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Minimally Invasive
Procedures:
Today and the Future
(An Online Continuing Education Activity)
A Continuing Education Activity
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Welcome to
Minimally Invasive Procedures:
Today and the Future
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following
steps:
1. Read the overview and objectives to ensure consistency with your own
learning needs and objectives. At the end of the activity, you will be assessed
on the attainment of each objective.
2. Review the content of the activity, paying particular attention to those areas
that reflect the objectives.
3. Complete the Test Questions. Missed questions will offer the opportunity
to re-read the question and answer choices. You may also revisit relevant
content.
4. For additional information on an issue or topic, consult the references.
5. To receive credit for this activity complete the evaluation and registration
form.
6. A certificate of completion will be available for you to print at the conclusion.
Pfiedler Enterprises will maintain a record of your continuing education credits and
provide verification, if necessary, for 7 years. Requests for certificates must be
submitted in writing by the learner.
If you have any questions, please call: 720-748-6144.
CONTACT INFORMATION:
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All rights reserved
Pfiedler Enterprises, 2101 S. Blackhawk Street, Suite 220, Aurora, Colorado 80014
www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196
DSL #13-0181
OVERVIEW
This continuing education activity will provide an overview of the clinical considerations
related to current techniques in Minimally Invasive Procedures (MIPs). The historical
evolution of MIPs, including the overall patient benefits, will be reviewed. The most current
MIPs being implemented across multiple surgical specialties today will be explored.
Emerging technologies that support MIPs – single site laparoscopy, natural orifice
transluminal endoscopic surgery (NOTES), and robotics – will also be discussed.
Objectives
Upon completion of this continuing nursing education activity, the participant should be able
to:
1. Discuss the history and continuing evolution of minimally invasive procedures.
2. Compare the risks and benefits of MIPs versus open surgical approaches for all
procedures.
3. Outline the rationale for the slow adoption of minimally invasive procedures by
surgeons.
4. Explain where the MIP field may be expanding beyond traditional laparoscopic
approaches.
5. Identify which procedures, and what clinical and economic evidence exists to
support the use of robotics in MIPs.
INTENDED AUDIENCE
This continuing education activity is intended for nurses, certified surgical technologists,
and other health care personnel who are interested in learning more about the evolution of
and latest techniques in minimally invasive procedure techniques across multiple surgical
specialties.
CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hour(s).
Obtaining full credit for this offering depends upon completion, regardless of
circumstances, from beginning to end. Licensees must provide their license numbers for
record keeping purposes.
The certificate of course completion issued at the conclusion of this course must be
retained in the participant’s records for at least four (4) years as proof of attendance.
3
AST Credit
This continuing education activity is approved for 7.75 CE credits by the Association of
Surgical Technologists, Inc. for continuing education for the Certified Surgical Technologist
and Certified Surgical First Assistant. This recognition does not imply that AST approves or
endorses and product or products that are discussed or mentioned in enduring material.
IACET Credit for Allied Health Professionals
Pfiedler Enterprises has been accredited as an Authorized Provider by the International
Association for Continuing Education and Training (IACET), 1760 Old Meadow Road, Suite
500, McLean, VA 22102.
CEU STATEMENT
As an IACET Authorized Provider, Pfiedler Enterprises offers CEUs for its programs that
qualify under ANSI/ IACET Standard. Pfiedler Enterprises is authorized by IACET to offer 0.2
CEUs (2.0 contact hours) for this program.
RELEASE AND EXPIRATION DATE
This continuing education activity was planned and provided in accordance with accreditation
criteria. This material was originally produced in April 2013 and can no longer be used after
April 2015 without being updated; therefore, this continuing education activity expires in April
2015.
DISCLAIMER
Accredited status as a provider refers only to continuing nursing education activities and does
not imply endorsement of any products.
SUPPORT
Grant funds for the development of this activity were provided by Ethicon.
AUTHORS/PLANNING COMMITTEE/REVIEWERS
Anthony Adams, CST
Certified Surgical Technologist
University of Colorado Hospital
Aurora, CO
Julia A. Kneedler, RN, MS, EdD Director of Education
Pfiedler Enterprises
Aurora, CO
Judith I. Pfister, RN, BSN, MBA Program Manager
Pfiedler Enterprises
Aurora, CO
4
Elizabeth Deroian, RN, BA Program Manager
Pfiedler Enterprises
Aurora, CO
Rose Moss, RN, MN, CNOR Nurse Consultant
Elizabeth, CO
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FOR THOSE IN A POSITION TO CONTROL CONTENT FOR THIS
ACTIVITY
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interests or influences pose a potential bias of content, recommendations or conclusions.
The intent is full disclosure of those in a position to control content, with a goal of
objectivity, balance and scientific rigor in the activity.
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reselling, or distributing health care goods or services consumed by, or used on, patients.
Activity Planning Committee/Authors/Reviewers:
Anthony Adams, CST
No conflicts of interest
Julia A. Kneedler, RN, MS, EdD
Co-owner of company that receives grant funds from commercial entities
Judith I. Pfister, RN, BSN, MBA
Co-owner of company that receives grant funds from commercial entities
Elizabeth Deroian, RN, BA
No conflicts of interest
Rose Moss, RN, MN, CNOR
No conflicts of interest
5
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6
OvERVIEW OF MIPs: CLINICAL BENEFITS AND HISTORICAL
EVOLUTION
Overview & Clinical Benefits
Minimally invasive procedures (MIPs) are defined as surgical procedures performed
through small incisions or the natural orifice using video cameras and specialized
instrumentation; this approach is often referred to as “laparoscopic”. MIP techniques
have been shown to be as effective as open surgery, with demonstrated benefits
including1:
•
•
•
•
Shorter length of stay (LOS) in the hospital;
Less overall complications and postoperative pain;
Quicker recovery and thus a quicker return to work and normal activities; and
Lower rates of surgical site infections.
Table 1 outlines the advantages of MIPs over traditional open procedures.
Table 1 – Advantages of MIP over Open Procedures2
MIP
Open
Ambulatory or short hospital stay.
Hospital admission.
Short postoperative recuperation.
Four to six week recuperation.
Decreased postoperative pain; reduced need
for postoperative pain medications.
Postoperative pain related to the surgical site;
more analgesics required.
Quicker return to normal activities/lifestyle.
Return to normal activities/lifestyle varies with
recuperation period.
Lower rates of surgical site infection.
Higher risk for surgical site infections and
subsequent readmission.
In a meta-analysis of 112 articles on MIPs versus open surgical procedures, the
evaluated measures included length of stay in the hospital; return to work; and return
to normal activities (return to preoperative work level) – all of these measures were
improved in patients undergoing MIPs. These results are depicted in Figures 1, 2, and 3.3
7
Figure 1 – Weighted Average: Length of Stay: MIP versus Open Surgical
Procedures
Lap
Ventral Hernia Repair
2.01
9 studies
Open
Vag
Hysterectomy
8 studies
2.91
3.88
Abd
Lap
Hysterectomy
19 studies
Length of Stay for
MIP is shorter than
for Open procedures.
3.95
2.70
Abd 3.89
Lap 2.70
Vag 2.91
Hysterectomy
10 studies
Lap
Fundoplication
3.56
7 studies
37 studies
Open
7.69
2.28
Lap
Appendectomy
Open
2.92
Lap
Colectomy
5.82
16 studies
Lap
Cholecystectomy
3.23
0
2
8.17
Open
14 studies
4
9.24
Open
6
8
10
12
14
16
18
20
22
DAYS
Figure 2 – Weighted Average: Return to Work: MIP versus Open Surgical
Procedures
Return to work
for MIP is shorter
than for Open
procedures.
Ve ntral He rnia Re pair
1 s tudy
Hys te re ctom y
1 s tudy
Lap
Open
Vag
Lap
Hys te re ctom y
25.95
35.00
Abd
Abd
Lap
1 s tudy
Lap
Appe nde ctom y
26.60
Vag
39.93
35.00
11.32
Open
10 s tudie s
14.54
Lap
Cole ctom y
23.06
Open
2 s tudie s
Lap
Chole cys te ctom y
13.91
5
10
15
20
25
30
DAYS
8
41.98
35.08
Open
8 s tudie s
0
41.51
22.77
4 s tudie s
Hys te re ctom y
47.80
35
40
45
50
55
60
Figure 3 – Weighted Average: Return to Normal Activities: MIP versus Open
Surgical Procedures
Lap
Ventral Hernia Repair
1 study
21.10
Open
Vag
Hysterectom y
36.75
39.90
Abd
1 study
Lap
Hysterectom y
22.19
Abd
1 study
Lap
Hysterectom y
36.75
Vag
11.69
Lap
Open
14 studies
39.90
22.19
1 study
Appendectom y
Return to Normal
Activities for MIP is
shorter than for Open
procedures.
33.75
17.78
Lap
Colectom y
31.11
Open
2 studies
Lap
Cholecystectom y
2 studies
0
5
10
13.06
Open
15
20
71.51
24.45
25
30
35
40
45
50
55
60
65
70
75
DAYS
Another important advantage of MIPs is that these techniques may reduce the odds of
acquiring a hospital-acquired infection (HAI), or nosocomial infection, in comparison to
open surgery in certain procedures. In an analysis based on 399 nosocomial infection
markers (NIM) in 337 patients, laparoscopic cholecystectomy and hysterectomy each
reduced the overall odds of acquiring nosocomial infections by more than 50%; these
procedures also resulted in statistically significantly fewer readmissions with nosocomial
infections.4 Excluding appendectomy, the odds ratio for laparoscopic versus open NIMassociated readmission was 0.346. Laparoscopic appendectomy did not significantly
change the odds of acquiring nosocomial infections. Further, minimally invasive
approaches significantly reduce the rate of each type of nosocomial infection, specifically:
•
•
•
•
•
Respiratory tract:
Bloodstream: Wound: Urinary tract: Others: 80% reduction
69% reduction
59% reduction
39% reduction
8% reduction
Laparoscopic cholecystectomy and hysterectomy resulted in an overall 65% reduction in
associated readmission for nosocomial infections.
These clinical advantages also have an impact on both direct and indirect costs. The
shorter LOS, the shift to an outpatient setting, and reduced postoperative pain contribute
to less follow-up care and treatment, thereby decreasing direct costs of care. Because
patients can resume their normal activities, including return to work, there is reduced
9
80
absenteeism and improved presenteeism, thereby reducing indirect costs. As a result,
MIPs have immediate cost savings potential.
As we will discuss, while MIP techniques have come a long way, their development
and evolution continue to go further. There is a clear trend demonstrating a decrease in
invasiveness as medical devices and skills develop.
Historical Evolution of MIPs5,6,7
Despite physicians’ desire to visualize the interior of the body organs, the development of
endoscopy and minimally invasive surgery was relatively slow. Early scopes were used
as specula for inspection of natural body orifices. The first recorded minimally invasive
procedure was performed around 400 BC when Hippocrates described the use of a
primitive speculum and resectoscope to evaluate hemorrhoids; his contemporaries were
using vaginal specula. Since Hippocrates, several surgeons have experimented with
MIS techniques. Archigenes from Syria developed a vaginal speculum and also wrote
instructions about patient positioning for optimal use of the instrument. This idea was
later embellished when Abul Kasim (AD 936-1013), an Arabian physician, used a series
of mirrors to enhance illumination for inspection of the vagina and cervix.
With each generation of surgeons, surgical techniques and devices were continually
advanced and refined. Technology was limited and surgeons typically practiced new
techniques on animals, while developing new equipment, particularly light sources used
to illuminate dark body cavities. In the early 1800s, endoscopic surgery began to take on
new meaning when Philip Bonzzini (1773-1809) developed the Lichtleiter, which was a
modified light conductor made from mirrors, tin, and leather; illumination was provided by
a candle. This device was the forerunner of the modern endoscope. A French surgeon,
Antonin Jean Desormeaux (1815-1881), introduced a cystoscope that burned alcohol
and turpentine for illumination around 1853; he considered using electricity for the
device, but thought that the fuel-burning model was more portable. Desormeaux has
been referred to as the “Father of Endoscopy”. A few years later, a dentist, Julius Bruck,
developed the first internal light source composed of looped platinum wire heated to
glowing brightness by electricity. The inherent risks were obvious, because surrounding
structures were frequently burned by the intense heat. Bruck subsequently developed
a series of water-cooling covers, but these increased the size of the device, making it
awkward to handle.
It was not until the early nineteenth century when Maximilian Nitze (1848-1906), an
Austrian urologist, developed a urologic instrument that became the basis of modern
endoscopy. Nitze used the light source developed by Bruck and, assisted by an optician,
created a tri-lensed endoscope that allowed a greater field of vision with an internal
illumination source. By 1880, his cystoscope was featured in medical catalogs. Next,
the entire concept of internal illumination for endoscopy was revolutionized by Thomas
Edison’s invention of the incandescent light bulb. By 1886, miniature light bulbs were
placed in the cystoscopes for internal examination of the bladder.
In the early 1900s, Dr. Chevalier Jackson of Philadelphia further improved endoscopy by
the development of a laryngoscope and bronchoscope. Introduced in 1902, endoscopic
10
inspection of the human abdominal cavity was enhanced in 1910 by, Swedish surgeon,
Hans Christian Jacobaeus (1879-1937) when he first introduced the concept of creating a
working space by insufflating air into the peritoneum and viewing the abdominal contents
with the Nitze cystoscope.
The first use of carbon dioxide (CO2) as a means of creating a working space in the
abdomen was described by Richard Zollikofer of Switzerland around 1924. Zollikofer
demonstrated that CO2 was not explosive within the abdomen and also that it was readily
absorbed without event. Later, this was supported in the literature by a German surgeon,
Roger Korbsh. Korbsh found that the intra-abdominal pressure should be maintained
at 15 cm H2O or lower in order to avoid the physiologic complications associated with
pressure on the diaphragm. Initially, the delivery of CO2 into the peritoneal cavity was
done through the sheath for the cystoscope. Then, around 1938, a spring-loaded needle
that had been developed by a Hungarian surgeon, Janos Veress, for the purpose of
draining ascites, was used for insufflation. This needle, which is referred to as the Veress
needle, is still the preferred method of insufflation. Because CO2 is nonflammable, tubal
ligation using electrocoagulation was possible in the 1950s and then popularized by
gynecologic surgeons Raoul Palmer from France and Frangenheim from Germany.
In England in the late 1960s, Professor Harold Hopkins developed the rodless system
of rigid endoscopes that improved clarity and brightness. Hopkins traveled to Germany
to work with Karl Storz on his prototype; thus, the fiberoptic system for illumination was
born, allowing color photography of the body’s internal surface to be performed clearly.
By the late 1970s, gynecologic surgeons embraced laparoscopy and thoroughly
incorporated these techniques into their practice. In the late 1970s to early 1980s,
endoscopic surgery moved from the category of diagnostic to operative. Semm termed
his pioneering work pelviscopy; his work led to many technological advances in
instrumentation, equipment, and practices. Flexible and rigid endoscopic procedures
were also increasing for other surgical specialties. In the 1970s, orthopedic surgeons
began to develop the art or arthroscopy. The first laparoscopic-assisted appendectomy
was performed in 1977; the first recorded liver biopsy was performed in 1982. In France,
surgeons reported the first surgical laparoscopic cholecystectomy in 1987. Surgeons
in both the United States and United Kingdom, began performing these procedures
laparoscopically in 1988.
Thus, the “laparoscopy revolution” began in earnest in the United States in the late
1980s. Surgeons developed and refined techniques to perform procedures using
the laparoscope, thereby eliminating the need for a large incision. Since the 1990s,
equipment, instrumentation, surgical skills, and perioperative nursing knowledge have
markedly expanded as MIS has become a safe approach for a multitude of surgical
interventions.
Since the widespread introduction of MIS techniques in the late 1980s, current trends in
surgery are increasingly moving toward minimal access approaches, including reducing
both the size as well as the number of access sites (see Figure 4). The reduction
of the number of trocars, and therefore port site incisions, is one way to minimize
11
the invasiveness of the surgical intervention. Two emerging techniques: single site
laparoscopy (SSL) and natural orifice transluminal endoscopic surgery (NOTES) offer
patients the least invasive surgical approach. These techniques will be described in
greater detail later in this study guide.
Figure 4 – Evolution of MIP
Clinical Benefits of MIPs
The early advances in MIPs occurred long before the modern concerns of decreasing
surgical costs and reducing the patient lengths of stay. There are several factors
that contribute to the initial and ongoing success of minimally invasive surgery.8, 9, 10
Technology is often blamed for increasing health care costs; however, some medical
advances such as minimally invasive surgery, have demonstrated effectiveness in
improving the efficiency of health care, enhancing the quality of care provided, and
reducing overall expenses. The clinical advantages of MIS – smaller incisions, reduced
bleeding, decreased postoperative pain, shorter lengths of hospital stays, lower rates
of surgical site infections, and faster recuperation – are well documented. Additionally,
patients report higher quality of life scores after minimally invasive surgery when
compared to traditional, open procedures; the need for overnight stay is eliminated; and
patients are able to return to work sooner. These are benefits not only to the patients,
health care facilities, insurers, surgeons, and health care plans, but to the overall health
care economy as well (see Table 2).
12
Table 2 – Benefits of MIPs
Patient
Less scarring
Reduction in postoperative pain
Shorter recovery
Quicker return to activities of daily living and work
Decreased risk of nosocomial infection
Employers
Lower total cost of care
Employees recover and return to work faster
Improved productivity
Lower replacement and overtime costs
Surgeon
Better clinical outcomes
Improved quality of care
Differentiate and appeal to patients
Health Care Facility
Reduced costs through reduced lengths of stay
Improved clinical outcomes
Leverage for improved reimbursement
Differentiation
Growth potential
Health Care Plans
Lower medical costs
Lower disability costs
Improved clinical outcomes
Reduced total health care costs to employees
Improved clinical care
Competitive differentiation
Measurable quality improvements
Member satisfaction
The remainder of this study guide will discuss MIPs across multiple surgical specialties,
as these techniques are becoming increasingly adopted (see Table 3); this discussion
will include the various types of procedures, the rationale for their use, patient selection
criteria, and clinical results.
13
Table 3 – MIP Adoption Rates11
Procedure
Rate of MIP Adoption
Hemorrhoidectomy
9%
Colectomy
28 %
Hysterectomy
30 %
Appendectomy
82 %
Reflux Surgery
90 %
Bariatric Surgery
90 %
Cholecystectomy
95 %
Video-Assisted Thoracic Surgery (VATS)
- Pulmonary Wedge Resection
- Lobectomy
- Partial or Complete Pneumonectomy
35 %
27 %
43 %
Inguinal Herniorrhaphy
19 %
Ventral Herniorrhaphy
35 %
Support for MIPs: Medical Society Statements
Today, as MIPs continue to evolve, they are the standard of care and preferred
treatment option for many indications across multiple surgical specialties. This is
evidenced by statements from several medical societies supporting the use of MIPs,
as outlined below.
• American Society of Breast Surgeons
“A major goal of modern breast medicine is to minimize the number
of patients with benign lesions who undergo open surgical breast
biopsies for diagnosis. Image guided percutaneous needle biopsy
is the diagnostic procedure of choice for image-detected breast
abnormalities.”12
• American Society of Colon and Rectal Surgeons
“Laparoscopic colectomy for curable cancer results in equivalent
cancer related survival to open colectomy when performed by
experienced surgeons.”13
• National Comprehensive Cancer Network (NCCN)
“The NCCN guidelines recommend laparoscopic colectomy as
an option because clinical trials have shown that laparoscopic
colectomy is as good a procedure as abdominal colectomy.”14
14
GENERAL SURGERY
This section will discuss minimally invasive approaches for appendectomy;
cholecystectomy; colorectal procedures; procedures on the pancreas (resections
and pseudocysts), spleen, thyroid, and tonsils; bariatric surgery; and gynecological
procedures (hysterectomy, bilateral salpingo-oophorectomy, and colposuspension).
Appendectomy
Appendicitis is considered in the differential diagnosis of almost every patient who
presents with acute abdominal pain; furthermore, acute appendicitis is the most
common cause of an acute surgical abdomen in the United States. Therefore,
appendectomy is the most common emergency surgical procedure of the abdomen
and is performed in cases of acute appendicitis; four appendectomies are performed
for every 1,000 children annually in the United States.15, 16 The patient typically
presents with periumbilical pain followed by anorexia and nausea. The pain then
localizes to the right lower quadrant as the inflammatory process progresses to
involve the parietal peritoneum overlying the appendix. This classic pattern of
migratory pain is the most reliable symptom of acute appendicitis. Fever then
ensues, followed by the development of leukocytosis.
Laparoscopic appendectomy (LA) was first described by Semm in 1983, but
its potential has not yet been fully realized.17, 18 This is partially because open
appendectomy is not considerably more traumatic than LA and also that LA is not
driven by patient requests because it is usually an emergency procedure and thus
the surgeon determines the surgical approach.
While several prospective randomized studies have compared both open and
laparoscopic appendectomy, the overall differences in outcomes remain small.
However, the percentage of appendectomies performed laparoscopically continues to
increase (see Table 4).19
15
Table 4 – Laparoscopic Appendectomy Procedure Data, as a % of Total, U.S.,
2006-2012*20
Year
Total Procedures
% Laparoscopic
Laparoscopic
Procedures
2006
353,000
35.7%
126,000
2007
356,000
36.2&
129,000
2008
359,000
36.7%
132,000
2009
362,000
37.2%
135,000
2010
366,000
37.7%
138,000
2011
369,000
38.2%
141,000
2012
372,000
38.7%
144,000
*Note: Numbers may not add to totals due to rounding.
While LA is being performed with increased frequency, it continues to be used
selectively. The laparoscopic approach is at least as safe as the corresponding
open procedure and offers benefits in terms of lower wound infection rates and
shorter hospital stay and recovery period. Clinically, obese patients have reported
having less pain and shorter lengths of hospital stays after laparoscopic versus open
appendectomy.21 Also, patients with perforated appendicitis have reported having
lower rates of wound infection following laparoscopic removal of the appendix.22, 23 In
addition, patients treated laparoscopically have also been shown to have improved
quality-of-life scores two weeks postoperatively and lower readmission rates.24, 25
However, in comparison with open appendectomy, the laparoscopic approach involves
higher operating room costs, but these have been counterbalanced in some series by
the shorter lengths of stay.26
There are certain contraindications for LA; these include extensive adhesions,
radiation or immunosuppressive therapy, and severe portal hypertension
coagulopathies.27 Laparoscopic appendectomy is also contraindicated in the first
trimester of pregnancy.
Cholecystectomy
Open cholecystectomy has been performed for over a century, but the first
laparoscopic cholecystectomy (LC) on a human was reported in 1985.28 By 1994, LC
accounted for approximately 90% of elective procedures and has been recognized as
the standard of care since then.29 By 2005, 86% of all cholecystectomies in the U.S.
were performed laparoscopically; as noted above, projections indicate that this has
16
increased to over 95%.30 Tables 5 and 6 present procedure history and forecasts for
open and laparoscopic cholecystectomy.31
Table 5 – Cholecystectomy Surgical Procedure Volumes*
Year
OC
%
Annual
Change
LC
%
Annual
Change
Total
2005
108.0
-
669.5
2.2
777.5
-
2006
105.5
-2.3
684.0
2.2
789.5
1.5
2007
103.3
-2.4
699.0
2.0
802.0
1.6
2008
100.5
-2.4
713.2
2.0
813.7
1.5
2009
98.0
-2.5
727.8
2.0
825.8
1.5
2010
96.0
-2.0
742.8
2.0
838.2
1.5
2011
94.0
-2.1
757.4
2.0
851.4
1.6
2012
92.0
-2.1
772.3
2.0
864.3
1.5
2013
90.0
-2.2
789.0
2.2
879.0
1.7
2014
88.0
-2.2
805.0
2.0
893.0
1.6
Compound Annual Growth
Rate (CAGR)
(2005-2014)
-2.3%
-
2.1%
-
1.6%
_
* Procedure volume in thousands.
17
%
Annual
Change
Table 6 – Laparoscopic Cholecystectomy Procedure Data, as a % of Total, U.S.,
2006-2012*
Year
Total Procedures
% Laparoscopic
Laparoscopic
Procedures
2006
1,032,000
93.7%
967,000
2007
1,048,000
94.0%
985,000
2008
1,063,000
94.3%
1,003,000
2009
1,092,000
94.6%
1,020,000
2010
1,106,000
94.9%
1,037,000
2011
1,118,000
95.2%
1,053,000
95.5%
1,068,000
2012
CAGR (2008-2012)
1.6%
*Note: Numbers may not add to totals due to rounding.
Gallstone disease is the most common gastrointestinal reason for hospitalization in the
U.S.32 Cholecystectomy is performed primarily to ameliorate the morbidity associated
with gallstones in the gallbladder and/or biliary tree. A gallstone can cause symptoms
by one of two mechanisms: either it obstructs the cystic duct or common bile duct,
or more rarely, erodes through the gallbladder wall.33 However, most patients remain
asymptomatic from their gallstones.34 Although the mechanism is unclear, some patients
develop symptomatic gallstones with biliary colic due to a stone obstructing the cystic
duct.
There are contraindications for laparoscopic cholecystectomy. Absolute contraindications
include the inability to tolerate general anesthesia, refractory coagulopathy, and suspicion
of gallbladder carcinoma. Relative contraindications are primarily dictated by a surgeon’s
management approach and experience, and include previous upper abdominal surgery,
cholangitis, diffuse peritonitis, cirrhosis or portal hypertension, chronic obstructive
pulmonary disease, cholecystoenteric fistula, morbid obesity, and pregnancy.35
In a Cochrane review of randomized controlled trials comparing LC to OC published
in 2006, no difference was found in operative mortality, the rate of intraoperative
complications, or the overall rate of minor complications.36 Intraoperative complications
were reported in 30 trials and affected 0.9% of laparoscopic and 0.1% of open patients.
Approximately 2% of patients treated by laparoscopy experienced minor complications,
18
compared to 3% of patients in the open group; however, the overall risk of experiencing
any complication at all was modestly lower. Notably, the risk of bile duct injury did
not differ between the two procedures. In regard to clinical outcomes, there was no
statistically significant difference in operating time between the two procedures; however,
patients treated with LC were discharged from the hospital three days sooner and
returned to work 22.5 days sooner than the patients treated with OC. For these reasons,
LC is now the preferred surgical approach.
Colectomy
Over 500,000 surgical procedures are performed each year to treat colon diseases; the
most common procedures include partial or total colectomy, hemorrhoidectomy, and
sigmoidectomy.37 Laparoscopic and other minimally invasive procedures have been slow
to be adopted because of the relative complexity of colorectal procedures; however, while
open colectomy remains the gold standard, laparoscopy is being used more frequently.
Table 7 summarizes the near future forecast of colon procedure volumes in the U.S.
19
Table 7 – Surgical Procedure Volume Forecast in U.S., by Type of Procedure (20052014)*
Year
Partial
Colectomy
% Annual
Change
Total
Colectomy
% Annual
Change
Sigmoidectomy
% Annual
Change
Total
% Annual
Change
2005
141.6
-
11.7
-
89.0
-
242.3
-
2006
144.5
2.1
11.9
1.7
90.1
1.2
246.5
1.7
2007
147.5
2.1
12.1
1.7
91.4
1.4
251.0
1.8
2008
150.5
2.0
12.4
2.5
92.7
1.4
255.6
1.8
2009
153.7
2.1
12.7
2.4
94.0
1.4
260.4
1.9
2010
157.0
2.1
13.0
2.4
95.4
1.5
265.4
1.9
2011
160.5
2.1
13.3
2.3
96.8
1.5
270.6
2.0
2012
164.0
2.2
13.6
2.3
98.1
1.3
275.7
1.9
2013
167.5
2.1
13.9
2.2
99.5
.4
280.9
1.9
2014
170.8
2.1
14.2
2.2
101.1
1.5
286.0
1.8
CAGR
(20052014)
2.1%
-
2.2%
-
1.4%
-
1.9%
-
* Procedure volume in thousands.
20
The leading indications for colectomy include malignant conditions such as colon and
rectal cancer, as well as benign conditions such as polyps, inflammatory bowel disease,
diverticulitis, hemorrhage, ischemia, trauma, and redundancy, for example volvulus,
constipation, or rectal prolapse.
In 2006, there were an estimated 148,600 new cases and 58,000 deaths related to
colorectal cancer in the U.S.38 Colorectal cancer is the second leading cause of cancer
death in the U.S. and the fourth most common newly diagnosed internal cancer overall.
Surgical resection is the treatment option of choice for most patients with colorectal
cancer. The goals of surgery are wide resection of the involved segment of the bowel
and removal of its lymphatic drainage. Colon resections should include radical en bloc
removal of the draining lymphovascular complex, with bowel margins wide enough
to limit intraluminal and pericolic (lymphatic) recurrence. In most cases, intramural
spreading of cancer should not exceed 2 cm, but an oncologic resection of the abdominal
colon should aim at achieving proximal and distal margins of at least 5-10 cm to ensure
adequate procurement of the epicolic and pericolic lymph nodes.39
The approach toward rectal cancers depends on the location of the lesion. For lesions of
the rectosigmoid and upper rectum, low anterior resection can be performed through an
abdominal incision, followed by primary anastomosis. Surgical treatment of rectal cancer
should employ total mesorectal excision. Even for low rectal lesions, a sphincter-saving
resection can be performed safely if a distal margin of at least 2 cm of normal bowel
can be resected below the lesion, a goal that is now facilitated by end-to-end stapling
devices.40
There is increasing evidence that suggests the quality of the procedure performed to
treat colorectal carcinoma is directly correlated with the quality of the oncologic outcome;
while the majority of this evidence comes from the rectal carcinoma studies, the
correlation appears to hold true for colon cancer.41 In a study conducted by the German
Colon Cancer Study Group, the treating surgeon and the treating institution were found
to be independent variables that affected both survival and locoregional recurrence after
colon cancer resections.42 Furthermore, there is controversy regarding the routine use
of no-touch isolation for curative treatment of colon cancer because this practice is not
evidence-based; however, some sources recommend the following practices to minimize
the risk of locoregional recurrences43:
• Wide mesenteric clearance, including high ligation of all draining mesenteric
vessels;
• Minimization of trauma to the tumor during mobilization;
• Adequate proximal and distal bowel margins;
• Wide clearance of tumor in cases of contiguous organ invasion; and
• Complete and accurate intraoperative exploration.
Laparoscopic colectomy is also a surgical approach for certain inflammatory conditions
such as Crohn’s disease and diverticulitis. These inflammatory processes may result
in such severe pericolic inflammation and thickening that dissection of the mesentery
close to the bowel wall may not be possible. For these patients, it is often necessary
21
to perform a more radical mesenteric dissection in an area where the mesentery is
softer. In addition, severe inflammatory adhesions can cause the bowel to be stuck
to the retroperitoneum, thus making the usual lateral mobilization of the colon almost
impossible. In these cases, early division of the mesentery (ie, medial-to-lateral
mobilization of the colon) may provide easier access to the proper plane of dissection,
where the tissues are soft. This approach is undertaken to help minimize the risk of injury
to retroperitoneal organs.
The differences between segmental colon resections for benign disease and those
for malignancies are fundamentally important and may have a substantial effect on
outcome.44 For patients with benign colon disease, removal of the diseased portion of
the bowel in a manner that leaves uninvolved, healthy, and well-vascularized margins
should be sufficient treatment. Electrosurgical devices can reliably seal mesenteric
vessels as large as 7 mm in diameter without the traditional clamping and tying; they can
also reduce operating times during more extensive colon resections for both minimally
invasive and open approaches.
Minimally invasive colorectal surgery involves the use of several small incisions through
which a specialized camera and several laparoscopic instruments are inserted. An
insufflator is used to inflate the peritoneal cavity with carbon dioxide (CO2), thereby
creating a pneumoperitoneum that provides a working space to perform the operation.
Tilting of the operating room table in various positions during the procedure utilizes
gravity to allow the intra-abdominal organs to fall away from the area of dissection,
providing the requisite exposure that would normally be achieved through the use of
retractors in an open procedure. Intestinal resection requires laparoscopic ligation
of large vessels, mobilization and removal of a long floppy segment of colon, and
restoration of intestinal continuity. Once the colon segment has been completely
mobilized and its blood supply divided, a small skin incision is made to exteriorize the
colon, a resection and anastomosis are performed extracorporeally, and the rejoined
colon is placed back into the abdomen.45
Though the benefits are clear, they have not been as compelling when compared to the
clear advantages associated with other laparoscopic procedures. The primary reason
is that a colectomy, whether open or laparoscopic, results in a delayed return of bowel
function; although this return of bowel function occurs sooner after laparoscopic surgery,
the difference is approximately one or two days, resulting in a similar reduction in the
length of hospital stay. Additionally, the laparoscopic approach is associated with longer
operating times. Although the long-term benefits of open and laparoscopic techniques
are equivalent, the short-term benefits are distinct advantages for the patient. In practical
terms, the laparoscopic approach is associated with less pain, a faster recovery, earlier
return of bowel function, a shorter hospital stay, possible immune benefits, and smaller
scars, thereby making it the preferred method for intestinal resection.46
Most patients are suitable candidates for a laparoscopic approach; with an experienced
surgeon, even patients with a history of prior abdominal surgery are candidates. The
laparoscopic colectomy technique has a somewhat long learning curve because of
the advanced laparoscopic skills it involves. Unlike other laparoscopic procedures,
22
for example, Nissen fundoplication or cholecystectomy, colorectal procedures entail
dissection and mobilization of intra-abdominal organs in multiple quadrants. The
lack of tactile feedback during laparoscopic surgery can make tumor localization
difficult, especially if the lesion location has not been tattooed on the colon wall prior
to the procedure. It is imperative that the exact location of the tumor is known prior to
proceeding with a colectomy. Even when the lesion location has been tattooed onto the
colon, the mark can often be difficult to see, or there may be confusion regarding the
location of the tattoo in relation to the tumor (either proximal or distal), which can affect
surgical margins.47 Other factors that increase the difficulty of laparoscopic-assisted
colectomy include48:
• Operative exposure is difficult to obtain.
• It requires the control of numerous vessels encased in a fatty mesentery.
• The 2-dimensional view and loss of tactile sensation increases the risk for injury
to vital structures.
• In the presence of inflammation, mobilization of the colon becomes more difficult
and the identification of vital structures becomes less obvious.
The laparoscopic-assisted approach continues to gain popularity and has evolved to
include not only “pure” laparoscopic techniques, but also hand-assist devices. Therefore,
HALS (hand-assist laparoscopic surgery) for colorectal cancer is an important variant
of the laparoscopic approach that also merits discussion. It is considered a minimally
invasive procedure and is similar to the laparoscopic approach, but includes the
intraprocedural insertion of the hand into the abdominal cavity. However, the size of the
incision is smaller than that used in the open approach.
Hand-assisted laparoscopic surgery can be used as a bridge for surgeons who are
not completely familiar with laparoscopic techniques; even for the most experienced
laparoscopic surgeons, it is often the preferred technique for surgery involving left-sided
pathology (that is, the descending or sigmoid colon and the rectum).49 The use of a handassist device has several advantages, including50:
• A decrease in the learning curve associated with laparoscopy;
• The provision of tactile feedback for the surgeon; and
• Reduction of operating time, while still preserving many of the advantages of
laparoscopic surgery.
By combining laparoscopic surgery with the tactile feedback of a hand-assist device,
surgeons can not only reduce operating time, but also have a lower procedure
conversion rate. The technique involves making an incision the width of a hand and
placing a simple, ring-like hand-assist device to facilitate laparoscopic dissection
(see Figure 5). New hand port devices facilitate this technique without the loss of
pneumoperitoneum, which is essential for performing laparoscopic procedures. Because
an incision (usually 4-5 cm) is necessary to remove the colon specimen at the end of
a laparoscopic operation, the difference between a pure laparoscopic procedure and
the hand-assisted technique is generally a few additional centimeters (usually 3-4 cm)
of incision length. Several clinical trials have demonstrated that there is no difference
23
in patient recovery or discharge for laparoscopic versus hand-assisted techniques.51,
This technique has particular advantages with overweight or obese patients, since
larger incisions are often needed and also because of the increased risk of both wound
infection and pulmonary complications.53
52
Figure 5 – Hand-Assist Device
The latest generation of hand-assist devices allows the surgeon to insert the device at
the beginning of the procedures and then use it as either a hand port or laparoscopic
instrument port throughout the remainder of the procedure. The insertion site of the handassist device also provides a useful location for performing extracorporeal anastomosis
and removal of a bulky specimen without contamination and a separate, larger incision,
as noted above.54
At this time, there is no indication that the laparoscopic approach is associated
with poorer long-term outcomes than open colectomy, so there are very few true
contraindications; however, some conditions make the laparoscopic approach more
difficult, such as55:
•
•
•
•
Intra-abdominal adhesions from prior surgical intervention;
Bleeding disorders;
Obesity; and
Pregnancy.
Other factors that may preclude the laparoscopic approach include56:
• Patients with severe restrictive pulmonary disease – these patients cannot
tolerate the acidosis generated by the carbon dioxide pneumoperitoneum. In
addition, the restrictive pulmonary disease limits the rate of ventilation that can be
provided by the anesthesia provider.
• Patients with large, bulky lesions – in these patients, larger incisions are required
in order to obtain the specimen; therefore, it makes little sense to attempt a
laparoscopic approach.
• Gender – men may be more difficult to operate on than women due to a greater
prevalence of fat in the mesentery, regardless of overall body weight.
24
A Cochrane systematic analysis of randomized controlled trials comparing laparoscopic
and conventional colorectal resection was published in 2005.57 In terms of surgeryrelated complications, laparoscopic colorectal resection is associated with a lower rate of
total morbidity. Seventeen studies reported the incidence of wound infection; the relative
risk was also lower in laparoscopic patients. However, the incidence of intra-abdominal
abscesses was not significantly different between the two procedures. Postoperative
ileus was less frequent among patient undergoing laparoscopy. Postoperative bleeding
and mortality, though, were infrequent events under both surgical approaches, and were
reported in 16 to 17 studies respectively. In regard to other outcomes, a total of 22 trials
reported operating time with laparoscopic colorectal resection was a longer procedure by
approximately 42 minutes. Blood loss was 72 mL less in laparoscopic patients, although
the variability in this outcome was high. Pain perception on the first postoperative day
was assessed in six trials; laparoscopy was associated with a nine point lower reporting
on a 100 point visual analog scale for pain. Length of hospital say was also one and onehalf days shorter for laparoscopic patients.
In the past, concerns regarding port-site recurrences initially kept laparoscopy from being
widely accepted in the treatment of colorectal carcinoma.58 However, several randomized,
controlled studies have reported that the wound recurrence rates with laparoscopic
resections are no different from those with open resections.59, 60 Particularly significant
were the long-awaited results of the randomized, prospective trial carried out by the
Clinical Outcomes of Surgical Therapy (COST) Study Group, which found the oncologic
outcomes of open and laparoscopic surgery to be similar after a median follow-up period
of 4.4 years.61 Also noteworthy was a randomized, prospective trial from Barcelona,
which reported that cancer-related survival was actually better after laparoscopic surgery
for colon cancer than after open surgery.62 Further randomized trials are under way
in Europe and Australia. These studies have helped to lift the virtual moratorium on
laparoscopic treatment of colorectal cancer, but surgeons must be reminded that they
must first gain adequate laparoscopic experience with benign conditions of the colon
before attempting laparoscopy for malignant disease.
In regard to oncological outcomes, a recent report summarized the results of a
systematic review of randomized controlled trials by comparing the overall complication,
mortality, and recurrence rate between laparoscopic resection and open surgery for
colorectal cancer.63 Fifteen trials with 4,207 patients who reported long-term outcomes
of the overall complication, mortality, and recurrence rate were included. The combined
results of the individual trials showed no statistically significant difference in the odds
ratio for overall recurrence, local recurrence, distant metastasis, wound-site recurrence,
colorectal cancer-related mortality, colon cancer-related mortality, rectal cancer-related
mortality, and overall mortality between the laparoscopic surgery and open surgery
groups. The overall complications in the laparoscopic surgery group were much lower
than that in the open surgery group. This meta-analysis showed that the successful
laparoscopic colorectal resection for colorectal cancer was as effective as open surgery
in terms of the oncological outcomes, thereby suggesting that laparoscopic surgery can
be continued in patients with colorectal cancer.
25
Laparoscopic surgical treatment of colorectal disease has been slow to gain acceptance,
largely because the techniques are difficult to master, the procedures are longer, and
the ileus response is still not eliminated after the procedure. However, controlled studies
performed by experienced surgeons have found laparoscopy to have advantages
over open resection in terms of resolution of ileus, duration of hospitalization, level of
postoperative pain, recovery of pulmonary function, and complication rates. Studies
also suggest that there appears to be a lower incidence of surgical site complications
after laparoscopy than after open surgery, as well as a lower incidence of postoperative
adhesions.
Pancreas
The principles of traditional pancreatic surgery have always been wide exposure,
gentle tissue manipulation, preservation of blood supply, and accurate reconstruction
of the pancreatic duct.64 While minimally invasive surgery is now the preferred method
of surgical management for a variety of diseases of the gastrointestinal tract, those of
the pancreas remain some of the most challenging surgical situations encountered by
the general surgeon. However, minimally invasive techniques are now being applied to
diseases of the pancreas. With less than a decade of experience, this class of techniques
has permanently altered the surgical approach to most surgically treated diseases.
Once a patient is through the acute phase of pancreatitis, one of the later complications
is a pancreatic pseudocyst.65 In the past, surgeons operated on pseudocysts that were
6 cm or larger that persisted longer than six weeks after the episode of acute
pancreatitis.66 Current data indicate that asymptomatic pseudocysts can be safely
observed and many of them will resolve spontaneously. If the patient complains of
persistent pain, early satiety, or has weight loss due to the cyst, a minimally invasive
approach to drainage is indicated; today, a minimally invasive approach is standard.
Pseudocysts that do not have a large component of solid debris can be addressed with
endoscopic transgastric drainage. Using endoscopic ultrasound, an incision is made
through the posterior wall of the stomach into the anterior aspect of the pseudocyst; this
allows stents to be placed (typically, multiple stents are used). Another minimally invasive
technique is to place a transpapillary pancreatic duct stent; this stent can be placed into
the cyst or it can bridge the defect in the pancreatic duct to facilitate drainage into the
duodenum. In patients whom these techniques fail, or when the cyst has a large amount
of solid debris, a minimally invasive approach can still be undertaken with a laparoscopic
cystgastrostomy. This technique simulates the open surgical approach and can be
accomplished using endoscopic stapling devices.
However, not all pancreatic cysts are pseudocysts; identification of cystic neoplasms
of the pancreas are becoming increasingly common, due to the prevalence of
computerized tomography (CT) imaging.67 In the past, most surgeons were aggressive
about recommending pancreatic resection for all cystic lesions of the pancreas, except
pseudocysts; however, this strategy has recently been under consideration. Observation
is now the recommended treatment, especially for pancreatic cystic neoplasms smaller
than 2-3 cm in diameter and in the absence of atypical cells or other markers. When
resection is performed, a minimally invasive approach is gaining in popularity. As
26
discussed, it is now routine to approach many abdominal operations using laparoscopic
techniques including more complex operations such as colon resection as well as
gastric and esophageal resection. Pancreas resection is one of the most difficult types
of abdominal surgery and is complicated by several factors, including its retroperitoneal
location; intimate relationship to other organs such as the spleen, stomach, duodenum,
and bile duct; and relationship to major vascular structures, eg, the superior mesenteric
vein, splenic vein, portal vein, branches of the celiac axis, and superior mesenteric
artery. The issue of the transected pancreatic parenchyma and potential for a pancreatic
leak also complicate this procedure. However, despite these challenges, an increasing
number of reports in the literature describing laparoscopic pancreatic surgery are
beginning to appear. Laparoscopic distal pancreatectomy was approached first.
Endoscopic stapling devices have proven an effective way to control not only the splenic
artery and vein, but also the transected pancreatic margin. In addition, small series of
laparoscopic Whipple procedures are also emerging. As seen in many other types of
MIPs, reduced blood loss, less pain, and decreased length of hospital stay seem to be
emerging as potential advantages.
Splenectomy68
Splenectomy – either the total or partial removal of the spleen – is performed for
various reasons and with different degrees of urgency. Most splenectomies are
done after a patient has been diagnosed with hypersplenism, which is not a specific
disease but a syndrome. However, there are two diseases for which a splenectomy is
the only treatment – primary cancers of the spleen and the blood disorder hereditary
spherocytosis (HS). In HS, the absence of a specific protein in the red blood cell
membrane leads to the formation of relatively fragile cells that are easily damaged when
they pass through the spleen. This cell destruction does not occur anywhere in the body
and ends when the spleen is removed. HS can appear at any age, including newborns,
although doctors prefer to delay splenectomy until the child is about five to six years of
age. Splenectomy is also indicated for the following disorders:
• Idiopathic thrombocytopenic purpura (ITP). This is a disease in which platelets
are destroyed by antibodies in the body’s immune system. A splenectomy is the
definitive treatment for this disease and is effective in about 70% of cases of
chronic ITP.
• Trauma. The spleen can be ruptured by blunt as well as penetrating injuries to the
chest or abdomen. Motor vehicle accidents are the most common cause of blunt
traumatic injury to the spleen.
• Abscesses. Abscesses of the spleen are relatively uncommon, but have a high
mortality rate.
• Rupture of the splenic artery. This artery sometimes ruptures as a complication of
pregnancy.
As of 2003, there are no medical alternatives to splenectomy. In patients who are poor
candidates for surgery, splenic embolization is one alternative. Embolization involves
occluding the splenic artery with synthetic substances (eg, polyvinyl alcohol foam,
polystyrene, and silicone), in order to shrink the size of the spleen. The primary risk
27
associated with splenectomy is postsplenectomy sepsis. Mortality from postsplenectomy
sepsis is highest in children, especially in the first two years after surgery; however,
this risk can be reduced by vaccinating the child preoperatively. In some cases, a twoyear course of penicillin postoperatively, or long-term treatment with ampicillin, may
be recommended. Other risks associated with the procedure include pancreatitis and
atelectasis. For some patients, a splenectomy does not address the underlying causes of
splenomegaly or other conditions. Another potential complication is excessive bleeding
postoperatively, especially for patients with ITP. Infection of the incision immediately after
surgery may also occur.
Results of the procedure depend on the indication. In blood disorders, removing the
spleen removes the cause of the blood cell destruction. Normal results for patients with
an enlarged spleen are relief of pain and the complications of splenomegaly. However,
it is not always possible to predict which patients will respond well or to what degree.
Morbidity and mortality associated with splenectomy vary with the underlying disease
or the extent of other injuries. Rates of complete recovery from the surgery itself are
excellent, in the absence of other severe injuries or comorbidities.
In recent years, as with other surgical specialties, minimally invasive techniques for
splenectomy have been used with more frequency. However, as of 2003, a laparoscopic
procedure is contraindicated if the patient’s spleen is greatly enlarged. Most surgeons will
not remove a spleen longer than 20 cm (as measured by a CT scan) by this method. The
laparoscopic approach for splenectomy has been shown to have several benefits over
conventional open splenectomy.69 A quicker return to function, earlier discharge from the
hospital, less postoperative pain, and better cosmesis due to the smaller incisions have
been reported by multiple authors. Decreased intraoperative blood loss and transfusion
requirements have also been described.
Thyroidectomy
Traditional thyroid surgery is not a severely deforming operation but does leave a scar
in an area that, unlike chest or abdominal procedures, is visible on a daily basis.70 While
minimally invasive thyroid surgery has no formal definition, it is primarily defined by the
smaller length of the incision. As with other minimally invasive approaches, the goals of
endoscopic thyroid surgery include reduction in the length of the scar; decreased pain;
earlier discharge; and shorter recovery time. Thyroidectomy evolved since the turn of the
last century when Kocher took a dangerous procedure and improved its safety; prior to
Kocher, 40% of thyroid surgery patients died; after Kocher less than 1% died. However, at
that time, incision length was not a major concern. As the last century progressed, thyroid
goiter became less prevalent due to the addition of iodine to salt; as a result, thyroid
nodules were detected when they were smaller in sizes. As surgical techniques were also
being refined during this period, thyroidectomy incisions could therefore start to decrease
in size. In general, incisions for thyroid surgery currently vary in size based on the:
• Size of the gland (goiters need larger incisions);
• Presence of thyroiditis (inflammation increases the difficulty of the procedure); and
• Patient’s body (obesity or a short neck also increases the difficulty).
28
Minimally invasive thyroidectomy is indicated for thyroid cancers less than 2 cm;
thyroid nodules less than 3.5 cm; small goiters; and glands that are free of thyroiditis.
Contraindications (ie, conditions that require a standard incision) include:
•
•
•
•
Large thyroid goiters;
Large thyroid cancers (greater than 2 cm);
Thyroiditis; and
Thyroid cancer that has metastasized to the lymph nodes.
The first case of endoscopic thyroid surgery was described in 1997.71 In 2000, the
cosmetic results of endoscopic thyroid surgery were further improved by performing an
endoscopic thyroidectomy via an axillary and anterior breast approach.72, 73 This scarless
(ie, in the neck) endoscopic thyroidectomy (SET) attracted widespread attention due
to its very good cosmesis. The primary disadvantage of SET is the much larger plane
of tissue dissection.74, 75 In one study comparing the conventional surgical approach to
SET, the total length of the incisions and volume of blood loss in SET were significantly
lower; in addition to the superior cosmetic result, postoperative pain was significantly
less severe and rates of paresthesia and discomfort with swallowing were also markedly
lower in the patients in the endoscopic group.76
An endoscopic transaxillary approach to total thyroidectomy has also been reported,
as endoscopic neck surgery for the thyroid and parathyroid continues to be explored
as an alternative to open thyroidectomy. A recent study of 22 patients was conducted
to determine the safety and feasibility of endoscopic transaxillary total thyroidectomy
(ETTT).77 In this study of 20 females and 2 males, average age 49.3 ± 12.9 years, no
conversions to an open procedure were necessary. Mean operating time was 238 ±
72.7 minutes; average blood loss was 40 mL ± 28.3 mL; mean weight of the gland was
137.05 g ± 129.21g. The recurrent laryngeal nerve was identified with no permanent
injury. Six patients developed hoarseness of the voice for an average of 15.1 ± 8.01
days. None of the patients developed tetany or hypocalcemia requiring treatment. Six
patients experienced transient numbness in the anterior chest wall lasting two weeks
in five patients and two months in one. All patients were discharged within 24 hours of
admission. The authors concluded that while ETTT requires additional operating time
compared with the open approach, visualization of the nerve and parathyroid is improved
and it is cosmetically favorable. Although the learning curve is steep, with experience
the operative time will decrease. ETTT is a different approach, but one that is safe and
feasible.
Tonsillectomy78, 79
A minimally invasive approach to tonsillectomy – powered intracapsular tonsillectomy
(PIT) in which the tonsils are partially removed with a microdebrider – is also gaining
popularity today. Traditional tonsillectomy procedures remove the tonsil tissue
completely, thereby exposing the underlying throat muscles to bacteria and endotoxins,
thermal injury, and inflammation. These factors are believed to contribute to the severe
pain, slower recovery, and higher rate of complications associated with these traditional
approaches. However, in many cases, a near-complete removal of tonsil tissue provides
29
a safe and effective treatment, but with considerably less pain and a faster recovery.
With this technique, the surgeon can precisely remove 90-95% of the tonsils, using the
microdebrider; essentially, the tonsil is removed from the outside in, as the resection
is performed distal to the branching of the primary tonsillar vessels, thereby exposing
only the smaller branched arterioles. The thin layer of tonsil tissue that is intentionally
left intact acts as a protective shield for the delicate throat muscles, thus reducing the
amount of postoperative pain and recovery time.
The advantages of a powered intracapsular tonsillectomy include:
• Reduced postoperative pain – Because PIT protects the delicate throat muscles
from exposure by leaving a thin layer of tonsil tissue intact, the amount of pain
most patients experience postoperatively is greatly reduced.
• Faster recovery and return to normal activity – Because the throat muscles are
protected and the pain is greatly reduced, the recovery is typically twice as fast.
Children who undergo the PIT technique can expect to return to normal activity in
2.5 days; this also means parents can go back to work sooner.80
• Fewer hospital readmissions for complications – Dehydration and bleeding
are the two primary complications associated with traditional tonsillectomy
procedures. In a study comparing 150 children who underwent PIT with 162
children who had standard tonsillectomy, only one patient in the PIT group, but
five in the standard procedure group were readmitted due to dehydration; in all,
11 readmissions were needed in the standard tonsillectomy group, whereas only
two were required in the PIT group.81
One disadvantage of PIT is that because the tonsils are not completely removed, the
potential exists that the tonsils may regrow and thus need to be removed or that they
may become infected; however, the risk of regrowth does not appear to be significant.
Another disadvantage is that it may take longer to perform than total tonsillectomy;
because larger tonsils have more volume, tissue removal often takes longer to perform.
The PIT technique may be contraindicated for patients with chronic or recurrent tonsillar
infection because it obviates the risk that a patient will require additional surgery in the
future.
Bariatric Surgery
Today, an estimated 200 million adults in the U.S. (68% of the adult population) are
categorized as being overweight or obese. Obesity is the second-leading cause of
preventable death in the U.S., resulting in nearly 112,000 deaths every year; in addition,
the condition is a leading cause of type 2 diabetes, disability, and heart disease, and
is a significant contributor to the rising costs of health care. Despite the critical need
for weight loss in the majority of the adult population, research has found that diet and
exercise alone is unsuccessful in 80-85% of patients at one year; furthermore, only
approximately 1% of eligible obese people currently undergo bariatric surgery due to its
high cost and high risk of complications.82
Bariatric surgery, also called weight reduction or weight loss surgery, is the surgical
treatment of obesity; up until the 1990s, open procedures were the norm for virtually
30
all bariatric procedures; however, minimally invasive laparoscopic surgery has become
the technique of choice for bariatric procedures and some procedures have moved
to ambulatory surgery units (the historical development of bariatric surgery is briefly
summarized in Table 8).83
Table 8 – Historical Development of Bariatric Surgery
Decade
Procedural Development
1950s
Jejunoileal bypass
1960s
Jejunocolic bypass
Gastric bypass
1970s
Gastroplasty
Biliopancreatic diversion
1980s
Gastric banding
Adjustable gastric banding
1990s
Laparoscopic access becomes approach of choice
2000s
Laparoscopic-adjustable gastric band (LAGB) approved by the U.S. Food & Drug
Administration
Gastric and vagal pacing developed
Endoscopically accessed interventions evolve with implanted balloon and stapling
delivery devices
Today, the rate of MIP for bariatric surgery is 88%.84 However, while the current economic
conditions continue to restrain market growth, the U.S. market for minimally invasive
bariatric surgical devices is expected to exhibit relatively strong growth over the next
five years; the U.S. minimally invasive bariatric surgical products market is expected
to increase at a compound annual rate of 6.6%. Benefits are expected from increased
utilization of LAGB systems, the growing use of single-incision procedures, as well as
emerging incisionless technologies, such as intragastric balloons and other transorally
inserted weight loss devices, in addition to gastric stimulators or vagal blocking systems.
Minimally invasive robotic surgery is also expected to continue to significantly improve
bariatric surgical outcomes.85
There are three categories of bariatric surgical procedures:86, 87
• Restrictive – with restrictive procedures (eg, vertical gastric banding, adjustable
gastric banding, and sleeve gastrectomy), the size of the stomach is reduced,
ie, the basic anatomical structure and capacity of the stomach is altered,
without affecting the normal digestive processes; therefore, caloric and nutrient
absorption are not affected. After having this type of procedure, when the patient
eats, the food is digested and absorbed normally, but the patient feels fuller
sooner due to the smaller capacity of the stomach; therefore, he/she eats less.
31
• Malabsorptive – malabsorptive procedures (eg, biliopancreatic diversion) are
more technically complex; these procedures reduce the absorptive capacity of
the small intestine with a bypass of a segment or segments of the proximal small
bowel. As a result, the digestion process is incomplete, thereby diminishing the
amount of calories and nutrients the body can effectively absorb.
• Combination – the Roux-en-Y gastric bypass – is largely restrictive and mildly
malabsorptive. This procedure reroutes the passage of ingested food and
fluid from a small pouch created in the proximal stomach to a segment of the
proximal small bowel. Thus, the amount of food a patient can comfortably eat is
reduced (ie, restriction), and the amount of calories that can be digested in the
small intestine (ie, malabsorption) is also reduced. This combination of bariatric
methods leads to greater weight loss; therefore, the Roux-en-y procedure is seen
as one of the best ways to treat clinically severe obesity.
Obese patients typically present with serious co-existing health conditions, such as
cardiopulmonary disease, type 2 diabetes, and obstructive sleep apnea; therefore, any
patient seeking bariatric surgery must meet the following eligibility criteria in order to be a
suitable candidate88:
•
•
•
•
•
•
Is morbidly obese, complicated by medical conditions secondary to obesity;
Has a history of failed diet therapy;
Is motivated;
Is psychologically stable;
Has acceptable operative risks; and
Is well-informed regarding the procedure, recovery, and postoperative lifestyle
modifications.
Contraindications are not easily generalized, because morbidly obese patients are
usually at greater risk for any surgical procedure; however, patients at highest risk
include those89:
•
•
•
•
•
With end-stage heart and lung function;
Who are unable to ambulate;
Who weigh more than 600 pounds (272 kg);
Who are younger than late teens or older than 65 years; and
With Prader-Willi syndrome.
Hysterectomy
In women of childbearing age, hysterectomy is the second most frequently performed
surgical procedure, after cesarean section.90 The prevalence of hysterectomy procedures
in the U.S. is approximately 5.6 per 1,000 women. In 2005 alone, over 533,300
hysterectomies were performed in the U.S. In general, the surgery is considered an
elective procedure and done when less-invasive options have failed. Table 9 presents
procedure history and forecasts for abdominal, vaginal, and laparoscopically assisted
vaginal hysterectomies (LAVH).91
32
Table 9 – Hysterectomy, U.S. Procedure Volumes Forecast by Type, 2005-2014*
Year
Abdominal
Procedures
%
Annual
Change
Vaginal
Procedures
%
Annual
Change
LAVH
Procedures
%
Annual
Change
Total
%
Annual
Change
2005
404.0
-
229.5
-
101.3
-
734.8
-
2006
405.5
0.4
223.5
-2.6
110.9
9.5
739.9
0.7
2007
406.8
0.3
217.5
-2.7
120.3
8.5
744.6
0.6
2008
408.0
0.3
211.5
-2.8
130.8
8.7
750.3
0.8
2009
409.2
0.3
205.8
-2.7
141.5
8.2
756.5
0.8
2010
410.4
0.3
200.0
-2.8
152.3
7.6
762.7
0.8
2011
411.8
0.3
194.0
-3.0
162.6
6.7
768.4
0.7
2012
413.0
0.3
189.0
-2.6
174.8
7.5
776.8
1.1
2013
414.2
0.3
184.
-2.6
187.1
7.0
785.3
1.1
2014
415.5
0.3
178.0
-3.3
198.7
6.2
792.2
0.9
(CAGR)
(20052014)
0.3%
-
-2.8%
-
7.8%
-
0.8%
-
* Procedure volume in thousands.
The leading indications for hysterectomy include abnormal uterine bleeding (AUB),
fibroids or leiomyomas, endometriosis, uterine prolapse, and gynecological cancer.
In regard to gynecological cancer, malignant etiologies include cervical intraepithelial
neoplasia, endometrial adenocarcinoma, uterine sarcoma, leiomyosarcoma, and ovarian
carcinoma.
Hysterectomy is performed either via an open abdominal procedure or vaginally, using
a laparoscope.92 There are four major types of hysterectomy: total (removal of both the
uterus and cervix); total with bilateral salpingo-oophorectomy (a total hysterectomy with
removal of the ovaries and fallopian tubes); subtotal (known as partial or supracervical
because the cervix is left intact); and radical (usually performed for cancer and includes
removal of the upper portion of the vagina and pelvic lymph nodes). There are also four
categories of minimally invasive approaches: vaginal hysterectomy; laparoscopically
assisted vaginal hysterectomy; laparoscopic hysterectomy; and total laparoscopic
hysterectomy.93
Overall, hysterectomy rates vary widely in different parts of the U.S.; about 55% of
hysterectomies are still performed abdominally.94 The common factor in determining
the surgical approach to hysterectomy has been found to be the comfort level of the
surgeon with a specific procedure; this, both nation-wide and world-wide, results in a
predominance of abdominal hysterectomies.95
MIPs have been promoted as being advantageous due to shorter hospitalization and
recovery time compared to abdominal hysterectomy. However, the surgeon must be
33
experienced in the procedure before these benefits can be realized. The disadvantages
include potentially longer operating times (directly related to how much of the procedure
is performed laparoscopically), higher costs, and an increased risk of damage to the
urinary tract.
In examining outcomes between abdominal and laparoscopic hysterectomy, when
complications were compared, the evidence supported a lower risk of wound and
abdominal infections with the laparoscopic approach, along with a lower risk of an
infection of any type.96 There was also a lower risk of an operative or early postoperative
complication of any type as well as a lower risk of a major complication (eg, bleeding
and ureter injury). Laparoscopic hysterectomy patients also reported returning to work
about 13.6 days sooner. In one study, the median length of stay was three days for
laparoscopic hysterectomy patients versus four days for abdominal hysterectomy;
patients returned to work 11.1 weeks after their laparoscopic procedure, compared to
13.6 weeks after abdominal hysterectomy.97
Compared to abdominal hysterectomy, laparoscopic hysterectomy procedures are
typically longer by an average of 10.6 minutes. Laparoscopically assisted vaginal
hysterectomy is shorter by an average of 7.6 minutes.98 Within MIP subtypes, vaginal
hysterectomy is a significantly shorter procedure than laparoscopic hysterectomy
(41.5 minutes shorter on average); laparoscopically assisted vaginal hysterectomy is
significantly shorter than laparoscopic hysterectomy with uterine artery ligation (average
of 25.3 minutes).
BLADDER SUSPENSION
Despite the growing body of medical knowledge on stress urinary incontinence
(SUI), controversies over its management remain.99 SUI is the most common type of
incontinence and occurs almost exclusively in females. SUI affects approximately 16.5
million women in the United States; nearly two-thirds of these women are under 50 years
of age. Risk factors for developing SUI include:
•
•
•
•
•
•
•
Age > 60 years;
History of prior incontinence surgery;
History of pelvic radiation;
Positive standing stress test without hypermobility;
Positive standing stress test with an empty bladder;
Leakage much greater than stress load; and
Decreased tactile resistance when placing a cotton swab transurethrally.
Various treatment options have been developed to rectify the negative impact of SUI on
an individual’s quality of life, including both medical therapy and surgical procedures.100
Surgical treatment offers the highest cure rate (85-90%) when compared to medical
options; the Burch colposuspension procedure in which the bladder and urethra are
suspended, has been the gold standard for surgical treatment. This same procedure can
be done using minimally invasive techniques; however, this procedure has a significant
34
learning curve so it has not been done by the majority of gynecological laparoscopists.101
It is often done along with a paravaginal repair, where the sides of the vagina have
become disconnected from the pelvic side wall and need to be reattached to better
support the bladder.
In 1991, the Burch procedure by laparoscopic approach was described and performed
with a technique similar to conventional surgery.102 In recent years, laparoscopic Burch
colposuspension has become increasingly popular and also offers the best surgical
treatment option for genuine stress incontinence. The use of the laparoscopic technique
allows the suprapubic approach to the bladder neck without the need for laparotomy, thus
providing postoperative benefits associated with MIPs. Advantages of the laparoscopic
approach include elimination of the abdominal incision and better visual access and
exposure of the anatomic structures. The visual clarity and magnification of tissues
facilitates more precise dissection and better hemostasis. As with other MIPs, the patient
usually experiences much less discomfort and pain postoperatively, has a quicker
recovery, and shorter length of hospital stay. Postoperative complications including
wound infection, retropubic hematoma, and detrusor instability may also be reduced.
A Cochrane systematic analysis of 22 randomized and quasi-randomized controlled
trials in women with symptomatic or urodynamic diagnosis of stress or mixed
incontinence that included laparoscopic colposuspension as the intervention was
reported in 2006.103 Ten of the 22 studies involved comparison of laparoscopic with
open colposuspension. While the women’s subjective impression of cure was similar
for both procedures, with short- and medium-term follow-up, there was some evidence
of poorer results with colposuspension on objective outcomes. Trends shown indicated
fewer perioperative complications, less postoperative pain, and shorter hospital stay for
laparoscopic procedures as compared to open colposuspension; however, laparoscopic
colposuspension was more costly. Eight studies compared laparoscopic colposuspension
with newer “self-fixing” vaginal slings. While there were no significant differences in the
reported short- and long-term subjective cure rates, the objective cure rates at 18 months
favored the slings. No significant differences were observed for postoperative voiding
dysfunction and perioperative complications; however, laparoscopic colposuspension
had a significantly longer operating time and hospital stay. Significantly higher subjective
and objective one-year cure rates were found for women randomized to two paravaginal
sutures when compared to one suture in a single trial; three studies compared sutures
with mesh and staples for laparoscopic colposuspension and demonstrated a trend
towards favoring the use of sutures. The current available evidence suggests that
laparoscopic colposuspension may be as good as open colposuspension at two years
postoperatively. However, the newer vaginal sling procedures appear to offer even
greater benefits, better objective outcomes in the short term, and similar subjective
outcomes in the longer term. If laparoscopic colposuspension is performed, the use of
two paravaginal sutures appears to be the most effective method.
35
VIDEO-ASSISTED THORACIC SURGERY (VATS)
Indications and Contraindications for Thoracic MIPs104
Today, thoracic MIPs is effective as both a diagnostic and therapeutic tool for a variety of
thoracic diseases, including complex problems. General indications and contraindications
are outlined below; additional indications and contraindications identified for specific
thoracic MIS procedures also are presented.
Indications
Diagnostic indications for thoracic MIS include:
•
•
•
•
•
•
•
•
•
Undiagnosed pleural effusion;
Indeterminate pulmonary nodule;
Undiagnosed interstitial lung disease;
Pulmonary infection in an immunosuppressed patient;
To define the cell type in known thoracic malignancy;
To define the extent of a primary thoracic tumor;
Nodal staging of a primary thoracic tumor;
Diagnosis of intrathoracic pathology to stage a primary extrathoracic tumor; and
Evaluation of intrapleural infection.
Therapeutic indications for minimally invasive thoracic procedures include:
• Lung
◦◦
◦◦
◦◦
◦◦
◦◦
◦◦
◦◦
Spontaneous pneumothorax;
Bullous disease;
Lung volume reduction;
Persistent parenchymal air leak;
Benign pulmonary nodule;
Resection of a primary lung tumor (in highly selected cases); and
Resection of pulmonary metastasis (in highly selected cases).
• Mediastinum
◦◦ Drainage of pericardial effusion;
◦◦ Excision of bronchogenic or pericardial cyst;
◦◦ Resection of selected primary mediastinal tumors;
◦◦ Esophageal myotomy;
◦◦ Facilitation of transhiatal esophagectomy;
◦◦ Resection of primary esophageal tumors;
◦◦ Thymic resection; and
◦◦ Ligation of thoracic duct.
• Pleura
◦◦ Drainage of an early empyema;
◦◦ Drainage of a multiloculated effusion; and
◦◦ Pleurodesis.
36
Contraindications
Minimally invasive thoracic surgery is contraindicated in the following situations:
•
•
•
•
•
Extensive intrapleural adhesions;
The inability to sustain single-lung ventilation;
Extensive involvement of hilar structures;
Preoperative induction of chemotherapy or chemoradiation; and
Severe coagulopathy.
Thoracic MIPs Available Today
As both the numbers and types of thoracic MIPs continue to evolve, the procedures
available today are briefly described below.105
• Wedge resection – excision of a wedge of the lung that contains the malignant
tissue along with a margin of the surrounding healthy tissue. MIS wedge
resections are performed for non-small cell lung cancer or pulmonary metastasis;
for small (less than 3 cm) peripheral masses; and patients who are not
appropriate candidates for lobectomy (eg, those with pulmonary hypertension
and severe medical illnesses). It is contraindicated in patients with prior ipsilateral
thoracic surgery or radiation and in pregnant patients.
• Lobectomy – removal of an entire lobe of a cancerous lung. Most lobectomies can
be performed by VATS. A lobectomy performed by VATS should be a standard,
anatomic resection, just as the procedure performed through a thoracotomy.
The indications for VATS lobectomy include Stage 1 lung cancer; a tumor
less than 6 cm in diameter; and benign disease (eg, bronchiectasis). Relative
contraindications include a tumor 5-8 cm in diameter; preoperative irradiation or
chemotherapy; sleeve resections; and chest wall invasions. Contraindications
are tumors greater than 8 cm in diameter; mediastinal invasion; and surgeon
discomfort.
• Pneumonectomy – removal of an entire lung in order to treat the cancer. A
pneumonectomy can be performed by VATS, and the specimen usually fits
through the same size of incision that is used for a VATS-type lobectomy,
depending on the size and location of the lesion. In general, a large central tumor
is not appropriate for VATS due to involvement of the mediastinal structures.
The surgeon must ensure that the tumor is not amenable to a sleeve resection,
which may be difficult to determine by the VATS approach. Therefore, rarely is
pneumonectomy best handled by VATS.
• Sleeve lobectomy – a lung resection in which a section of bronchus or trachea is
removed along with diseased lung tissue after which the proximal and distal ends
are anastomosed. Surgeons with excellent video skills can perform a standard
sleeve lobectomy by VATS.
• Segmentectomy – removal of a segment that contains malignant tissues from a
lobe of the lung. Segmentectomy is an option for small, anatomically well-situated
lung cancer. The creation of a segmental fissure and dissecting out the segmental
vessels can be done using a thoracoscopic technique.
37
• Mediastinal and esophageal procedures:
◦◦ Mediastinoscopy. This is an important procedure for staging lung cancer.
Video-assisted mediastinoscopy has greatly improved the quality and
safety of the procedure. Node dissection can be performed with the
standard video mediastinoscope.
◦◦ Mediastinal lymph node dissection (right- and left-sided). This is a critical
part of any lung cancer procedure. Lymph node dissection should be
performed for all types of cancer resections (eg, wedge, segmentectomy,
lobectomy, pneumonectomy) to ensure proper staging and for possible
therapeutic benefit. No additional incisions are made for mediastinal
lymph node dissection; the procedure uses the existing incisions for the
video-assisted lobectomy, which usually precedes node dissection.
◦◦ Esophageal mobilization. Mobilization of the esophagus by VATS
provides the advantage of a complete cancer operation performed by
minimally invasive technique. Although most VATS procedures are
performed with the patient in the lateral decubitus position, the prone
position offers several advantages for surgery on structures in the
posterior mediastinum. For example, in the prone position, lung retraction
is not needed because gravity causes the lung to fall out of the way.
◦◦ Thymectomy. Using the VATS approach for this procedure is an excellent
technique for patients with myasthenia gravis and small (less than 4 cm)
thymomas that do not appear to invade other structures.
• Lung volume reduction surgery (LVRS) – a procedure in which nonfunctional
lung tissue in emphysema patients is removed, thereby allowing more room
in the thoracic cavity for good, relatively healthy tissue, thus improving lung
function. In comparison with medical management, LVRS can improve quality of
life, pulmonary function, exercise tolerance, and survival for selected patients.
Although LVRS can be performed by VATS or a median sternotomy with the same
morbidity, mortality, and benefits, the VATS approach costs less and provides
faster recovery. Patients who are candidates for LRVS as symptomatic, despite
maximal medical management, including oxygen supplementation, inhalers, and
pulmonary rehabilitation. Patients with severe emphysema are deconditioned;
rehabilitation reconditions the leg muscles and decreases dyspnea. Patients who
are better conditioned are better prepared to cooperate with their postoperative
care regimen, such as immediate ambulation and use of incentive spirometer,
to reduce respiratory complications. Patients who do not cooperate well or fail at
rehabilitation are poor candidates for LVRS. The most important patient selection
factor is a heterogeneous pattern of emphysema identified on CT and lung
perfusion scanning.
• Resection of pulmonary blebs and bullae. One of the earliest and most widespread
uses for VATS was in the treatment of patients with spontaneous blebs. Bleb
resection by VATS has become a standard procedure; however, this method
for pleurodesis remains controversial. Studies of treatment of spontaneous
pneumothorax have not shown that one method of pleurodesis is more successful
38
•
•
•
•
•
than another. Video-assisted resection of bullae is part of LVRS for the treatment
of end-stage emphysema.
Thoracic sympathectomy. Thoracic sympathectomy has been used for the
treatment of sympathetic dysfunction since it was first described in the 1940s;
with the advent of VATS, the procedure has become more widely applied. VATS
provides excellent visual acuity and the potential for doing the procedure more
quickly and with fewer complications. Thoracic sympathectomy is indicated
for various sympathetic disorders, but it is most commonly performed for
hyperhidrosis. Less common indications include reflex sympathetic dystrophy,
upper extremity ischemia, Raynaud’s disease, debilitating facial blushing, and
splanchnicectomy for pancreatic pain.
First rib resection for thoracic outlet syndrome (TOS). TOS refers to compression
of the subclavian vessels or the brachia plexus, or both by the first rib and
adjacent structures at the superior aperture of the chest; therefore, treatment
of TOS requires resection of the first rib. The most common symptoms are
neurologic and are related to compression of the brachial plexus in the distribution
of the ulnar nerve. While there are several approaches for TOS, the VATS
approach has several advantages. For example, the shoulder does not need to
be lifted or held for an extended period of time; the exposure is good; and the
cutaneous nerves in the axilla are not disturbed.
MIS for atrial fibrillation. Due to the technological advances in MIS instrumentation
and the increase in surgeons’ experience with VATS approaches, surgical
ablation for atrial fibrillation can now be successfully performed using minimally
invasive techniques.
Thoracoscopic approach to spinal deformities. The conventional approaches
to the spine have been posterolateral, costotransverse, and anterior; to reach
the anterior spine, anterior thoracotomy has traditionally been used. There are
several problems associated with thoracotomy, such as the long incision, rib
resection, significant rib spreading, tissue desiccation, alteration of pulmonary
and shoulder girdle function, pain, associated morbidity, and poor cosmesis. The
VATS approach presents the spinal surgeon with a minimally invasive option for
approaching the anterior vertebral column. The goals of VATS in spine surgery
are the same as for thoracotomy in reducing the surgical morbidity associated
with open procedures. In addition, the VATS approach has led to many exciting
new techniques for the treatment of disc space. Surgical instruments guided
through an endoscope, are able to gain access to the chest through 15-20 mm
ports rather than through an 8-10 inch long incision required for thoracotomy.
Diaphragmatic plication. Plication of a paralyzed diaphragm can relieve dyspnea
and substantially improve pulmonary function. The procedure is considered to be
underused and may be performed by VATS techniques. The diaphragm absorbs
the pleural fluid created daily in the pleural space; when the diaphragm is plicated
well, there is much less absorptive surface. Postoperatively, the patient may drain
a remarkably large amount of fluid through the chest tube.
39
Table 10 shows the volumes forecast for VATS procedures for 2005 through 2014.
Approximately 26,000 thoracoscopies were performed in the U.S. in 2005. The number
of these procedures is expected to increase over the forecast period at a compound
annual rate of 5.6% to reach an estimated 43, 000 in the year 2014. MIPs are expected
to be utilized in more lung procedures due to improved instrumentation and broader
acceptance of thoracoscopy by chest surgeons.106
Table 10 – Thoracoscopy (VATS), U.S. Procedure Volumes, 2005-2014107
Year
Thoracoscopy
% Annual Change
2005
26,000
-
2006
27,000
3.9
2007
28,100
4.1
2008
29,300
4.3
2009
30,700
4.8
2010
32,500
5.9
2011
34,500
6.2
2012
36,800
6.7
2013
39,500
7.3
2014
43,000
8.9
(CAGR)
(2005-2014)
5.6%
-
Patient Benefits of Thoracic MIPs
As with other minimally invasive techniques, VATS offers patients a number of important
clinical benefits when compared to open surgical procedures, such as108, 109:
• VATS is associated with a significantly lower risk (70%) of overall postoperative
complications.
• VATS only requires a number of small incisions and causes less physical injury
to the patient’s body while allowing the surgeon to perform a highly effective
procedure.
• Compared with open surgery, which typically requires four to six weeks of
recovery time, VATS patients can often return to work and resume other activities
as soon as one week after surgery.110
40
• VATS may significantly reduce postoperative pain and need for additional
treatment. Research has demonstrated that postoperative pain measured after
more than one year was reduced by 61% with VATS versus open surgery. In
addition, VATS procedures may significantly reduce the total dosage, duration,
and total administration of analgesia.
• Delivery of planned adjuvant chemotherapy may be more feasible after VATS
compared to open surgery.
CARDIAC SURGERY111, 112
Minimally invasive cardiac surgery is defined as cardiac surgery without the use of
cardiopulmonary bypass or without the use of a sternotomy for patients with coronary
artery disease; some patients can have this procedure without either one. The primary
rationale for minimally invasive cardiac surgery is to reduce the morbidity of cardiac
operations.
The traditional approach to coronary artery bypass graft (CABG) surgery, as well as
aortic and mitral valve replacements, requires a sternotomy and subsequent opening
of the chest cavity. This causes a great deal of trauma to the patient, increasing
the recovery time as well as the level of pain the patient experiences. Unlike the
traditional approach, which involves a 10-12 inch incision and placing the patient on the
cardiopulmonary bypass machine, new minimally invasive approaches may avoid placing
the patient on this machine and can be performed through a smaller 3-5 inch incision,
made between the ribs, or may be done with several small incisions. Endoscopic bypass
procedures, which are still in development, are performed through small incisions,
approximately 1-2 inches long. The potential benefits of minimally invasive coronary
artery bypass surgery include:
• Decreased length of hospital stay – because patients experiences less pain and
therefore are able to cough and breathe deeply postoperatively, they are often
discharged from the hospital in two to three days, as compared to the typical five
to ten days for conventional CABG surgery.
• Quicker recovery – avoidance of the cardiopulmonary bypass machine and the
use of smaller incisions may reduce the risks of complications such as stroke and
renal failure; as a result, patients can return to their normal activities in two weeks
rather than the typical six to eight weeks with conventional surgery.
• Reduced bleeding and blood trauma – avoidance of cardiopulmonary bypass
eliminates the need for systemic anticoagulation and administration of blood
products and also reduces hemolysis. All of these factors may adversely affect
the blood’s ability to clot after surgery.
• Reduced rate of infection – a smaller incision results in less exposure and
handling of tissue, which may reduce the risk of infection.
• Increased patient indications – some patients are poor candidates for traditional
bypass surgery because their illness is too advanced, their heart is too weak,
they have multiple comorbidities, or because they will not accept blood products.
41
Therefore, some patients are able to receive this life-saving surgery through
minimally invasive techniques.
• Decreased costs – the cost of minimally invasive cardiac surgery may be
approximately 25% less than the cost of traditional bypass surgery.
As with minimally invasive CABG, minimally invasive heart valve procedures also result
in less pain for the patient, a shorter hospital stay, and a quicker recovery time; there is
also less bleeding and potential for infection.
ORTHOPEDIC SURGERY (rotator cuff, knees, & hips)
Orthopedic surgery is a dynamic, ever-changing specialty; technological advances in
the multitude of instrumentation, hardware, and systems have resulted in the improved
treatment of orthopedic disorders.113 This section will focus on MIPs in rotator cuff repair
and total knee and hip arthroplasty.
Rotator Cuff Repair
The majority of rotator cuff tears occur through the insertion of the tendinous fibers
of the supraspinatus muscle that attaches onto the greater tuberosity of the proximal
humerus.114 Supraspinatus syndrome, also known as impingement syndrome, can
involve several pathologic conditions, including calcium deposits, bicipital tendonitis,
subacromial bursitis, tenosynovitis, and other nonarticular lesions along with a cuff
tear. Partial rotator cuff tears and impingement syndrome typically affect people in the
middle decades of life or later; these conditions are often attributable to aging and the
degenerative process. Complete rotator cuff tears are the result of accidental injuries in
younger patients, typically those who engage in sports, eg, quarterbacks and pitchers.
The method of treatment depends upon the size and shape of the tear; many can be
treated conservatively with physical therapy and non-steroidal anti-inflammatory drugs.
Surgery may be performed when conservative treatment is unsuccessful. The goals of
any treatment option are the restoration of joint stability, pain relief, and return to normal
activities of daily living.
Traditionally, surgical repair of a torn rotator cuff has been performed through an open
or mini-open approach that requires a 1.5-4 cm incision, with a slow recovery period
and significant postoperative pain.115 Today, surgical techniques for rotator cuff repair
have progressed to more minimally invasive procedures, facilitated by improved
instrumentation. As a result, repair with a minimally invasive technique is making a
dramatic difference in postoperative pain and comfort, while providing excellent results.
With each advance in technique, surgeons experience a learning curve to master
the new technique.116 Initially, some tears were considered too large to be treated
with minimally invasive techniques. As surgeons become more experienced in using
less invasive techniques, they are better able to treat most tears with a less invasive
approach. The most recent development is the all-arthroscopic technique. Each step
toward less invasive surgery has benefited the patient by reducing:
• Surgical blood loss;
• Postoperative pain;
42
• Postoperative stiffness; and
• Length of hospital stay.
As noted, some people with rotator cuff disease do not require surgical treatment, but
when surgery is indicated most patients are candidates for arthroscopic repair of rotator
cuff tendon tears.117 While arthroscopic surgery does represent a viable option for many
patients with rotator cuff injury, some patient considerations are contraindications; these
include a long-standing tear accompanied by arthritic changes, previous infection, and
nerve or muscle damage. Therefore, the decision on how to treat rotator cuff tears is
based on the patient’s severity of symptoms, functional requirements, and presence of
other illnesses that may complicate treatment.118
Total Knee Arthroplasty
Total knee arthroplasty is performed for individuals with a painful, disabling, degenerative
joint that is no longer responsive to conservative therapy in order to restore motion of the
joint and function to the muscles and ligaments.119
Over 542,000 people undergo this procedure annually.120 The goal of knee replacement
is to provide a pain-free knee that allows relatively normal activities and lasts for a long
time. To achieve these goals, it is important that the knee implants be inserted with
proper positioning. The bones and ligaments are prepared very carefully to allow the
knee to be functional and durable. Using the current techniques, 90% to 95% of knee
replacements last 15 years or longer.
Minimally invasive total knee replacement involves the use of a smaller incision than the
one used in traditional knee replacement, which typically averages 8-10 inches in length.
In minimally invasive knee surgery, the incision is only 4-6 inches long.121 Because there
is less damage to the tissue around the knee, patients who undergo this procedure may
expect a shorter hospital stay, a shorter recovery, and improved cosmesis. While there is
no doubt that an artificial knee can be implanted through a smaller incision, controversy
still exists among surgeons as to whether it can be done as well as with the traditional
approach. Today, however, new techniques for opening the knee may be more important
than the length of the incision. For example, some techniques are “quadriceps-sparing”
because they protect the quadriceps tendon and muscle in the front of the thigh. Other
techniques, ie, “mid-vastus” and “sub-vastus” still create small incisions in the muscle but
are also less invasive.
Several early studies of minimally invasive knee replacement surgery have shown some
benefits compared with traditional knee replacement, such as less blood loss, shorter
hospital stay, and better motion. However, other studies have shown a higher rate of
complications with minimally invasive knee surgery, including poorer positioning of the
knee implants.122
Total Hip Arthroplasty123, 124
Total hip arthroplasty is also a common orthopedic procedure, performed on patients with
hip pain due to degenerative joint disease, rheumatoid arthritis, or avascular necrosis.
Furthermore, as the population ages, it is expected to become even more common to
relieve pain and improve mobility.
43
Minimally invasive hip arthroplasty procedures allow the surgeon to replace the hip
through one or two small incisions. Candidates for MIPs are typically thinner, younger,
healthier, and more motivated to have a quick recovery compared with patients who
undergo the traditional surgery. Minimally invasive hip arthroplasty procedures, similar
to open procedures, are technically demanding; therefore, they require that the surgeon
and operating team have considerable experience.
The implants used for minimally invasive hip arthroplasty are the same as those used
for traditional hip replacement; however, specially designed instruments are needed to
prepare the socket and femur and in order to properly place the implants. The surgical
procedure is similar, but there is less soft-tissue dissection. A single minimally invasive
hip incision may measure only 3-6 inches, but is dependent upon the size of the patient
and the difficulty of the procedure. The incision is usually made over the outside of the
hip. The muscles and tendons are dissected, but to a lesser extent than in the traditional
hip replacement procedure; these muscles and tendons are routinely repaired after
the implants are in place to promote healing and help prevent dislocation of the hip.
Two-incision hip arthroplasty involves making a 2-3 inch incision over the groin for
placement of the acetabular cup and a 1-2 inch incision over the buttock for placement
of the femoral stem. To perform the two-incision procedure, the surgeon may need
fluoroscopic guidance; operative time may be longer for this procedure than for traditional
hip arthroplasty.
The reported benefits of less invasive hip replacement include:
• Reduced postoperative pain;
• More cosmetic incisions;
• Less muscle damage;
• Shorter lengths of hospital stay; and
• Faster rehabilitation.
For traditional hip replacement, the hospital stay averages four to five days. Many
patients need extensive rehabilitation afterward. With less-invasive procedures, the
hospital stay may be as short as one or two days; some patients may be discharged the
day of surgery.
EMERGING TECHNIQUES THAT ENHANCE MIPs
Technological advancements that support and enhance MIPs have the potential to further
revolutionize the practice of surgery in almost every specialty. Since the widespread
introduction of minimally invasive techniques in the late 1980s, current trends in surgery
are increasingly moving toward minimal access approaches, including reducing both
the size as well as the number of access sites. The reduction of the number of trocars,
and therefore port site incisions, is one way to minimize the invasiveness of the surgical
intervention. Three developing techniques that support MIPs: single site laparoscopy
(SSL), natural orifice transluminal endoscopic surgery (NOTES), and robotics are
described in greater detail below.
44
Single Site Laparoscopy
Single site laparoscopy (SSL) is an innovative approach to MIPs. SSL may also be
referred to as laparoendoscopic single site surgery (LESS) and single-port-access (SPA)
surgery. Traditional laparoscopic surgery enables surgeons to perform minimally invasive
procedures through three to five small incisions in a patient’s abdomen, through which
the endoscope and instrumentation are inserted. Single site laparoscopy involves making
one small incision (about 2 cm) in the umbilicus area and inserting multiple instruments
through a single deployment device.
SSL is currently being used in various general surgery (eg, gall bladder, hernia,
spleen, colorectal), gynecologic, and urologic procedures.125 While the multidisciplinary
applications of SSL are expanding, the potential significance of the technique is yet
to be recognized. Safety and efficacy studies of SSL are currently underway in many
institutions. The technique has potential incremental advantages over traditional MIS for
cosmesis, wound infection, postoperative pain (especially in upper abdominal surgery),
and recuperation. Specialized disposable and reusable instruments are being produced
to facilitate SSL; however, no major capital expenditures are required. Many advanced
laparoscopic procedures are being performed via SSL using traditional laparoscopic
instruments, thus keeping costs competitive with those for traditional MIS. Traditional
laparoscopic two-handed dissection, ablation, and suturing techniques are also utilized,
so surgeon training in SSL should be a much easier transition than that which occurred
from open surgery to traditional laparoscopic surgery in the early 1990s. Most procedures
are currently being performed using a 5 mm camera trocar and two 5 mm working
trocars, all introduced through a single access device in one periumbilical incision.
Specialized equipment for SPA surgery falls into two broad categories: access ports
and hand instruments. A typical SSL access port consists of two 5 mm seals and a
larger 15 mm seal in a low profile design that allows surgeons to use a wide variety
of instrumentation (eg, straight, angled, curved) across several different procedures.
Some of these devices are available with 360 degree rotation of the seal cap, which
enables quick re-orientation of instruments during procedures and reduces the need
for instrument exchanges. Standard hand instruments are rigid in design and were
developed over the last 30 years for use in laparoscopy. Articulation is designed to
overcome one of the challenges inherit in SSL, decreased triangulation of instruments.
A number of factors influence a surgeon’s decision to use standard or articulating hand
instruments including which access port they use, their own surgical skills, and cost as
articulating instruments are significantly more expensive than standard instruments.
NOTES126, 127
Another advanced minimally invasive technique is NOTES: natural orifice transluminal
endoscopic surgery, in which the surgeon operates almost exclusively through a single
entry point, for example, the mouth, vagina, or rectum. This technique, which is presently
experimental and being studied at research hospitals and facilities around the world,
has the potential for more significant improvements in cosmesis, skin infections, hernias,
postoperative pain, and recuperation. NOTES must, however, be distinguished from
fully endoluminal, natural orifice surgery (NOS), such as cystoscopic, colonoscopic,
45
transanal, and endoscopic procedures performed within a hollow structure. The NOTES
technique, by contrast, is designed to produce an opening in an unrelated organ which
must be safely and reliably repaired at the conclusion of the procedure. In NOTES, a
highly specialized, sophisticated instrument is passed through an incision in the stomach,
vagina, bladder, or colon to access the peritoneal cavity, thus increasing the potential
severity of complications as a result of this entry method. Animal studies are underway
in many institutions to evaluate the risks of this type of transluminal entry and develop
the optimal endoscopic closure technique along with the ideal endoscopic vehicle and
instrumentation. It is widely recognized that substantial technological development and
years of experience in dedicated centers will be needed to evaluate and perfect the
NOTES technique. As the instrumentation evolves, safety and efficacy studies will be
needed, followed by extensive outcome studies comparing NOTES results with those for
traditional MIS.
It is apparent to see why the NOTES technique has the potential to reduce or even
eliminate some of the complications associated with surgical and/or invasive procedures.
Patients would realize the benefits of less invasive surgery by decreased recovery time;
less physical discomfort associated with traditional procedures; and have virtually no
visible scarring postoperatively.128
Surgical site infection is always a risk for the surgical patient. The skin is the most
common source for bacterial surgical site infections; therefore, clinicians hypothesize
that the absence of transabdominal incisions with a NOTES approach may decrease
postoperative infections.129 An early NOTES trial following an incompletely closed
gastrotomy found an intra-abdominal abscess and suppurative peritonitis, though not
involving a skin infection; this highlights the critical significance of the viscerotomy
closure.130 Most early animal (swine) NOTES studies do not show a high rate of
postoperative intra-abdominal infections; however, the rate of intra-abdominal infection
has not been studied in large trials. While abdominal wall infections should not be seen
with NOTES procedures, it is not clear whether the overall postoperative infection rate
will be decreased.
46
Robotics131, 132
Robotic technology has also transformed MIPs. Robotic systems enhance the surgeon’s
dexterity – the use of specialized instruments with increased degrees of freedom
greatly improves the surgeon’s ability to manipulate instruments and tissues. Other
important advantages include the restoration of proper hand-eye coordination and an
ergonomic position. Essentially, a robotic system eliminates the fulcrum effect, thus
making instrument manipulation more intuitive. With the surgeon sitting at a remote,
ergonomically designed workstation, the systems currently available eliminate the
need for him/her to twist and turn in awkward positions in order to manipulate the
instruments and/or visualize the monitor. The enhanced vision provided by a robotic
system is also noteworthy. The 3-dimensional view with depth perception is a significant
improvement over the conventional laparoscopic camera views. Another advantage is
the surgeon’s ability to directly control a stable visual field with increased magnification
and maneuverability. All of this creates images with increased resolution that, combined
with the increased degrees of freedom and enhanced dexterity, greatly enhances
the surgeon’s ability to identify and dissect anatomic structures and also to perform
microanastomoses.
Robotic systems do, however, have some disadvantages, including:
• Cost. For many institutions, the startup and ongoing costs of a system may be
prohibitive. In addition, the costs associated with system upgrades, depending
on how much needs to be updated and how often, may also be significant. For
many facilities, in order to justify the purchase of a robotic system, they must gain
widespread multidisciplinary use.
• Size. A robotic system requires adequate space for the additional equipment and
personnel; most systems are relatively large and have somewhat cumbersome
robotic arms. This is an important disadvantage in today’s already crowdedoperating rooms. Miniaturizing the robotic arms and instrumentation will address
the issues related to their current size. In many cases, larger operating suites with
multiple ceiling-mounted booms and wall mountings will be needed to consolidate
the equipment and accommodate the additional space requirements of robotic
surgical systems.
• Lack of compatible instruments. Lack of certain instruments increases the
reliance on assistants to perform part of the procedure; however, this is a
temporary disadvantage because new technologies continue to be developed to
address these shortcomings.
• Procedural revisions. Many standardized procedures will need to be revised in
order to be adapted to robotic technology.
• Learning curve and time required for training.
In regard to outcomes, the results of analyses of both cost and safety outcomes
associated with robot-assisted laparoscopic hysterectomy were recently reported. In
one study, the clinical and economic outcomes (ie, hospital costs) for women over 18
years of age undergoing laparoscopic hysterectomy performed with and without robotic
assistance in inpatient and outpatient settings were compared; the association between
47
robot-assisted hysterectomy and adverse events, hospital costs, surgery time, and length
of stay were examined.133 Of the 36,188 patient records analyzed from 358 hospitals,
95% (n = 34,527) of laparoscopic hysterectomies were performed without robotic
assistance. Inpatient and outpatient settings did not differ substantively in frequency
of adverse events. For cardiac, neurologic, wound, and vascular complications,
frequencies were less than1% for robot and non-robot procedures. In both inpatient
and outpatient settings, use of robotic assistance was consistently associated with
statistically significant, higher per-patient average hospital costs: inpatient procedures
with and without robotic assistance cost $9,640 versus $6,973, respectively; outpatient
procedures with and without robotic assistance cost $7,920 versus $5,949, respectively.
Inpatient surgery times were significantly longer for robot-assisted procedures, 3.22
hours compared with non-robot procedures at 2.82 hours. Similarly, outpatient surgery
times with robot averaged 2.99 hours versus 2.46 hours for non-robot procedures.
These findings reveal little clinical difference in terms of perioperative and postoperative
events. This, combined with the increased per-case hospital costs of the robot, suggests
that further investigation is warranted when considering this technology for routine
laparoscopic hysterectomies.
In another prospective matched case-control study at one institution, perioperative data
from the initial 40 consecutive total robot-assisted hysterectomies for benign indications
were recorded and matched 1:1 with total laparoscopic hysterectomies according to
age, body mass index (BMI), and uterus weight.134 Surgical costs were calculated for
both procedures. Surgeons’ subjective impressions of robotics were evaluated with a
self-developed questionnaire. The results indicated that no conversions to laparotomy
or severe perioperative complications occurred. Mean operating time was 109 minutes
for the robotic group and 83 minutes for the conventional laparoscopic group. Mean
postoperative hospitalization for robotic surgery was 3.3 days versus 3.9 days for
the conventional laparoscopic group. The average surgical cost of a robot-assisted
laparoscopic hysterectomy was 4067 euros compared to 2151 euros for the conventional
laparoscopic procedure at this institution. For the robotic group, wider range of motion
of the instruments and better ergonomics were considered to be an advantage, and
lack of direct access to the patient was stated as a disadvantage. This study concluded
that robot-assisted hysterectomy is a feasible and interesting new technique with
comparable outcomes to those of total laparoscopic hysterectomy. Operating times of
total laparoscopic hysterectomy seem to be achieved quickly, especially for experienced
laparoscopic surgeons. However, the costs of robotic surgery are still higher than for
conventional laparoscopy. Therefore, randomized clinical trials need to be conducted
to further evaluate benefits of this new technology for patients and surgeons and also
analyze its cost-effectiveness in gynecological surgery.
48
SUMMARY
Historically, surgery was performed through traditional, open incisions. As a result of
the ingenuity and efforts of many pioneering surgeons, minimally invasive surgical
techniques were born. Over the past several decades, numerous technological
advances have dramatically expanded these approaches since the early, rudimentary
endeavors. With the advent of minimally invasive techniques, many procedures in almost
every surgical specialty are performed through small incisions and are more effective
treatment options for the patient. Today, emerging techniques such as SSL and NOTES
offer exciting new treatment options for many patients. Compared to open surgical
procedures, MIPs offer distinct benefits for the patient including decreased postoperative
pain, less trauma to the tissues, a shorter recovery period and length of hospital stay,
and potentially lower risk of infection. Perioperative personnel must continually work to
acquire and update the requisite knowledge and skills in order to safely integrate the
latest techniques for MIPs into their daily practice. Through the enhancement of technical
expertise, the surgical team can assist in the evolution of minimally invasive surgery and
maximize the benefits of the latest MIPs to ultimately promote optimal patient outcomes.
49
Glossary
Laparoscopy
Endoscopic examination of the peritoneal body
cavity through a percutaneous access portal,
placement of expansion medium to create
a working space, and manipulation of intraabdominal organs.
Minimally Invasive Procedures
(MIPs)
Surgical procedures performed through small
incisions or the natural orifice using video cameras
and specialized instrumentation; often referred to
as the laparoscopic approach.
Natural Orifice Transluminal Endoscopic Surgery (NOTES) An advanced minimally invasive surgery technique in which the surgeon operates almost exclusively
through a single entry point, typically the patient’s
umbilicus, mouth, or vagina.
Pneumoperitoneum
The state of the peritoneal cavity being filled with gas, often induced for diagnostic or therapeutic
purposes.
Single Site Laparoscopy (SSL)
The use of one incision, rather than several
incisions, to insert laparoscopic instrumentation.
Also referred to as LESS: laparoendoscopic singlesite surgery and SPA: single port access.
Trocar
A surgical instrument that consists of a sheath
with a sharp (or blunt) obturator used to puncture
or penetrate multiple layers of tissue. The sheath
remains in place as the obturator is removed.
Additional instruments are passed through the
sheath.
50
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