Surgery: The Big Trend for the Small Incision

Colleagues advised him to get his head examined. Obviously, there was something wrong with him, they said. Once during a lecture, someone pulled the plug on his overhead projector. At another lecture, a professor interrupted him: ‘Distinguished students, if you want to get ahead in the academic world, do not listen to this absolute nonsense.’

Gynaecologist Kurt Semm (1927 – 2003) met with massive resistance when he presented his discovery. Nevertheless, his alleged nonsense revolutionised the world of surgical medicine only a few years later.

What we talk about is the invention of minimal invasive surgery (MIS). Semm was not only a physician, but also a precision mechanic by training. He broke new grounds when he moved his idea forward: In 1980, he conducted the world’s first minimal-invasive appendix operation. The publication of his scientific paper on the procedure was rejected, however.

Today, however, many surgeons are very thankful for Semm’s persistence, as his minimal-invasive procedure has become the new gold standard for many operations.

So, what makes the difference? What is new compared to conventional open surgery? With open surgery, the layers of skin and tissue are cut open with a scalpel in order to make corrections inside the body. Minimal invasive surgery, on the other hand, aims to keep the incisions as small as possible. It is therefore colloquially known as keyhole surgery, and also called laparoscopy.

Extended Surgical Hands

Through the little incision, the surgical team insert a video camera, a source of light, and the necessary surgical instruments. Surgery happens from the outside, so to speak. Special tools extend the hands of the surgeons, and everything is observed on a monitor.

‘Since the beginning of the millennium, minimal invasive surgery is on the rise internationally and also in Germany’, says Professor Matthias Anthuber, director of general, visceral and transplantation surgery at Augsburg University Hospital. ‘And in some areas, especially the abdomen, minimal-invasive operations are more common today than open surgery.’ If, for instance, a gall bladder has to be removed, surgeons in German hospitals use minimal invasive surgery in 95 per cent of the cases.

Keyhole Surgery on the Up

Keyhole surgery is not as widespread yet with orthopaedic, cardiologic or ophthalmologic operations. But in these areas, MIS is also on the up. Even artificial hip joints can be inserted minimal-invasively today. Although, ‘minimal-invasive’ is not related to the length of the incision with hip operations; that still has to be a couple of centimetres.

But certain new techniques and instruments enable the surgeons to minimise injury to the tissue structure, like muscle tissue for example. Herniated disks, circulatory disorder, oesophageal tumours and certain eye conditions can easily be treated minimal-invasively today.

Surgeons using minimal invasive surgery aim for one thing first and foremost: to strain the patient as little as possible in order to enable a speedy recovery. And that gave the method the push it got in recent years.

Open is Not Over, However

‘Basically, the method has huge advantages. The speedy recovery is certainly foregrounded’, says Dr Claudia Benecke, specialised physician for general, visceral and vascular surgery at the University Medical Center Schleswig-Holstein (UKSH) in Lübeck. After a minimal-invasive operation, patients can often leave the clinic much sooner. Or they do not even stay overnight, getting treated as outpatients. As this also saves a lot of money, health insurers usually cover the costs.

However, Benecke likes to emphasise that despite all the advantages MIS has, conventional open surgery has not become superfluous: ‘There are also situations and requirements that necessitate open surgery.’ Matthias Anthuber agrees: ‘Conventional open surgery will not become extinct in the near future.’ That would even be dangerous, he adds, as open surgery is still necessary for example with complex tumours in the abdomen.

What are the advantages and disadvantages of either technique? On what basis do surgeons decide which method to recommend to the patient? And how do patients find the right hospital for the procedure?

Minimal Invasive Surgery: How to Find the Right Hospital

Patients often feel insecure before surgery: What if there are complications? So, the first step has to be an exhaustive medical consultation with the patient. ‘Rather vital: The patient always has to have the option to decide between the minimal-invasive and the open surgery method, following comprehensive information on both methods’, says Matthias Anthuber. Generally speaking, the more often a certain minimal-invasive operation has been conducted in a certain hospital, the more experienced and knowledgeable the staff is.

As a means of orientation, the German Society for General and Visceral Surgery certifies hospitals in three categories: competence centre, reference centre, and excellence centre. To be considered a competence centre for gall bladder removal, for example, a hospital has to conduct that specific surgery at least a hundred times a year. To be a considered a reference or even an excellence centre, it is twice as many surgical procedures per year. Also, for the latter two, at least three experienced surgeons need to be at the operating table.

Finally, patients should ask their surgeon of choice since when he or she has been using the method, how many operations he or she has conducted in total, and per year.

The Advantages of Either Method

Open Surgery:

Easier Position With open surgery, the patient can be positioned flat on his or her back, or only slightly tilted, whereas with minimal invasive surgery, the operating table needs to be tilted more to one side to enable the surgeon to have a better view. The first option is better for the patient. The positioning during minimal invasive surgery can lead to a higher strain on the patient:

‘By pushing the thoracic diaphragm up, the pressure on the chest area is increased. That influences breathing and blood pressure’, says Professor Grietje Beck, director of anaesthesia, ambulance medicine, and pain therapy at the Helios Dr Horst Schmidt Hospital in Wiesbaden. The added pressure on the abdominal organs might also hinder the blood circulation, she adds. With open surgery, these complications do not exist. With minimal invasive surgery, the surgeons need to know about them and be ready to counter-act – or go for open surgery in the first place.

Easier Access If the area to be operated upon cannot be opened up or disinfected easily, open surgery is unavoidable. This might be the case with heavy scarring, extended inflammations of the abdomen, or bowel occlusion. ‘The intestine might be so distended that it is not possible to insert the operating instruments, to move them around and to use them’, says Claudia Benecke.

Instinctive Touch With open surgery, the surgeons can use their natural tactile sense. With minimal invasive surgery, however, they use instruments to transmit their finger movements into the body. That makes it more difficult to estimate the pressure on the relevant tissue structure. It requires a lot of practice and experience to transmit one’s tactile sense onto the instruments.

Anthuber reckons that it is possible to achieve: ‘But it does not compare to the hand itself inside the body.’ For that reason, it might be necessary to switch to open surgery with a longer abdominal incision mid-surgery if complications like unpredicted bleeding occur.

Spatial View There is still a difference in perception between the two-dimensional view on a monitor and the actual three-dimensional view coming with open surgery. Even today’s high-resolution 3-D cameras used in minimal invasive surgery do not make up the difference. For a better view, some complicate cases might require the open-surgery incision, for example when eliminating larger tumours.

It is also inopportune to cut them apart inside the abdominal cavity in order to remove them, as that might spread the cancer. On the other hand, minimal-invasive cameras offer special views and enlargements of the area to be operated upon, views not available with open surgery.

Minimal Invasive Surgery:

Faster Recovery Patients spend a lot less time in intensive care units and in hospital in general after keyhole surgery. Some procedures can even be conducted on out-patients, umbilical hernia for example. ‘Quite often the patients can get up a few hours after surgery. Their digestive tract recovers quicker. On top of that, the small incision wounds mostly heal better and become infected less often’, says Claudia Benecke.

Relief of Post-Operational Strain on Heart and Lungs ‘As a minimal-invasive procedure is mostly less painful in the aftermath, patients need less pain-killers’, anaesthetist Grietje Beck explains. That imposes less strain on the cardiovascular system. Also, the lung function is less often impaired after minimal invasive surgery.

As minimal-invasive procedures nowadays take just as long as conventional surgery, patients do not have to undergo a longer anaesthesia, as it used to be the case. In some cases, it is even reversed: Minimal invasive surgery on the gall bladder, for instance, is often quicker than conventional open surgery.

Smaller Wounds The smaller incision has several advantages. ‘The distinctly lower loss of blood during the procedure makes for a faster recovery of the patient’, says Beck. Also, a shorter scar heals more quickly than a longer one. And you should not forget the cosmetic aspect. Take gall bladder surgery, for example: In the past, open surgery left a ten-centimetre scar on the belly, whereas you hardly notice the scar left today after minimal invasive surgery.

Less Pain Fewer and smaller incisions into the abdominal wall cause less trauma to the tissue of skin, muscles, and fasciae. That significantly lowers the pain. Also, there is less inner adherence and adhesion, for example on intestinal loops. ‘With open surgery, trauma to the soft tissue is significantly higher, and more pain is caused by the large abdominal incision and the use of tissue retractors and surgical staples to keep the wound open’, says Matthias Anthuber.

Surgical procedures where the minimal-invasive method is used particularly often:

The German medical guidelines have been recommending laparoscopy for gall bladder removal operations in most cases since the mid-1990s. Similarly, most appendix operations are done minimal-invasively, between 55 and 70 per cent. With some weight loss surgery, sleeve gastrectomy for example, keyhole surgery is used in well over 90 percent of the cases. With inguinal hernia, in the past mostly treated with open surgery, about a third of the operations are now done minimal-invasively.

In urology, keyhole surgery is used a lot, for example with prostate surgery, kidney tumours or kidney and bladder stones. In gynaecological procedures in the lesser pelvis – the removal of ovarian cysts or the halting of endometriosis, for example – and elsewhere, keyhole surgery is also very common nowadays. In many bowel surgery procedures like surgery necessitated by chronically inflamed intestines, minimal-invasive surgery is seen as the new gold standard.