Leading articles Br. J. Surg. 1990, Vol. 77, July. 721-722

Minimally invasive surgery In the late 1970s and early 1980s an entirely new attitude began to appear within some branches of surgery which opened the path for minimally invasive surgery. This change is best illustrated in the history of renal stone surgery where the development of percutaneous stone removal at the Institute of Urology in London' and the University of Mainz in Germany' ensured that the trauma of surgical access was reduced to a minimum. New endoscopic instruments were produced giving the urologist an excellent view of the interior of the kidney and thereby decreasing the time spent operating while ensuring that stones could be satisfactorily removed and that postoperative complications were minimized. Eventually, in 1980, the treatment of urinary calculi by extracorporeal shockwave lithotripsy (ESWL) was reported3. This was an entirely new concept whereby an electrical discharge from outside the body could fragment calculi within the urinary tract. This ensured that the physical trauma inflicted upon the patient was reduced to a minimum while achieving a maximum therapeutic result. Although the various methods for treating urinary calculi have never been submitted to a clinical trial, ESWL does seem to be the most satisfactory method of treating stones of 3 cm or less in diameter. In the case of staghorn calculi, a combination of percutaneous debulking and ESWL is preferable. Thus the removal of most renal stones has been transformed from an aggressive, debilitating operation necessitating prolonged hospitalization and convalescence to an out-patient procedure. Minimally invasive procedures may be carried out through natural tracks or tracks prepared by the interventional radiologist or surgeon. A philosophical leap was required in the acceptance of prepared tracks for minimally invasive surgery, but such procedures have now been performed for many years. For example, Wittmoser introduced transthoracic endoscopic sympathectomy in the 1950s4, Burhenne has extracted residual stones percutaneously from the common bile duct through the T tube tract since 19725, and Fernstrom carried out the first percutaneous removal of a renal stone in 19766. In spite of this, it is interesting that some surgeons initially preferred open renal stone removal through a lumbotomy incision, and mini-cholecystlithotomy through a small abdominal incision, to the less invasive and technically easier percutaneous procedures. Percutaneous endoscopic resection of upper urinary tract transitional cell tumours has been performed7, and how far away are we from percutaneous aspiration of a renal cell carcinoma following ultrasonic destruction of the tumour with the Cavitron (C.U.S.A.:@, Valleylab, London, UK) Arthroscopy is now accepted as the method of choice for the management of tears of the menisci in the knee. It has also been used to examine many joints, including the wrist, elbow, shoulder and ankle. Percutaneous discectomy is currently under evaluation and appears to be extremely useful in selected cases. It is surely not beyond the bounds of possibility that, in future, percutaneous hip replacement may be performed. Great interest has also been shown in the fragmentation of gallstones by ESWL8. The results have been encouraging, but the technique is limited by the requirement that the gallbladder must be functioning and that best results are obtained if ESWL is followed by prolonged administration of bile acids. Percutaneous cholecystlithotomy and ch~lecystlithotripsy~ have been suggested as an adjunct to ESWL, but they may also be performed as independent procedures with a high success rate and a low incidence of complications. Dubois and colleagues' have performed 250 laparoscopic cholecystectomies with excellent results and in some cases this may be performed as a day case under local anaesthesia. Under laparoscopic vision, the view of the gallbladder is exactly the same as if the abdomen were laid open before the operating surgeon. Through two separate stab incisions other instruments are introduced. The approach to the cystic duct and cystic artery is magnified, and the gallbladder can be dissected from the liver with endoscissors and diathermy. A cannula can be inserted into the common bile duct to perform a cholangiogram; if a stone is seen a flexible ureteroscope may be inserted through the cystic duct stump and the stone broken up under direct vision using the laser.

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Leading articles

The transthoracic endoscopic approach to the sympathetic chain is well known and widely used. Transanal resection of rectal tumours located up to 20 cm from the anal verge with full thickness excision of the rectal wall and end-to-end anastomosis has also been performed. Instead of the blind approach to the thoracic oesophagus in transhiatal oesophagectomy, the thoracic dissection can now be performed under endoscopic control with accurate diathermy of individual vessels. Semm' ' has performed many gynaecological techniques through the laparoscope including removal of the adnexae, excision of ovarian cysts, myomectomy, management of tubal pregnancies, and tubal ligation. He has introduced laparoscopic techniques for tying ligatures around structures and has been the leader in the introduction of laparoscopic appendicectomy. It is an indication of the interdisciplinary nature of minimally invasive surgery that gynaecologists are now using the transurethral resectoscope to resect the endometrium under local anaesthesia as an alternative to hysterectomy in selected cases. In December 1989 the inaugural meeting of the Society of Minimally Invasive Therapy was held at the Royal Institution in London. The aims of the Society are to include: development of a closer cooperation between clinicians and manufacturers in research and development; to present papers which offer practical help to those embarking on minimally invasive surgery; and to introduce courses throughout the world instructing surgeons in the various minimally invasive techniques. The era of minimally invasive therapy has begun. It is likely that percutaneous removal of organs will become commonplace and that percutaneous reconstructive procedures will become possible. New instruments will be made which will facilitate and accelerate these procedures. New imaging techniques will provide a clear view of the internal organs while therapeutic procedures are performed. It is essential that we as surgeons grasp the opportunity provided by the new minimally invasive techniques but, unhappily, many areas have been taken over by the interventional radiologists. This is entirely our own fault for not adopting the new instrumental techniques that are rapidly becoming available. It is important to appreciate that these concepts are beginning to cause a different approach to various common operative procedures. We must begin to appreciate the advantages afforded to the patient by minimally invasive techniques and turn our minds to minimizing trauma while still achieving our therapeutic aims.

J. M. Fitzpatrick J. E. A. Wickham Surgical Professorial Unit St. Peter j . Hospital and Institute o f Urology Maier Misericordiae Hospital and University of Londin University College Dublin I72 Shaftsbury Avenue 47 EccIes Street London W C 2 Dublin 7 UK Ireland 1.

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Wickham JEA, Kellett MJ. Percutaneous nephrolithotomy. Br Med J 1981; 283: 1571-2. Marberger M, Stack1 W, Hruby W. Percutaneous litholapaxy. Eur Urol 1982; 8: 236-42. Chaussy C, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by shockwaves. Lancet 1980; ii: 1265-8. Wittmoser R . Thoracoscopic sympathectomy in circulatory disorders of the arm. Lanyenbecks Arch Chir 1959; 292: 318-23. Burhenne JH. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR 1980; 134: 888-98. Fernstrom I, Johannson B. Percutaneous pyelolithotomy: A new extraction technique. Scand J Urol Nephrol 1976; 10: 257-61.

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Woodhouse CRJ, Kellett MJ, Bloom HJG. Percutaneous renal surgery and local radiotherapy in the management of renalpelvic transitional cell carcinoma. Br J Vrol 1986; 58: 245-9. Sauerbruch T, Delius M, Paumgartner G et a/. Fragmentation of gallstones by extracorporeal shockwaves. N Engl J Med 1986; 314: 818-21. Kellett MJ, Wickham JEA, Russell RCG. Percutaneous cholecystolithotomy . Br Med J 1988; 2%: 453-5. Dubois F, Berthelot G, Levard H. Cholecystectomie par Coelioscopie. La Presse Medicale 1989; 18: 98&2. Semm K. Dic Pelviskopische Appendektomie. Drsch Med Wochenschr 1988; 113: 3-5.

Br. J. Surg., Vol. 77, No. 7, July 1990

Minimally invasive surgery.

Leading articles Br. J. Surg. 1990, Vol. 77, July. 721-722 Minimally invasive surgery In the late 1970s and early 1980s an entirely new attitude bega...
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