Development of Minimally Invasive Surgery

Minimally invasive surgery (MIS) is surgery conducted using very small incisions, through which slender instruments and a laparoscope are inserted to perform and visualize the procedure. MIS is often associated with lesser trauma and scarring, fewer complications, and faster recovery time for the patient.¹ Over the past 40 years, the development and improvement of MIS has changed surgical practice considerably.²

Much of the improvements to MIS have been facilitated by technological innovations; however, as U.K. researchers found in a quantitative analysis of electronic patent and publication databases over the interval 1980-2011, since the mid-1990s, these changes have been driven by gradual refinement as opposed to radical inventions, with only a few interruptions by entirely new approaches or tools.² These new approaches and tools have nevertheless been critical to the continued enhancement of MIS and surgical procedures in general and merit further discussion.

One new approach has been surgical robotics, the growth of which has shown gradual and exponential patterns starting in the mid-1990s and throughout the 2000s.^2,3 Robot-assisted surgery allows physicians to perform complex procedures with greater precision, flexibility, and control than would be possible without this technology, and the use of this technology has become integral to MIS.⁴ Beyond providing necessary tools for modern MIS procedures, surgical robotics have helped expand its practice, which has resulted in increased usage of robotics in various procedures and the use of surgical robotics as a complementary technology for other existing MIS methods.³

Another significant innovation in minimally invasive surgery is single-incision laparoscopic surgery (SILS), first described in general surgery in 1997.^3,5 As its name suggests, only one incision is required for SILS procedures, allowing it to have cosmetic advantages over standard laparoscopic surgery, which is more likely to result in postoperative scars. The risk of complications (such as port site hernias, hematomas, and wound infection) is also reduced relative to standard laparoscopic surgery for SILS. While SILS procedures are longer than standard laparoscopic surgeries, SILS research is a rapidly developing field, and the technologies for these procedures have continued to improve over the years.⁵

Finally, natural orifice transluminal endoscopic surgery (NOTES) has been another, relatively recent development in MIS approaches.³ These surgical procedures involve intra-abdominal interventions performed through naturally occurring orifices as opposed to through skin incisions.⁶ Some advantages associated with NOTES include no scars, less external pain, and lower costs. However, the development and application of NOTES has been stymied by barriers such as difficulty in the closure of enterotomy, in learning the procedure, and in preventing the transluminal spread of infection.³ NOTES application has mostly been restricted to animal tests,⁶ but recent clinical trials with natural-orifice peritoneoscopy, the first of which took place in 2008, has demonstrated the safety, feasibility, and potential benefits of utilizing NOTES procedures for human patients.⁷

As exciting as MIS and its associated benefits are, however, there is still a need for physicians and researchers to exercise caution in applying MIS techniques, as there are some significant risks associated with this approach. For instance, in 2019, Kim et al. found that, compared to patients who underwent conventional open surgery for radical hysterectomy as their primary treatment for stage IB1-IIA2 cervical cancer, patients who underwent MIS experienced higher recurrence rates.⁸ Physicians will have to consider carefully the potential benefits and risks of MIS versus those of standard procedures for each case to determine whether a particular patient would benefit from the use of minimally invasive surgery techniques.

References 

(1) Minimally Invasive Surgery > Fact Sheets > Yale Medicine. 

(2)  Hughes-Hallett, A.; Mayer, E. K.; Pratt, P. J.; Vale, J. A.; Darzi, A. W. Quantitative Analysis of Technological Innovation in Minimally Invasive Surgery. British Journal of Surgery 2015, 102 (2), e151–e157. https://doi.org/10.1002/bjs.9706. 

(3)  Siddaiah-Subramanya, M.; Tiang, K.; Nyandowe, M. A New Era of Minimally Invasive Surgery: Progress and Development of Major Technical Innovations in General Surgery Over the Last Decade. Surg J 2017, 03 (04), e163–e166. https://doi.org/10.1055/s-0037-1608651. 

(4)  Robotic surgery – Mayo Clinic. https://www.mayoclinic.org/tests-procedures/robotic-surgery/about/pac-20394974. 

(5)  Greaves, N.; Nicholson, J. Single Incision Laparoscopic Surgery in General Surgery: A Review. Annals 2011, 93 (6), 437–440. https://doi.org/10.1308/003588411X590358. 

(6)  Arulampalam, T.; Paterson-Brown, S.; Morris, A.; Parker, M. Natural Orifice Transluminal Endoscopic Surgery. Annals 2009, 91 (6), 456–459. https://doi.org/10.1308/003588409X464487. 

(7)  Hazey, J. W.; Narula, V. K.; Renton, D. B.; Reavis, K. M.; Paul, C. M.; Hinshaw, K. E.; Muscarella, P.; Ellison, E. C.; Melvin, W. S. Natural-Orifice Transgastric Endoscopic Peritoneoscopy in Humans: Initial Clinical Trial. Surg Endosc 2008, 22 (1), 16–20. https://doi.org/10.1007/s00464-007-9548-6. 

(8)  Kim, S. I.; Cho, J. H.; Seol, A.; Kim, Y. I.; Lee, M.; Kim, H. S.; Chung, H. H.; Kim, J.-W.; Park, N. H.; Song, Y.-S. Comparison of Survival Outcomes between Minimally Invasive Surgery and Conventional Open Surgery for Radical Hysterectomy as Primary Treatment in Patients with Stage IB1–IIA2 Cervical Cancer. Gynecologic Oncology 2019, 153 (1), 3–12. https://doi.org/10.1016/j.ygyno.2019.01.008.