Minimally invasive surgery

Revisado por Prof. Cathy Jackson, MRCGPÚltima actualización por Dr Laurence KnottÚltima actualización 14 Jan 2013

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Synonyms: keyhole surgery, laparoscopic surgery

This involves procedures performed by entering the skin via small incisions or by a body cavity, with two aims:

To produce the least possible damage to structures.
At the same time, to achieve the same result as if performed by open or more invasive surgery.

Specialist equipment is required, including fibre optics, camera and equipment with handles.

Antecedentes¹

The use of light-containing probes to view internal cavities has a long history. Philip Bozzini (1771-1809) a German-born urologist, was the earliest deviser of such equipment which was called the 'Lichtleiter' and was primarily used to examine the vaginal cavity. In 1877 Maximilian Carl-Friedrich Nitze produced the first workable cystoscope; this was also the first instrument with a mechanism to light the inside of an organ. In 1929 Heinz Kalk, a German gastroenterologist, used laparoscopy to diagnose hepatobiliary disease.

30 years later the automatic insufflator was invented and used to perform an appendectomy as part of a gynaecological procedure. However, it was not until the early 1980s that laparoscopic procedures began to be performed on a regular basis in the USA and, subsequently, the UK, leading to regulation regarding procedure and training aspects.

Recent advances include the use of robotic-assisted surgery²and single-point entry laparoscopy.³

Advantages and disadvantages of minimally invasive surgery

Advantages

Disadvantages

Less expensive.

Shorter duration of hospital stay.

Less trauma to the patient.

Less pain.

Less blood loss.

Smaller skin scars.

Becoming more common for major surgical procedures - eg, cardiac surgery.

Requires special equipment.

Specialist training is required.

Equipment is more expensive.

Some procedures, especially the latest ones, may take longer.

Some complications can be masked - eg, biliary peritonitis.

Patient suitability

Not all patients will be suitable for minimally invasive procedures. For example, raised body mass index, previous abdominal surgery leading to adhesions or other underlying medical conditions may affect the decision on whether to proceed towards more invasive surgery.

Types of procedures performed using minimally invasive surgery⁴

Body system	Procedures performed
Cardíaco	Closing atrial septal defects. Coronary artery bypass graft ('off pump'). Repairing patent foramen ovale. Valve surgery.⁵
Gastrointestinal	Appendicectomy. Adrenalectomy. Cholecystectomy. Lymph node biopsy. Splenectomy. Hiatus hernia, umbilical and inguinal hernia repairs. Colonic cancer. Enfermedad diverticular. Enfermedad inflamatoria intestinal. Rectal prolapse. Dividing adhesions.
Gynaecological	Polipectomía. Sterilisation. Endometrial ablation. Fibroid removal.
Neurológico	Removal of pituitary tumours. Treatment of intracranial aneurysms. Carotid angioplasty. Radiosurgery for brain tumours.
Orthopaedic	Arthroscopy of joints. Carpal tunnel release. Pelvic fracture repair. Rotator cuff repair.
Otorhinolaryngology	Removal of nasal/sinus tumours. Lymph node biopsy.
Respiratory/Thoracic	Lung surgery. Recurrent pleural effusions.
Urología	Biopsia. Removal of kidney and ureteric calculi. Nephrectomy.⁶
Vascular	Stenting carotid and renal arteries. Repair of thoracic and abdominal aneurysms.⁴ Várices.

Complicaciones⁷

Risks and complications of anaesthesia.
Sangrado.
Infección.
Shoulder pain from CO₂ insufflation.
Injury to organs; this may go unnoticed - eg, biliary tract damage.
Thromboembolic disease.
It may be necessary to proceed to open surgery if complications occur.
Muerte.

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Lecturas adicionales y referencias

Iribarne A, Easterwood R, Chan EY, et al; The golden age of minimally invasive cardiothoracic surgery: current and future perspectives. Future Cardiol. 2011 May;7(3):333-46. doi: 10.2217/fca.11.23.
Ahmad G, O'Flynn H, Duffy JM, et al; Laparoscopic entry techniques. Cochrane Database Syst Rev. 2012 Feb 15;2:CD006583. doi: 10.1002/14651858.CD006583.pub3.

Morgenthal CB, Richards WO, Dunkin BJ, et al; The role of the surgeon in the evolution of flexible endoscopy. Surg Endosc. 2007 Jun;21(6):838-53. Epub 2006 Dec 16.
Humphreys MR; The emerging role of robotics and laparoscopy in stone disease. Urol Clin North Am. 2013 Feb;40(1):115-28. doi: 10.1016/j.ucl.2012.09.005.
Rehman H, Mathews T, Ahmed I; A review of minimally invasive single-port/incision laparoscopic appendectomy. J Laparoendosc Adv Surg Tech A. 2012 Sep;22(7):641-6. doi: 10.1089/lap.2011.0237.
Leaney B; What's new in vascular interventional radiology? Aortic stent grafting. Aust Fam Physician. 2006 May;35(5):294-7.
Vollroth M, Seeburger J, Garbade J, et al; Minimally invasive mitral valve surgery is a very safe procedure with very low rates of conversion to full sternotomy. Eur J Cardiothorac Surg. 2012 Jul;42(1):e13-5; discusson e16. doi: 10.1093/ejcts/ezs195. Epub 2012 May 18.
Benway BM, Bhayani SB, Rogers CG, et al; Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: a multi-institutional analysis of perioperative outcomes. J Urol. 2009 Sep;182(3):866-72. doi: 10.1016/j.juro.2009.05.037. Epub 2009 Jul 17.
Gordon A; Complications of laparoscopy, Geneva Foundation for Medical Education and Research, 2012