VALUABLE TOOLS Mini-lap instruments (top) help surgeons access targeted anatomy.

Mini-laparoscopy isn't groundbreaking — the technique has been around for more than a decade — but growing interest in reduced-port techniques has sparked a renewed focus on thinner instrumentation that lets surgeons manipulate tissue through smaller holes and improves their access to the abdominal cavity for faster and safer surgeries. Let's take a closer look at mini-lap, which has become one of the hottest trends in minimally invasive surgery.

Same technique, new benefits
The beauty of mini-lap is that surgeons don't need to learn new techniques; they perform laparoscopy as they're accustomed to doing, but with 2.5mm and 3mm instruments inserted through like-sized trocars. Having the option to operate through smaller holes instead of 5mm ports is hugely valuable. For example, surgeons might find it difficult to manipulate organs while maneuvering instruments through standard trocars, but by popping a mini-lap instrument through a small incision, they're able to retract organs or tissue and hold it in place without adding another port. Mini-lap can be a much safer technique than suture retraction because surgeons aren't inserting sharp instruments into the abdominal cavity to secure anatomy.

Surgeons must perform cases quickly and safely, regardless of technique, and mini-lap can help meet those goals. A surgeon struggling through a difficult lap chole can insert a mini-lap grasper into the abdomen's upper-right quadrant to retract the gallbladder, which helps the case go faster. My colleague, Stephanie King, MD, director of minimally invasive gynecologic surgery and post-graduate training here at Fox Chase Cancer Center in Philadelphia, will sometimes insert a mini-lap instrument into the lower-left or lower-right quadrant — or both — to lift an ovary for better exposure and improved, faster dissection.

For patients, the cosmetic benefits of mini-lap are obvious. In most cases you don't have to cover the 3mm ports with bandages after surgery; applying a small amount of adhesive wound-sealing glue renders scars nearly invisible.

IMPROVED EXPOSURE
Smaller Holes, Safer and Faster Surgery

WAIT AND SEE Surgeons must adapt to what they find within the abdomen instead of committing fully to a technique.

What do all laparoscopic case have in common? They all begin with cameras inserted through a port of entry, so surgeons can assess surgical cavities and plot their next moves. That means they shouldn't commit to specific approaches before gaining access to the abdomen — they might find they're able to complete the procedure through a single port, with standard 5mm instruments placed through multiple trocars, or with a combination of conventional and mini-lap instrumentation maneuvered through 5mm and 3mm holes.

The most immediate and practical application of mini-lap's smaller holes is their use in combination with 5mm trocars or during reduced-port techniques. Whether used alone or in combination with standard instrumentation, mini-lap leads to potentially safer surgeries because it gives surgeons better exposure to the surgical cavity.

Surgeons married to reduced-port techniques, however, sometimes hesitate to add an extra trocar because of scarring concerns, even if the additional port would make the surgery easier to perform. But most surgeons wouldn't mind making 3mm nicks that patients won't notice in order to use a mini-lap instrument, meaning they're more likely to use the tools that can lead to safer and faster operations. Inserting a mini-lap instrument through a minute skin incision to lift the gallbladder and achieve better exposure can mean the difference between making a challenging case more manageable and wasting valuable surgical time — or worse — harming the patient.

— Paul G. Curcillo II, MD, FACS

Instrument upgrades
The mini-lap movement is going to take some time before it gains widespread traction. The instruments need to get a bit stronger and handle designs need to evolve fully from tools that let surgeons push and pull to devices that let them grasp and maneuver, so they can operate without altering their preferred techniques. During one of my recent thickened and inflamed gallbladder removals that proved challenging, for example, using mini-lap instruments wasn't an effective choice. The thinner instruments aren't as strong as standard 5mm tools, and the graspers and dissectors on the ends of very fine tools aren't ideally suited for moving thick tissue or anatomy — you can pull most anything with a mini-lap instrument, but you can't always push tissue of significant weight.

Instrument manufacturers are reacting to the growing popularity of mini-lap with promising designs, including 3mm instruments that snap into standard laparoscopic handles. Also look for instrument sets that offer a complete array of miniaturized tools that match what's available in larger sizes. With the growing movement toward reduced-port or single-port surgery, the development of needlescopic and mini-lap technology has become incredibly important. Needlescopic instruments are disposable self-contained systems — the tips of the sheaths house needles, letting surgeons pop them through the abdominal wall and employ graspers without the use of an additional port. It's a useful and efficient design that improves mini-lap's cosmetic results even more, but dissection using the handles of these devices can be challenging.

Although current mini-lap trocar options are limited, more companies are designing smaller ports. In addition, newer 3mm endoscopic camera designs are much improved, providing surgeons with better views of the surgical cavity during mini-lap procedures.

CASE SELECTION
Mini-Lap's Many Applications

LEARNING CURVE Surgeons need to build their mini-lap skills before tackling the more challenging cases.

Surgeons skilled at mini-lap can apply it during any abdominal surgery, including difficult cases such as bariatric and colon procedures. But the technique isn't necessarily suitable for all surgeons — physicians who don't focus on the approach will likely have a difficult time incorporating smaller tools into their standard instrument sets.

Most general surgeons interested in adding mini-lap will adapt to the technique easiest during lap choles, appendectomies, small bowel work, or removal of the ovaries (particularly the BRCA ovary removed prophylactically) or a small uterus (the bigger the uterus, the harder it is to hold with thin instrumentation). Adrenalectomies can also be done with mini-lap techniques, but to control the local blood vessels during the procedure, surgeons must insert a 5mm trocar to accommodate a clip applier or tissue-sealing device, neither of which is yet available or truly effective in 3mm sizes.

Be aware that operating on the kidneys, pancreas, colon and stomach is more challenging with mini-lap techniques.

— Paul G. Curcillo II, MD, FACS