TINY HOLES Mini-laparoscopists use 2 mm to 3 mm instruments to convert secondary ports into mini-ports to reduce scarring.

Mini-laparoscopy is becoming increasingly popular, gaining a foothold in surgeries where fewer and smaller incisions matter from a cosmetic and an abdominal safety standpoint, including cholecystectomies, appendectomies and tubal ligations. Here's what 3 mini-lap surgeons say you should know before adding the technique to your repertoire.

Is mini-lap a difficult technique to master?
Dr. Novitsky: The techniques are nearly identical — you're just using smaller instruments and incisions. Whether you use mini-lap depends on the surgeon's skills, the patient's body habitus, and if the smaller tools and incisions are appropriate for that procedure.

Dr. Reardon: Making the move to mini-lap from laparoscopy is fairly easy, especially if you're converting to 3 mm instruments. I originally started using mini-lap in 1996, after a rep brought in the technology and asked if he thought I could use it. Funny enough, a gallbladder case came into the hospital while the rep was there, and I asked if we could test out the technology right away. That case went so smoothly that we've now grown to use 2 mm and 3 mm instruments in nearly all of our procedures.

Dr. Curcillo: There is a spectrum of laparoscopic surgeons using the technology. Some who use mini-lap exclusively, and then there are those who won't touch it. I think most fall in between and see it as another skill available for select cases.

Which procedures are good matches for mini-lap?
Dr. Novitsky: Mini-laparoscopy is fairly common in tubal ligations and other GYN procedures, as well as in cholecystectomies, appendectomies and select intestinal procedures. I wish it was used in more general surgery cases, like inguinal hernia repair, since it's much less invasive to the abdomen.

Dr. Curcillo: Colorectal and bariatric surgeons are also trying to get into it, though that's more of a challenge since the small instruments are hard to use on those who are obese or who have a lot of disease present. I typically perform single-port surgery, but when that isn't an option, I'll do a reduced-port procedure. If I'm doing a gallbladder through the belly button, but I can't quite maneuver it how I need to, I'll insert a 3 mm instrument percutaneously to assist me. This limits scarring while still giving me the help I need from an additional entry point.

Dr. Reardon: We use it as both an addition and an alternative to conventional laparoscopy. It depends on the case. For a surgery that doesn't require you to remove a specimen, insert a device (like mesh) or use a stapler, you can do the entire case through 2 mm or 3 mm ports. Otherwise, you can have 1 or 2 larger (5 to 12 mm) ports and just convert the secondary ones to mini ports. We recently added bariatric cases and use a 12 mm port for the stapler, a 5 mm port for the camera and 3 3-mm ports for the instruments.

Yuri Novitsky, MD, FACS
Dr. Novitsky is a professor of surgery, director of the Case Comprehensive Hernia Center and director of the advanced GI surgery and MIS Fellowship at University Hospitals Case Medical Center in Cleveland, Ohio.

Patrick Reardon, MD, FACS
Dr. Reardon is the chief of minimally invasive surgery and chief of foregut surgery at Houston (Texas) Methodist Hospital and professor of clinical surgery at Weill Cornell Medical College.

Paul G. Curcillo, II, MD, FACS
Dr. Curcillo is the director of minimally invasive surgical initiatives and development at Fox Chase Cancer Center in Philadelphia, Pa.

What's the No. 1 benefit of using mini-lap?
Dr. Novitsky: About a decade ago, I worked on a study that compared mini-lap with conventional laparoscopy, looking at blood loss, operative time, complications, early and late post-op incisional pain, and cosmetic results. Both techniques performed about the same, although we did see a small decrease in early post-op incisional pain for mini-lap. Its main advantage, though, was superior cosmetic outcomes.

Dr. Curcillo: When I put a 3 mm instrument through the skin and take it out, I don't have to stitch it up. I don't even have to put a Band-Aid on it. Patients really like that it's less traumatic and causes less scarring. But as far as a faster recovery or superior outcomes, there just isn't enough evidence to support that yet.

Dr. Reardon: The few studies out there seem to suggest that mini-lap patients have less pain, a lower use of narcotics and return to normal activities sooner than those who undergo conventional surgery, but the evidence is limited. The scarring is the most obvious benefit. Sometimes my 2 mm patients will come back and I can't even find the scars. When the field moved from open surgery to laparoscopy, it was a big jump and the benefits were clear. This progression is smaller, so it's harder to see the distinctions, though anything less invasive is better for the patient.

How do mini-lap instruments compare to conventional ones?
Dr. Curcillo: The handles are easy to use — in fact our mini-lap handles are the same as our 5 mm ones. It's more about the shaft and the tip. The mini instruments aren't as robust as the 5 mm ones. It's hard for them to lift livers or other heavy organs. They're good at pulling, but not so much for pushing. The jaw sizes are also smaller, so they don't have the big bite you sometimes need. Manufacturers are addressing this by using improved materials, like ceramic, to increase the instruments' strength, though they tend to be more expensive and have heat conductivity concerns.

Dr. Novitsky: The tools and supporting technologies are improving, but they haven't been developed to a point where it's become common in all facilities. My hospital doesn't offer it, simply because the hospital demands justification of the cost of acquiring new sets and we haven't been able to provide that yet. Hopefully, that will change as technology improves and patient demand increases.

Dr. Reardon: Laparoscopic surgeons with above-average skills, about 50% of the field, could easily move from 5 mm instruments to 3 mm ones, especially as the tools improve. Right now, we use some that are made of steel for increased rigidity and come at longer lengths for bariatric cases. Recently I had a fellow who assisted on a Roux-en-Y gastric bypass, though she never had done one before. She only used 3 mm instruments and everything went well. The 2 mm options are trickier, since they are less sturdy and harder to maneuver in the abdomen.

What about visualization during mini-lap?
Dr. Novitsky: The choice in mini scopes is a challenge, since the 2 mm and 3 mm optics may not be sufficient. That's fairly easy to overcome. Most common mini-lap cases use a 10 mm port to remove a specimen anyway, so you can just use a conventional scope.

Dr. Reardon: Mini cameras are adequate for most surgeries. You see a smaller, but just as high-quality, image with our 3 mm scope compared to our 5 mm one. Our 2 mm camera has a lot less resolving power, though it's still suitable for most cases. We've done 1,200 2-mm lap choles since 1996, and have had only 1 common bile duct injury — and that was due to poor cautery use, not poor visualization. The main problem is that the 2 to 3 mm cameras aren't yet long enough for bariatric cases.

Final words of advice about adding mini-lap?
Dr. Curcillo: It's a significant investment — each instrument can cost several hundred dollars, and each case may require several — but consider whether you're going to lose business not offering mini-laparoscopy. Patients aren't necessarily coming in demanding mini-lap, but they do ask for smaller incisions. And if the hospital down the street has the technology, their surgeons may go there instead.

Dr. Reardon: Our facility purchased 2 mm and 3 mm sets of instruments and cameras, though we already had great 5 mm options. Why? Because we saw the potential benefits: It's less invasive, increases patient satisfaction and is a service our competitors weren't offering. Since adoption, our reputation with the public and with referring physicians is improved, as is our patient satisfaction. The hospital committed to the concept and, so far, it's paid off.