The surgical world had a real revolution with the start of laparoscopic era, in fact it was huge, but it was almost 30 years ago, and now many surgeons are looking for the next step, something different, or just even through more minimal access. Several new surgical access modalities appear eager to hold the title as the major breakthrough. NOTES (Natural Orifice Translumenal Endoscopic Surgery), the one promising to be a scarless technique, was the most attractive. But NOTES has just become feasible as a result of a huge effort and investment of the surgical and medical community as well as the industry. Unfortunately several technical limitations, including major security issues, have compromised its development in the speed surgeons and industry have expected. But this effort was not in vain, and at least had favored the revival of philosophical concepts in new areas of minimal access that have been long forgotten, and have also forged the need to reinvent surgery and surgical access.
“The question is whether it is worth sacrificing safety for the sake of cosmesis, which is the only proven advantage of single port so far.”
From natural openings (NOTES), we moved towards natural scars. Surgeries are now performed with only one access – called single port, single incision or simple, single access – preferable at the umbilicus. It is amazing why no one has thought of this before. The concept of the original scar has a strong appeal, even as it remains the best gateway to regular laparoscopy itself. The problem is that single port is not really easy to perform and you need new surgical training to master this new access modality—the surgeon needs to sacrifice the original thinking of laparoscopy, such things as triangulation, visualization, and dexterity. The question is whether it is worth sacrificing safety for the sake of cosmesis, which is the only proven advantage of single port so far.
Considering that surgeons still want to do better, in terms of less trauma, less scars, less pain, but keeping the same standards of safety, some would find the answer in the robots, but that option certainly adds to surgery a totally new dimension in costs, that practically puts many, including the whole 3rd world out of the game. In that scenario mini, which keeps costs as well as safety standards at the same level that we have with mature laparoscopic surgery is possibly be the best response for performing a better surgery without needing to be trained in a totally new technique. In summary, mini is not only needed but desired by surgeons who want to offer a better result, without the need to be trained exhaustively in a totally new technique, with reasonably modest investment in terms of cost, while maintaining a safety profile that is as least as good as the conventional laparoscopy.
We were first exposed to the new mini technique in the late 90’s when Dr. Peter Goh came to introduce mini in Brazil. Soon we fell in love with the very promising new technique, but at that time mini trocars and instruments were mostly disposable, and quite expensive, and worse, we needed to import them. In 2002, we started to have difficulties finding the right mini instruments, and in particular, mini-trocars, to work. Trying to find a way to keep mini going, we looked for a “garage-made” trocar, to provide at least the same pattern as the mini disposables. We found a company that was making hand-made custom spare parts for imported cars, and as luck would have it, they could make some trocars for us. Unfortunately, for them it was technically impossible to make a proper trocar with all the valves and seals. So we gave them the idea to make the trocar, just like a big needle, with an internal diameter really close to the forceps diameter, making the gap between the forceps and trocar the smallest possible. We also demanded that they make the trocar a little longer, so that thosetwo modifications would possibly compensate the lack of valve and sealing minimizing the gas loss – to our surprise, we accidentally invented the first low friction trocars – and even more astonishing, we were doing surgery with the new low friction instruments in a way far better than with the original ones. The low friction trocars were really a game changer for us, allowing us to tie knots and dissect tissue with an unmatched dexterity and precision.
Gustavo Carvalho, M.D. presented mini-laparoscopy techniques at MIS Week 2015 and is due to further present to surgeons at this year’s MIS Week conference in Boston.