7. Significance of Minimally Invasive Surgery, Common Surgical Techniques

I. Minimally Invasive Surgery

• Minimally invasive surgery (MIS): Techniques used to operate with less body-wall and tissue damage than open surgery
• Access: Small incisions, natural orifices or percutaneous needle/catheter routes
• Instruments: Camera/endoscope/image guidance + long or robotic instruments
• Goal: Same surgical/oncological result → Less operative trauma and faster recovery
• Use MIS only if surgical safety and oncological radicality are not compromised

II. Laparoscopic Procedure

• Laparoscopy: Minimally invasive access to the peritoneal cavity using trocars, camera and long instruments
• Gas: CO2 → Non-flammable, soluble, creates working space

Steps

1. General anesthesia
2. Access to peritoneal cavity: Trocar or Veress needle through abdominal wall
3. Pneumoperitoneum: CO2 insufflation → Increased intra-abdominal pressure → Abdominal contents visible + operative space
4. Laparoscope: Inserted through trocar → Inspect abdominal cavity → Create other ports under vision
5. Operation: Dissection, hemostasis, resection/reconstruction with laparoscopic instruments

• Conversion to open surgery: Safety decision if bleeding, poor visibility, unclear anatomy, adhesions or patient condition make MIS unsafe

III. Advantages, Disadvantages and Contraindications

Advantages

• Smaller wound/scar → Better cosmetic result
• Less contamination and tissue trauma → Fewer wound infections, wound-healing problems and incisional hernias
• Less postoperative pain → Less opioid need
• Early mobilization → Less thrombosis, atelectasis and pneumonia
• Faster rehabilitation → Shorter hospitalization and earlier return to normal activity
• Less intraoperative blood loss in many procedures
• Magnified view → Better visualization of fine anatomy
• Earlier oncological therapy may be possible after faster recovery

Disadvantages / Limitations

• 2D image in conventional laparoscopy → Loss of normal spatial view/depth sensation
• No direct palpation and reduced tactile feedback
• Longer operation time in learning curve or complex cases
• Requires special equipment, trained team and experience
• Higher cost, especially robotic surgery
• Access injury risk: Bowel, vessel or bladder injury
• Some cases require conversion to open surgery

Contraindications

• Cardiorespiratory insufficiency: Cannot tolerate general anesthesia or pneumoperitoneum
• Hemodynamic instability: Often needs rapid open source control
• Third trimester pregnancy: Large uterus + physiology make laparoscopy difficult; relative in expert hands
• Portal hypertension / liver cirrhosis: Varices, ascites and coagulopathy → Bleeding risk
• Severe coagulation disorder: Correct before elective surgery if possible
• Surgical CI: Severe bowel distension, extensive adhesions, previous extensive operation, huge tumor or unclear anatomy

IV. Common MIS Techniques and Procedures

Laparoscopic Abdominal Surgery

• Cholecystectomy, appendectomy
• Hernia repair: Inguinal TAPP/TEP, ventral/incisional hernia in selected cases
• Anti-reflux procedures, hiatal hernia repair, gastrectomy
• Bariatric surgery: Sleeve gastrectomy, gastric bypass
• Colorectal cancer surgery, colectomy, rectal resection
• Adrenalectomy, nephrectomy, splenectomy
• Selected liver and pancreatic operations

Robotic-Assisted Surgery

• Surgeon controls robotic arms from a console
• Advantages: 3D vision, tremor filtering, articulated instruments, precision in narrow spaces
• Uses: Prostatectomy, gynecologic oncology, colorectal cancer, hiatal hernia repair

Thoracoscopic Surgery / VATS

• VATS: Video-assisted thoracoscopic surgery through small thoracic ports
• Uses: Lung wedge/lobectomy, pleural biopsy, pneumothorax repair, thymectomy

Endoscopic Surgery

• Uses natural orifices, e.g. GI tract or airway
• Examples: Polypectomy, GI bleeding control, EMR/ESD, ERCP with stone extraction/stent

Image-Guided / Interventional Radiology

• Percutaneous biopsy and abscess drainage
• Angioplasty/stenting, embolization for GI bleeding or tumors
• Biliary/urinary drainage and selected tumor ablation

NOTES

• NOTES: Natural orifice transluminal endoscopic surgery, e.g. transvaginal or transgastric access
• Avoids external incisions but remains limited/partly experimental