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HomeThe Bulletin of the Royal College of Surgeons of EnglandVol. 106, No. 2
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Published Online 1 March 2024
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MAXIMALLY INVASIVE SURGERY IN THE ERA OF ROBOTS AND KEYHOLES


Author: PM SagarAuthors Info & Affiliations
Publication: The Bulletin of the Royal College of Surgeons of England
Volume 106, Number 2
https://doi.org/10.1308/rcsbull.2024.30

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    * Abstract
    * SO IS MAXIMALLY INVASIVE SURGERY ON ITS WAY OUT?
    * ABDOMINAL TRAUMA
    * HPB SURGERY
    * ADVANCED PELVIC MALIGNANCY
    * CONCLUSIONS
    * References

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ABSTRACT

In an age of advanced robotic surgery, is there still a place for maximally
invasive surgery?
Way back in the 1890s, Dr William Halsted, known to be a highly skilled, bold,
fast and daring surgeon, proposed his principles of surgery that remain as
relevant today as they were then. His principles included gentle tissue
handling, anatomical dissection of tissue, minimising tissue tension with
accurate tissue apposition and strict asepsis.1
Another of his principles was surgical access: always making the surgical
incision large enough for adequate visualisation. The idea and concept of
maximally invasive abdominal surgery with stem to stern incisions pertained
through much of the 20th century until, in the late 1980s, the advent of the
laparoscopic approach, initially to the gallbladder, and shortly after to hernia
repair, fundoplication and appendicectomy. While general surgery was a little
behind the curve on techniques and procedures compared with gynaecology, the
rapid dissemination of experience led quickly to the widespread adoption of the
laparoscopic approach, first as an alternative and then as the established mode
of approach for a significant proportion of abdominal general surgical
procedures.
Laparoscopic colorectal resection was slower to become established, partly
because of the greater surgical challenge of working in more than one quadrant
of the abdomen and the lack of relative fixity of the target organ compounded by
initial concerns (ill-founded as it turned out) about port site recurrence after
resection for cancer. The randomised COST2 and CLASICC3 trials from the late
1990s permitted the (slow) adoption of laparoscopic colorectal resection for
cancer that has become the standard approach with clear benefits (albeit mainly
in the short term). These studies showed equipoise between open and laparoscopic
colonic (COST) and colorectal (CLASICC) resection but it should be remembered
that the surgical teams, and surgeons in particular, had little in the way of
training (since little if any was available), and that monitors and instruments
were rudimentary compared with currently available systems.
Abdominal surgeons had only just got to grips with the laparoscopic approach
when robotic surgery appeared. It was met at first with resistance but has
gained acceptance among surgeons despite our natural struggle with change and
perhaps wanting more control over the operating field than was provided by
robotic surgery.4 Indeed, Intuitive Surgical reports that over 10 million
procedures have been performed worldwide using its da Vinci® robot.5 The growing
acceptance of robotic surgery is likely to be due largely to the benefits for
patients, with quicker recovery times, as well as arguably improved performance
and ergonomic benefits for surgeons.4 Competition will reduce costs and
hopefully enhance innovation while exciting developments with artificial
intelligence are expected to aid surgeons by identifying structures (e.g.
ureters and bile ducts) and therefore reducing complications.


SO IS MAXIMALLY INVASIVE SURGERY ON ITS WAY OUT?

No. There will remain at least for the foreseeable future the need for surgeons
to be familiar with and recognise the advantages of maximally invasive abdominal
surgery. Three broad areas illustrate its continued value: abdominal trauma,
hepatopancreatobiliary (HPB) surgery and advanced pelvic malignancy.


ABDOMINAL TRAUMA

Laparotomy has traditionally been viewed as the standard surgical approach for
abdominal trauma, and although advancements in imaging and selective
non-operative management options have decreased use of the non-therapeutic
laparotomy for haemodynamically stable abdominal trauma patients, approximately
a quarter of abdominal trauma patients will require surgical abdominal
exploration.6 Laparoscopy may be used as a diagnostic tool to exclude occult
diaphragmatic injury and assess the extent of penetrating trauma (mostly
anterior or flank stab wounds, or tangential gunshot wounds), and in this role,
it may reduce negative laparotomy rates. However, the ability to perform a
complete and efficient emergency exploration of the abdominal and pelvic
cavities at laparotomy remains an essential skill for the trauma surgeon.
The procedure must be performed in a systematic and thorough fashion to control
haemorrhage, minimise contamination emanating from the gastrointestinal tract
and identify all injuries caused by the trauma to permit definitive repair or
instigation of a damage control management plan. Surgeons need to be able to
carry out definitive repair of injuries either at the initial operation or with
follow-up at relaparotomy in a timely manner. Training is key.
> The ability to perform a complete and efficient emergency exploration of the
> abdominal and pelvic cavities at laparotomy remains an essential skill for the
> trauma surgeon


HPB SURGERY

The Makuuchi, chevron, Mercedes-Benz and true Kocher incisions in maximally
invasive surgery remain a cornerstone approach in HPB cases with their
impressive exposure, and are key to strategies required to allow regenerative
options, and to permit vascular resections and reconstructions for normothermic
and hypothermic resections.7 Maximally invasive HPB surgery demands an
understanding of both the role of interventional radiology and tactics to
modulate portions of the liver to preserve future liver remnants, with extensive
liver resections preserving sufficient liver remnant and allowing subsequent
hypertrophy while avoiding postoperative liver failure. For this reason,
parenchyma-sparing, multistage and ex vivo liver surgery as well as extended
radical resections remain part of the armamentarium of HPB surgery at least in
the major centres.
> There remains a significant and important group of patients in whom a
> maximally invasive approach will be needed for the foreseeable future, either
> in lifesaving trauma cases or complex advanced oncological reconstructive
> procedures


ADVANCED PELVIC MALIGNANCY

Recognition of the benefits of surgical resection of recurrent rectal cancer
with improved quality of life and enhanced survival has encouraged the
development of a number of techniques taking surgical resection beyond the
traditional plane of total mesorectal excision and into en bloc resection of not
only adjacent organs but also pelvic side wall structures, pelvic bones and, by
going higher and wider, the upper sacral/lower lumbar segments, always with the
avowed intent to achieve an R 0 resection (i.e. microscopically clear margins).8
Familiarity with anatomical planes with adherence to Halsted's principles of
gentle tissue handling and ensuring sufficient access and visualisation at all
times will minimise the ever-present risk in such procedures of massive pelvic
bleeding. When encountered (as is almost inevitable with some of these large
pelvic tumours), familiarity with the range of vascular clamps, suturing
techniques, bypass techniques and the use of expandable/inflatable balloons as
well as judicious use of packing is critical, and may prove to be lifesaving.


CONCLUSIONS

Abdominal surgery has been revolutionised by the advent and development of
minimally invasive surgery, first with laparoscopic and most recently with
robotic approaches. Nevertheless, there remains a significant and important
group of patients in whom a maximally invasive approach will be needed for the
foreseeable future, either in lifesaving trauma cases or in complex advanced
oncological reconstructive procedures. Recognition and an understanding of the
principles through high-quality training remain key. The day will come when
technology advances to the point where Halsted's 'bigger is better' mantra is
redundant but that day is not yet upon us.


REFERENCES

1.
Wright JR and Schachar NS. Necessity is the mother of invention: William Stewart
Halsted‘s addiction and its influence on the development of residency training
in North America. Can J Surg 2020; 63: E13-E19.
Go to Citation
Crossref
Google Scholar
2.
Nelson H, Sarjent DJ, Wieand HS, et al. A comparison of laparoscopically
assisted and open colectomy for colon cancer. N Engl J Med 2004;
350:2,050-2,059.
Go to Citation
Crossref
Google Scholar
3.
Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional
versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC
CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365:
1,718-1,726.
Go to Citation
Crossref
Google Scholar
4.
McCartney J. Robotic surgery is here to stay - and so are surgeons. Bull Am Coll
Surg 2023 May 10.
Google Scholar
 * a [...] field than was provided by robotic surgery.
 * b [...] and ergonomic benefits for surgeons.

5.
Intuitive. Robotic-assisted surgery with da Vinci systems.
https://www.intuitive.com/en-us/patients/da-vinci-robotic-surgery/ (cited
February 2024).
Go to Citation
Google Scholar
6.
Sermonesi G, Tian BW, Vallicelli C, et al. Cesena guidelines: WSES consensus
statement on laparoscopic-first approach to general surgery emergencies and
abdominal trauma. World J Emerg Surg 2023; 18: 57.
Go to Citation
Crossref
Google Scholar
7.
Baimas-Goerge MR, Tschuor C, Martinie JB, et al. The Janus of mIS in
hepatobiliary surgery: importance of maximally invasive surgery in an era of
minimally invasive surgery. Hepatobiliary Pancreat Dis Int 2020; 19: 409-410.
Go to Citation
Crossref
Google Scholar
8.
Harji DP, Griffiths B, McArthur DR, and Sagar PM. Surgery for recurrent rectal
cancer: higher and wider? Colorectal Dis 2013: 15: 139-145.
Go to Citation
Crossref
Google Scholar
Show all references


INFORMATION & AUTHORS

InformationAuthors


INFORMATION

PUBLISHED IN

The Bulletin of the Royal College of Surgeons of England
Volume 106 • Number 2 • March 2024
Pages: 60 - 62

COPYRIGHT

Copyright © 2024 The Authors. This is an open-access article distributed under
the terms of the Creative Commons Attribution 4.0 International License, which
permits unrestricted use, distribution, reproduction, and adaptation in any
medium, provided the original work is properly attributed.

HISTORY

Published online: 1 March 2024
Published in print: March 2024


AUTHORS

AFFILIATIONSEXPAND ALL

PM SAGAR

Consultant Colorectal Surgeon Leeds Teaching Hospitals NHS Trust, UK
View all articles by this author

NOTES

*
petersagar@aol.com


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REFERENCES


REFERENCES

1.
Wright JR and Schachar NS. Necessity is the mother of invention: William Stewart
Halsted‘s addiction and its influence on the development of residency training
in North America. Can J Surg 2020; 63: E13-E19.
Go to Citation
Crossref
Google Scholar
2.
Nelson H, Sarjent DJ, Wieand HS, et al. A comparison of laparoscopically
assisted and open colectomy for colon cancer. N Engl J Med 2004;
350:2,050-2,059.
Go to Citation
Crossref
Google Scholar
3.
Guillou PJ, Quirke P, Thorpe H, et al. Short-term endpoints of conventional
versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC
CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365:
1,718-1,726.
Go to Citation
Crossref
Google Scholar
4.
McCartney J. Robotic surgery is here to stay - and so are surgeons. Bull Am Coll
Surg 2023 May 10.
Google Scholar
 * a [...] field than was provided by robotic surgery.
 * b [...] and ergonomic benefits for surgeons.

5.
Intuitive. Robotic-assisted surgery with da Vinci systems.
https://www.intuitive.com/en-us/patients/da-vinci-robotic-surgery/ (cited
February 2024).
Go to Citation
Google Scholar
6.
Sermonesi G, Tian BW, Vallicelli C, et al. Cesena guidelines: WSES consensus
statement on laparoscopic-first approach to general surgery emergencies and
abdominal trauma. World J Emerg Surg 2023; 18: 57.
Go to Citation
Crossref
Google Scholar
7.
Baimas-Goerge MR, Tschuor C, Martinie JB, et al. The Janus of mIS in
hepatobiliary surgery: importance of maximally invasive surgery in an era of
minimally invasive surgery. Hepatobiliary Pancreat Dis Int 2020; 19: 409-410.
Go to Citation
Crossref
Google Scholar
8.
Harji DP, Griffiths B, McArthur DR, and Sagar PM. Surgery for recurrent rectal
cancer: higher and wider? Colorectal Dis 2013: 15: 139-145.
Go to Citation
Crossref
Google Scholar
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    RCS bulletin
 2. Robotic oesophago-gastric cancer surgery
    Ann R Coll Surg Engl
 3. Robotic surgery: the future is now
    RCS bulletin
 4. Robotic repair of post-oesophagectomy hiatal hernia
    Ann R Coll Surg Engl

 1. Research progress of minimally invasive surgery for gastric cancer
    Hao Su et al., Chinese Journal of Cancer Research, 2023
 2. Chylous ascites has a higher incidence after robotic surgery and is
    associated with poor recurrence-free survival after rectal cancer surgery
    Xiaojie Wang et al., Chinese Medical Journal, 2022
 3. Robotic solution for orthopedic surgery
    Mingxing Fan et al., Chinese Medical Journal, 2023
 4. Open surgery in the era of minimally invasive surgery
    Zichen Zhao et al., Chinese Journal of Cancer Research, 2022

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publishing.rcseng.ac.uk Open in urlscan Pro 104.18.32.139 Public Scan

Form analysis 10 forms found in the DOM

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publishing.rcseng.ac.uk Open in urlscan Pro
104.18.32.139 Public Scan

Form analysis
10 forms found in the DOM