QUICK STUDY Surgeons who are adept in laparoscopic surgery can usually master mini-lap in 10 cases or fewer, says Dr. Redan.

Are your surgeons still making bigger holes in patients than necessary? Still creating scars and causing pain when they don't have to? It could be that they're not offering patients the best of minimally invasive surgery because they've bought into the many myths surrounding mini-laparoscopy. But as you'll see, it's easy to poke major holes in their mini-lap arguments.

1. It's not here yet. Mini-laparoscopic surgery isn't some fanciful idea whose day will come. It's here now. In surgery, we like to kick the tires and take our time before we adopt new ideas. But mini-lap isn't new. It's the current state of a natural evolution, one patients deserve and may even demand.

2. Mini tools aren't sturdy. Some say the instruments are too flimsy, that they're going to bend or even break. That's not true, as long as you use them properly. Twenty years ago, when we started doing laparoscopy, instruments were about 10 or 12 mm. Then, roughly a decade later, as the metals got better and the instrumentation got sturdier, we started seeing and using 5 mm tools. Now, those of us who are proficient at mini-lap are using 2 and 3 mm instruments. Combined with the stability and strength of the trocars we use with them, they've become much more robust. Improved trocars play a big role, too. Now they're made of titanium and they actually match the size of the instrumentation better. They provide stability in the abdominal wall, so the instruments don't bend or break the way they did 10 or 15 years ago. And instruments are getting better all the time. Manufacturers have caught on that mini-lap isn't just a fad. Where there used to be just one company making mini instruments, now there are several, and the competition is continually improving the instruments.

3. It's difficult to master. Actually, the reverse is true: Mini-lap is relatively easy to master. Having taught many other surgeons, I've seen again and again that as long as you're adept at standard laparoscopy, you typically need 10 cases or fewer to master mini-lap. Usually, once surgeons see it, and see how well it works, the light bulb goes on right away.

4. It's not for every patient. Some think that a high BMI makes mini-lap impossible. That's wrong. (A high BMI does make it more challenging, but it makes every surgery more challenging.) Some say because the instrumentation is smaller and sharper, it may traumatize patients. Not true. I think we're a little behind the curve in the United States, in part because we have the highest BMIs in the world. In Latin America, South America and Europe — places where culturally, people are very concerned about the appearance of their bodies and about scarring — mini-lap has become a phenomenon. There are social networking sites where people show off pictures of themselves after having mini-lap surgeries. Remember, though, high BMI doesn't have to be a deal-breaker, once you know what you're doing.

5. It's more expensive. Mini-lap instruments are typically less expensive than those of standard laparoscopic surgery. What's more, most companies are making their instruments reusable, so the cost per case is extremely low, only a few dollars.

SUTURELESS SURGERY
Mini-Lap: Exactly What Is It?

SPREADING THE WORD Dr. Redan (far left) helps instruct surgeons in mini-laparoscopy during a Society of Laparoendoscopic Surgeons Fellowship Summit at the Nicholson Center in Celebration, Fla.

To be clear on terminology, people sometimes use the term mini-lap interchangeably with percutaneous surgery. Either way, what we're talking about is surgery done with instruments that are no larger than 2 or 3 millimeters.

That's the defining characteristic. We're using instrumentation that looks like needle sticks. Mini-lap instruments can be inserted percutaneously — without making an incision — just by using a sharp trocar. Or they can be inserted by using a No. 11 blade scalpel, an elongated triangular blade with a strong pointed tip that makes it suitable for stab incisions. That's all you need with mini-lap — just a poke.

More to the point, true mini-lap doesn't require sutures to close; you can just cover the surgical site with a Steri-Strip or a drop of glue. That's really the defining line in my book as to whether it's mini or not. If you need sutures to close, it's probably not mini.

— Jay A. Redan, MD, FACS

Lone contraindication
We may someday get to where we can do incisionless surgery — where we'll simply use directive energy sources. Until then, we're going to need some sort of access to the abdomen. One of the next steps is likely to be robotic mini-lap. Companies are beginning to mold robots to be able to use mini instruments. Once that happens, it's going to be a no-brainer. Everybody's going to realize how easy it is to do these procedures.

Visualization is also getting better. We still usually use 5 mm laparoscopes when we go through the abdomen, and we use mini instruments outside the abdomen. But once the optics get better for the 2 or 3 mm laparoscopes, everyone is going to want to use them. The smaller articulating instruments are also going to be more flexible, like snakes that can flex in and out of small spaces.

BARELY LEFT A MARK People like to show off pictures of themselves on social media sites after having mini-lap surgeries.

The only real contraindication to mini-lap is lack of knowledge. A little additional education is required, not just for the surgeon, but for the OR staff, too. People need to learn where to place instruments such that they'll have the best possible access to the surgical site. But it's a matter of tweaking, not a matter of having to learn an entirely new approach. That's where the Society of Laparoendoscopic Surgeons (sls.org) and other societies come into play. We have programs and courses that help people learn how to use the newer instruments.

We should be doing mini-lap whenever we can. It's what our patients want, something I'm reminded of whenever the nurses in our hospital need a gallbladder out or some other kind of abdominal surgery. They always come and see me, because they know I'm going to use mini instruments whenever possible. And afterward, they love showing off their surgeries, or the lack of evidence thereof, to their friends. OSM