Minimally invasive surgery

In 1987, Mouret performed the first laparoscopic cholecystectomy - dramatically changing the history of surgical practice. No other aspect of surgery has developed with such vigor as laparoscopy. Previously, surgeons had attempted to define the maximum level of surgical intervention a patient could withstand - but as laparoscopic surgery developed, this paradigm was turned on its head. Minimally invasive surgeons are continuing to determine and redefine how much can be accomplished through smaller incisions and with minimal surgical stress. Laparoscopy is still only in its infancy. This article reviews current aspects of laparoscopic surgery in 1999-2000 in relation to gallbladder, gastric, colorectal, and splenic disease, as well as reviewing the current role of laparoscopic surgery in the treatment of abdominal wall hernias.     

Minimally invasive surgery

During the last 10 years, minimally invasive surgery has influenced the techniques used in every specialty of surgical medicine. This development has not only led to the replacement of conventional procedures with minimally invasive ones, but has also stimulated surgeons to reevaluate conventional approaches with regard to perioperative parameters such as pain medication. However, two major drawbacks have emerged with the introduction of this new technique: firstly, the prolonged learning curve for most surgeons, in comparison with the learning process in open surgery; and secondly, increased costs due to investment in the equipment required and the use of disposable instruments, as well as longer operating times. In the various health-care systems around the world, these increased costs are not always compensated for by shorter hospital stays. This review focuses on major areas of indication for minimally invasive surgery in the gastrointestinal tract. These include functional disorders of the upper and lower gastrointestinal tract, obesity surgery, minimally invasive techniques in gastric and hepatobiliary surgery and in other solid organs, and laparoscopic colorectal surgery. The shortening of the hospitalization period has led to increasing use of outpatient laparoscopic surgery, and many centers specializing in day-care surgery are using these techniques. The frontiers are being pushed even further, as the size of the instruments is reduced to achieve better cosmetic results. Clinical research has also focused on the topic of expanding the indications for minimally invasive approaches in the elderly and in high-risk patients, to take advantage of the shorter hospital stays and reduced surgical trauma that are possible. A considerable amount of basic research has been carried out on the stress response during and after minimally invasive procedures, and an improved immune response with the minimally invasive approach has been observed, leading to better results after extensive oncological procedures. Robotic surgery and telesurgery involve new computer-aided methods that allow greater precision in surgical technique, as well as offering an opportunity to supply surgical skill and expertise remotely, over long distances. Minimally invasive surgical techniques are thus now fully established in routine use, and the indications are continuing to expand.     

Minimally invasive neonatal surgery

Minimally invasive surgery is now an option to patients as light as 1.2 kg, extending the benefits of small incisions, faster recoveries, decreased pain, and more precise procedures in critically ill neonates. This article provides a review of the historical development of minimally invasive surgery and an overview of the equipment involved, identifies the roles of the neonatal and perioperative nurse, and briefly describes several minimally invasive surgery procedures currently performed in the neonatal population.     

Minimally invasive aortic valve surgery

Heart surgery has seen the emergence of minimally invasive surgery in the quest for less traumatic and less painful surgery. This procedure can be provided without the increased cost of endoscopic instrumentation by use of standard instrumentation, cannulation, and prostheses. A small incision and partially split sternum provide the patient with less postoperative pain and bleeding and early extubation and discharge from the hospital.     

微创技术与脊柱外科

微创脊柱外科（Minimally Invasive Spine Surgery，MISS）是指经非传统手术途径并借助特殊手术器械、仪器或手段进行脊柱疾患的诊断和治疗技术与方法。本文重点介绍经皮穿刺技术和内窥镜辅助的技术。     

Minimally invasive approaches in orthopaedic surgery

Performing orthopaedic interventions with reduced trauma to soft tissue is considered a way to shorten recovery time and improve surgical outcome. Based on an analysis of causes of invasiveness in orthopaedic surgery, associated fields of development are described that aim at the reduction of invasiveness. The causes in question are the need to have visual contact to the performed surgical action, to guide surgical instruments into the situs, and to introduce devices such as screws, plates, or endoprostheses for implantation. This article focuses in particular on the use of navigation technology as a visualization aid to overcome the first cause of invasiveness. Two pay-offs of this approach are discussed which have so far prevented computer-assisted surgery systems from being used less invasively than conventional instruments. Referencing of the anatomy is required to track the spatial position and orientation of the operated bone. Registration establishes a systematic link between all objects involved. Alternatively, contact-less solutions have been proposed for both actions; however, up to now with only limited success. Current trends in robotically supported surgery seem to indicate that this technology may play a more important role in minimally invasive interventions in the future.     

Minimally invasive surgery for esophageal cancer

Background: Esophageal cancer is among the most deadly cancers worldwide, and esophagectomy remains the standard of care in trying to cure this. Efforts to decrease the incidence of complications in esophagectomy without compromising the efficacy of the procedure have stimulated interest in minimally invasive esophagectomy (MIE), and a wide variety of MIE techniques have been refined by surgeons at specialized centers worldwide. Data sources: Systematic PubMed searches identified articles related to MIE technique, complications, and outcomes. Conclusions: Several techniques have been developed for MIE, none of which has been deemed superior, but as a whole, they represent a safe alternative to open surgery. Available results from case series and comparative studies suggest trends towards improved short‐term outcomes with equivalent efficacy but without definitive advantages.     

Minimally invasive surgery for morbid obesity

In patients with morbid obesity, surgery is the only treatment known to produce sustained weight loss and to reduce comorbidities. Traditional (open) gastric bypass surgery is associated with postoperative complications that include wound infection, pulmonary embolism, and pneumonia. Laparoscopic techniques achieve similar long-term results as does open surgery, with fewer postoperative complications.     

Minimally invasive coronary artery bypass surgery

Advances in videoscopic instrumentation and expanding experience with the performance of coronary artery bypass surgery without cardiopulmonary circulatory support is changing the surgical approach to many patients requiring coronary arterial revascularization. We describe the present status of minimally invasive coronary artery bypass surgery being used today.     

Minimally invasive surgery: hepatobiliary-pancreatic and foregut

This review is confined to the liver, biliary tract, pancreas, and foregut (oesophagus and stomach). The issues relating to laparoscopic cholecystectomy mainly concern the bile duct injuries associated with this operation. This review provides some evidence that although the risk for this iatrogenic injury is declining, it continues to be a problem and is accompanied by significant morbidity, mortality, and a huge escalation in care costs. Laparoscopic clearance of ductal stones is undoubtedly safe and effective, and issues have now focused on comparisons between this form of management and orthodox endoscopic clearance. Laparoscopic cardiomyotomy may well replace other forms of treatment of achalasia, including balloon dilation and botulinum toxin injection. As the results of laparoscopic antireflux surgery have been so good in the medium term, the question of medical versus laparoscopic treatment is being addressed by two randomized clinical trials. Gastric resection is established only in respect of excision of mesenchymal tumours. Gastric surgery for advanced gastric cancer must still be regarded as developmental. Laparoscopic liver resections and in situ ablation are still confined to developing centres, but the early results are promising. However, simpler hepatic procedures, such as de-roofing of symptomatic simple hepatic cysts, are well established and in widespread practice. Only a few centres have published their results on laparoscopic pancreatic surgery. The early reported outcome for internal drainage of pancreatic pseudocysts, enucleation of benign insulinomas, and distal pancreatic resections has been good, but the experience is limited.     

Minimally invasive surgery in breast cancer treatment

As genetic and biological treatment modalities are developed that can be custom-designed for individual patients, the possibility that breast cancer can be managed as a chronic long-term disease becomes more real, and the requirement for minimally invasive surgical intervention used as part of a multidisciplinary treatment approach becomes more pressing. Rather than fearing that they will be replaced, surgeons should enthusiastically move into this dynamic phase in the development of new surgical techniques for the treatment of breast cancer. This article will discuss such techniques in three evolving areas: 1) management of the axilla after neoadjuvant chemotherapy; 2) sentinel node dissection; and 3) radiofrequency ablation of primary tumors of the breast.     

Minimally invasive surgery. Bedside tracheostomy and gastrostomy

Minimally invasive surgical techniques have gathered tremendous momentum. Most patient benefit is realized in the ambulatory setting. Smaller incisions result in less pain and earlier return to activities. Critically ill patients typically do not benefit from minimally invasive techniques in this manner; however, they do benefit from other aspects of minimally invasive tracheostomy and gastrostomy. Small tracheostomy wounds are associated with reduced wound problems (infection and breakdown). The small stab wounds of minimally invasive gastrostomy are associated with less pain and with an absence of fascial dehiscence. Furthermore, because these procedures are performed easily and safely at the bedside, transport and operating room costs are avoided. Although these procedures are minimally invasive, they are major procedures. Devastating complications can become life-threatening. Attention to detail is required to avoid or respond promptly to complications. In this way, patients receive maximal benefit at minimal risk.