Less pain, less scarring, less risk of a hernia, happier patients what's not to like about microlaparoscopy?
It's no coincidence that those of us who've progressed to the next level of minimally invasive surgery (also called minilaparoscopy) and seen the benefits over a significant period of time (I started doing micro-laps about 6 years ago) are its biggest proponents. While it's true that some physicians, and people in general, are reluctant to transition to anything that's new or different, it's also reassuring that one of the attractive features of microlaparoscopy is that the learning curve for anyone already well versed in conventional laparoscopic surgery is modest.
Should you be encouraging your surgeons to take the big step to incisions so small, you don't need to close them, except at the skin level (or recruiting surgeons who've already downsized their incisions), while promoting the twin benefits of less pain and virtually imperceivable scarring to a public that's bound to be intrigued? Here are some factors to consider.
Unlike single-incision surgery or the NOTES (natural orifice translumenal endoscopic surgery) approach, the setup for micro-lap surgery is the same as it is for standard laparoscopy, so you don't have to modify your technique tremendously and the technique on the whole is much easier to teach. The small learning curve arises from the fact that you have to be more precise about where you put your trocars and more careful about their trajectory. This is important because poorly placed microlaparoscopic instruments can't withstand a lot of force in the abdominal wall that might be needed to counteract bad placement. They may even bend if you persist in fighting. The good news is they can be repositioned with minimal trauma.
Incidentally, some use the terms micro- or mini-laparoscopic surgery interchangeably with the term needlescopic surgery, but there's a difference, and I believe micro-lap with a trocar is safer than needlescopic surgery because micro-lap instruments aren't sharp. Needlescopic surgery relies on the sharpness of the instrument to obviate the need for a trocar.
Surgeons at the Vanderbilt University Medical Center in Nashville, Tenn., gave microlaparoscopy an enthusiastic endorsement. They chronicled in the Journal of Endourology their impressions of 46 transperitoneal pyeloplasty procedures done between 2009 and 2013. Comparing 27 procedures done via conventional lap surgery with 19 micro-laps (osmag.net/MbsKK7), they write that "from technical, perioperative and outcome perspectives, microlaparoscopy is both safe and feasible in our hands and results in subjectively superior cosmesis."
German researchers had similarly high praise in a 2012 study (osmag.net/2JyfBU), based on a retrospective review of general, gynecological, urological and thoracic surgeries. In describing what they call a "second generation" of endoscopes and increasingly effective instruments, microlaparoscopy, they say, "has (been) demonstrated to be feasible, safe and able to improve cosmetic and postoperative pain control."
Inspired by the resounding success of 79 cholecystectomies done via microlaparoscopy during a 24-month period, surgeons at Danbury (Conn.) Hospital say they're looking forward to "diminishing the surgical 'footprint' even further and contributing to better cosmesis and decreased postoperative pain in cholecystectomy patients." Of their 79 cases, only 3 had to be converted to conventional laps, and none had intra- or post-operative complications (osmag.net/Wj9XBk).
Cholecystectomies and appendectomies are the procedures most commonly associated with the micro approach, but I've used it in a variety of foregut cases, including hernias and Heller myotomies. Other possibilities include bariatric surgeries, small bowel procedures, oophorectomies and adrenalectomies. Biopsies and other diagnostic procedures may also lend themselves to smaller incisions.
Thinner patients usually make the best candidates, because their abdominal walls are thinner and more flexible, making it easier to use smaller instruments. But really it comes down to whether you expect a given procedure to be generally straightforward. If so, there's usually room to add another level of complexity and still have it end up being very reasonable. Hence, if you start with a micro approach but then decide to convert to a standard lap, you can add standard-size trocars without having a major impact on the case.
Conversely, micro-laps may not be the best choice if you know or suspect from the outset that you're going to be looking at a difficult surgery, because it does introduce an additional level of complexity.
Small but mighty
The instruments are of course smaller and more delicate, and one of the ongoing challenges for manufacturers is infusing those extremely thin instruments with adequate strength. It's tough, because the tools range in thickness (depending on the manufacturer) from about 2.7 mm to about 3.5 mm (or roughly one-ninth of an inch). But manufacturers seem to be embracing the challenge and figuring it out, innovating with newer materials and different configurations to try to overcome the strength issue.
Still, an inherent limitation is that the graspers and dissectors at the ends of micro tools may not be sturdy enough to move thick tissue or anatomy. With heavier tissue, smaller instruments are better at pulling than pushing. As such, in some micro-lap procedures, you may also need to augment with standard-sized tools that require larger incisions. For example, for suturing you still need a trocar you can fit a needle through (unless you pass the needle through the abdominal wall, which can be tricky). With many micro procedures, I end up also using some larger trocars, either to take something out or to put something in.
Creating comfortable handles seems to be another challenge. But in an increasingly competitive arena, manufacturers are also working to make handles more comfortable by, among other things, providing micro-sized instruments that attach to standard-sized lap handles.
Although there's a significant capital expense associated with instrument sets that contain the complete array of smaller tools, in the long run micro-laps can save money, because unlike standard disposable trocars, micro-lap ports are reusable.
One other caution: I don't do much cleaning of instruments, but I recognize that smaller instruments may be more challenging to clean and service than standard instrumentation. The channels are tiny, so finding small enough brushes can be a challenge, as can adequate flushing.
It may be hard to quantify all the benefits, but if a microlaparoscopic procedure ultimately takes about the same amount of time as a standard laparoscopic procedure, while resulting in less pain, less scarring and less risk, assessing the benefits is a matter of common sense. One thing I know for sure is that patients love it. They're up and out faster (which also saves money) and more and more are asking for it. As word spreads, there's a good chance more of your patients will be asking, too.