot-tying
technique. If an experienced surgeon is in charge, thelaparoscopic Hellar and Dor operation is an ideal andminimally invasive treatment for esophageal achalasia.
Laparoscopic Nissen fundoplication for gastro-esophageal re¯ux disease (GERD)
Patients with gastroesophageal re¯ux disease weretreated by laparoscopic Nissen fundoplication. Important technical points are similar to those of the laparoscopic operation for esophageal achalasia.
Patients were free from symptoms of heart burnwithout any medication postoperatively. The endoscopic examination revealed no esophagitis and the 24hour pH monitoring demonstrated no signi®cant gastroesophageal re¯ux. In addition, the upper GI series
showed no re¯ux of contrast medium from the stomach
to the esophagus in the Trendelenburg position.
Development of the Laparoscopic Surgery
for Colorectal Diseases
Laparoscopic colectomy for colorectal cancer
The argument of the application of laparoscopic surgery to the treatment of malignant diseases is mainly
concerned with the expectation that lymph node dissection under laparoscopic manipulation would be lesscomplete in comparison with that in open surgery.
Since the systematic lymph node dissection procedurein colonic surgery is relatively simple compared withothers including esophageal and gastric surgeries, coloncancer was the ®rst candidate to evaluate the curabilityof the laparoscopic surgery against a malignant diseaseof the digestive organs.
We have applied laparoscopic surgery for the treatment of colorectal cancer since 1992, to early cancers inthe ®rst 4 years, and then up to advanced cancers basedon the favorable results in the ®rst application.12 Evenpatients with lower rectal cancer were successfully
treated by laparoscopic techniques with a satisfactory
outcome in each.13 Between June, 1992 and December,
2000, 372 patients with colorectal cancer underwent
laparoscopic surgery in our institute. Among them, 274
patients (74%) had Dukes' A tumors, 48 (13%) Dukes'
B, 45 (12%) Dukes' C, and 5 (1%) Dukes' D. Oral intake was started on median postoperative day 1, andmedian postoperative hospital stay was 8 days. Postoperative complications included wound sepsis in 18(4.8%), anastomotic leakage in 13 (3.5%) and bowel
obstruction in 9 (2.4%). Eleven patients developed recurrence (liver: 5, peritoneum: 3, local: 3). No port site
recurrence was observed. The calculated 5-year survivalKeio J Med 2001; 50 (3): 167±174rate was 99.4% for Dukes' A, 100.0% for Dukes' B,
and 82.6% for Dukes' C. Thus, it is suggested that laparoscopic surgery was technically feasible and oncologically sound in the treatment of colorectal cancer withfavorable short- and long-term outcomes.14
Based on these results in the retrospective study, we
conducted a randomized controlled trial to compare
short-term outcomes of laparoscopic and open colectomy for advanced colorectal cancer.15 Fifty-ninepatients with T2 or T3 colorectal cancer excluding thetransverse colon and rectum were randomized to undergo laparoscopic (n  29) or open (n  30) colectomy between June, 1998 and October, 2000. Operative time was longer (p < 0.001), while blood loss
(p < 0.005) and postoperative analgestic requirement
was less in the laparoscopic group than the open group.
Earlier return of bowel motility and earlier discharge
from the hospital (p < 0.05) were observed after laparoscopic surgery. Serum C-reactive protein levels on
postoperative day 1 (p < 0.001) and 4 (p < 0.005) werelower in the laparoscopic group than the open group.
No signi®cant differences were found in leukocyte count,natural killer cell activity, and interleukin-6 levels between the two groups. Postoperative complications did
not differ between the two groups. These results suggestthat laparoscopic surgery for advanced colorectal cancer is feasible with favorable short-term outcome comparable to open surgery.
Application for Crohn's disease
Surgical treatment is often necessary for patientswith Crohn's disease complicated by intestinal stricturesor ®stulas. We examined the technical feasibility inpatients with Crohn's disease associated with stricturesand ®stulas.16 Laparoscopic surgery was attempted in
37 patients with structuring ileal or ileocolonic Crohn's
disease between 1994 and 2000 after failure of strict
nutritional therapy. Twenty-four patients underwent
ileocecal resection, 17 underwent strictureplasty, 15partial resection of anastomotic recurrence. Oral intake
was started a median of one day after the operation,and patients were discharged a median of 8 days after
surgery. Six complications were observed in 41 surgeries (14.6%), including two intestinal obstructions/
ileus, three wound infections, and one intraabdominal
abscess. Two of these complications were associatedwith laparoscopic intracorporeal ®stula takedown.
There were no intraoperative or postoperative deaths.
Four patients required convention to open surgery(9.7%). Six patients who required reoperation foranastomotic recurrence underwent repeated laparoscopic surgery using the same small incision. It is suggested that laparoscopic treatment for Crohn's disease

171

complicated by ®stulas is feasible, without high complication or conversion rates, and is applicable to reoperation for recurrent disease after laparoscopic treatment.
Development of Laparoscopic Surgery
for Hepatobiliary Diseases
Laparoscopic clipless needle cholecystectomy
Laparoscopic cholecystectomy has become the standard treatment for sympatic cholelithiasis. Since 3 mm
bipolar coagulation forceps and 2 mm instruments became available, our technique for laparoscopic cholecystectomy has changed. Bipolar energy never passes
through the body, thus reducing any potential for conductive injury around the bile duct. Since the 3 mm
bipolar coagulation can avoid using clips on the cystic
duct and artery, the total cost of the procedure was
reduced. Furthermore, the 2 mm and 3 mm incisionsites can be closed easily in one minute by surgicaltape without suturing. A 5-mm instrument is usually
the acceptable size. However, 2 to 3 mm devices are
more bene®cial, leaving smaller scars. On the other
hand, function of these instruments remains similar tothe standard 5 mm instruments with the advancementof micro-technology. With the 2 mm instruments and 3
mm bipolar forceps, our standard technique for laparoscopic cholecystectomy became faster, less traumaticand less expensive.
We use the open laparoscopy method to place a 12mm trocar through the umbilicus, and the abdomen isinspected using a ¯exible video laparoscope. One 3-mm
trocar and two 2-mm trocars are placed in the abdomen
under direct vision. These 2-mm instruments are stableenough for most lap-surgeries if a mini-port is used as asheath to cover their weakness in rigidity. The 3-mm
bipolar coagulation forceps and 2 mm mini-ties are used
to coagulate and ligate the cystic artery and duct, sothat clips for the artery and the duct will not be left in apatient's abdominal cavity. The clips left in the body
have potential risks, such as migration or interferencewith possible future imaging of the hilum. This laparoscopic clipless needle cholecystectomy can be regarded
as the optimum procedure for gall bladder removal.17
Laparoscopic Liver Surgery
Despite advances in laparoscopic techniques, laparoscopic liver surgery has not yet come into widespreaduse. However, we have accumulated patients with liverdiseases since June, 1992, who underwent laparoscopic
liver surgery including laparoscopic liver resection,
laparoscopic/thoracoscopic microwave coagulating of
the liver malignancies, laparoscopic deroo®ng of theliver cyst, and laparoscopic wedge biopsy of the liver.

172

Furukawa T, et al: Development of endoscopic surgery

Bleeding control, which is a basic element for liver surgery, needs to be better accessed by methods suitable
for laparoscopic surgery in order to perform safer laparoscopic liver surgery. In our hospital, laparoscopic
liver resections have been successfully performed by
the application of the hilar blood ¯ow control techniqueand automatic suturing devices. To establish a safer
technique and the signi®cance of laparoscopic liver
surgery, we analyzed the initial results from the pointof operative techniques and indications for laparoscopic liver surgery. Technical considerations for laparoscopic liver resection include intraoperative laparoscopic ultrasonography, abdominal wall lifting method,
and the Pringle maneuver with a combination of several
devices for hemostasis (microwave coagulator, laparoscopic coagulating shears, ultrasonic dissector, argon
beam coagulator, bipolar electronic cautery and automatic suturing device). Patients with primary or metastatic liver tumors, who underwent laparoscopic resection or lap/thoracoscopic microwave coagulation, wereseen during a four-year period at our hospital, and theresults were found to be comparable with those ofpatients with these hepatic malignancies who underwent open liver resection during the same time period.
The postoperative courses of these patients were uneventful. There were no postoperative bile leakage,
bleeding (blood transfusion), or other complications.
Postoperative hospital stay ranged from 4 to 8 days forlaparoscopic liver resection. Thus, laparoscopic liver
surgery can be safely performed and it can be wellestablished for certain hepatic diseases, although its
indications remain restricted. For a safer laparoscopic
liver resection, an abdominal wall lifting method ispreferable in combination with an ef®cient bleeding
control technique during parenchymal resection of theliver.18
Introduction of Robotics and Tele-commucation
Technologies to Endoscopic Surgery
The application of the minimally invasive procedure
to more complex operations requires new technology.
Presently, a majority of abdominal operations canbe done by the laparoscopic approach. However, there
are major dif®culties because the view of the operating®eld is restricted to a two-dimensional image, effecter
instruments have limited maneuverability due to therigid shaft axis ®xed to the abdominal wall by the entry
trocar, and loss of direct contact with organs results ininsuf®cient tactile information.
To overcome the dif®culties of endoscopic manipulation, major research efforts have been devoted todevelop a minimally invasive robotic surgery systemthat includes three-dimensional video imaging, telemanipulated ¯exible effector instruments, and tactile

feedback. Current applications of robotics include
progress in surgical assistance, image-guided therapy,
and dexterity enhancement.19
Robotic surgical assistance
The idea of surgical assistance by robots is the creation of robotic devices that will allow surgeons to perform tasks that currently require more than one person.
The robotic endoscope holder is an example of suchdevice. Since the vision of the operating surgeon
depends on the assistant responsible for holding andpositioning of the endoscope in endoscopic surgery, a
mis-directed and shakier image may be presented. To
circumvent this problem, robotic endoscope holders
have been developed which return direct control ofthe visual ®eld to the operating surgeon, and hold theendoscope with greater stability offering the surgeon astable image.
AESOP (Automated Endoscopic System for Optimal Positioning Computer Motion, Inc., Santa Babara,
Calif., USA) was the ®rst commercial laparoscope positioning system introduced in 1994. We have used thisrobot clinically since 1996, and safely performed over
100 cases of `solo-surgery' without human assistance.
There were no disadvantages observed such as prolonged surgical duration, increased volume of operative
bleeding, increased complication rate, or conversion to
open surgery, in comparison with surgery with humanassistance. Since a voice control human-machine-interface was developed, the robotic system has become
more user-friendly.
Master-slave manipulator
Dexterity is enhanced by a master-slave manipulator in which a microprocessor is placed between thesurgeons' hand (master) and the tip of the surgicalinstrument (slave). This system allows performance ofsuperhuman tasks that cannot be done without computer enhancement.
Major advantages using master-slave manipulators
are that the surgeon's tremor disappears at the robotic
site, and that the surgeon can freely scale-down robotic
movements. To date, several kinds of systems havealready been introduced to the clinical practice. Amongthem, the da Vinci system (Intuitive Surgical, Inc,
Mountain View, Calif., USA), equipped with two
articulated joints at the tip which permits the system tohave a total of 7 degrees of freedom and a high quality
3-D vision system, appeares to provide superior dexterity to surgeons. We have introduced the da Vinci
system to the laparoscopic surgery of gastrointestinal
diseases since March, 2000 (Fig. 3), and con®rmed theexcellent maneuverability especially in suturing andKeio J Med 2001; 50 (3): 167±174173

Surgical tele-mentoring

Fig. 3Operation using a master-slave manipulator.

ligating procedures. The surgeons can feel as if theirminiature wrist and ®ngers are operating in the abdominal cavity. We con®rmed in experiments of motion
analysis that restrictions on the rotation of the surgeons' movements observed in the endoscopic manipulations can be relaxed using this system.1 For example,
taking advantage of this system, we have developed anovel method of cholecystectomy, where we ligated thecystic artery and cystic duct using strings to complete
the procedure without leaving foreign bodies such as
clips, and sutured the liver bed after resection of thegallbladder to repair defects of the peritoneum andprevent adhesion after surgery. We also succeeded inperforming a complete endoscopic choledocho-jejunostomy in a non-resectable advanced pancreatic cancer
patient suffering from obstructed jaundice, which iscurrently performed by open surgery without this system. With research efforts devoted to such systems, themaster-slave manipulators will be improved to carry out
surgeries in a microscale or on moving organs throughmotion compensation.
The lack of tactile sensation, however, is the mostserious demerit of current master-slave manipulators. It
is one of the most dif®cult problems to overcome in thedevelopment of a robotic system. In the open air, wehave developed a tele-presence system which transmits
tactile sensations of remote objects using a PHANToM(Personal Haptic Interface Mechanism) system (Sensable Technology, Inc, USA). Tactile sensations of thesurface and elasticity of the remote object can be felt by
the ®ngers as if they are really being touched, and evena delicate maneuver such as turning book pages can bedone by tele-presence with complete tactile sensation.
We expect this transmission system can be applied
to the instruments of endoscopic surgery in the near
future.

Today, advanced tele-communication technology provides excellent motion images using only 3-ISDN (384kb) telephone lines. Recently, the feasibility and ef®cacy of tele-consultation with some external partners
during surgery has been demonstrated. Since endoscopic surgery is performed under video image, it isparticularly suitable for tele-communication. We also
constructed a tele-consultation system of endoscopic
surgery between some collaborative urban hospitals,
and developed a technique to tele-illustrate the colorlines on video images bilaterally to increase the effectiveness of tele-consultation.17 This annotation system considerably enhances the ef®cacy of surgical teleconsultation.
Experienced laparoscopic surgeons at collaborative
hospitals have been able to successfully perform complex procedures by consulting specialists in laparoscopic surgery at our institute. Considering that theprices of tele-communicative devices are being reduced
annually, and that the technological basis of the ISDN
telephone system is simple and standardized, teleconsultation in endoscopic surgery should soon beavailable for routine clinical practice.
Acknowledgements: We dedicate this article to the memory of a great
surgeon, Dr. Masahiro Ohgami, who took the most active part as aleader of our team of endoscopic surgery.

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