There is a saying or "cliche" that Chinese medicine is good at chronic disease modulation and health maintainence and Western medicine is best suited for surgical condition like tumour and/or obstruction, and traumatology. Nowadays, surgical condition is more and more treated by catheter or percutaneous manipulation method. Previous school of thinking on big incision and wide exposure has been out of favour and prevents patients' acceptance. The one and may be the only one question that patient want to ask about is whether there is minimally invasive surgery option available.
It appears that all invasive procedure or wide wound exposure is wrong and not serving patients good.
I may be over exaggerating the vision and trend of going minimally invasive and conservative in treating most mechanical or surgical disease.
However, as surgeon witnessing the evolution of minimally invasive approach in various conditions. I believed that the patient may have an incorrect idea of how minimally invasive surgery develops and contributes to expansion the treatment armentarium. So , the new paradigm of going minimally invasive is not a new invention but a means to perfect the appraoach to meet the old well established target. Should the operative target remain far from what minimally access approach can meet, old approach is as effective and the only soloution to be the best approach and fail safe approach.
Surgery includes ablation and reconstruction. In fact, the analogy of plumbers and surgeon is particularly intuitive as lot of lesions will be dealing of obstruction of tubular structure. Either replacing the entire passage with conduit or bypass or recannulating the stenotic part with stent or expansile scaffolding device will solve the condition.
So the use of stent and supporting stenting scaffold device will be universal in many disease system. For solid tumour in the body, so far ablation method using open appraoach stood the test of time. Complete removal leaving good margin of at least 5 mm or if not possible 3 mm clearance ensure minimal chance of local recurrence. Any other compromise in margin or breach across the tumour capsule or surronding tissue will deprive patient only chance of survival. Internal stenting may be used as temporarily a salvage option or pre operative optimisation. Radical removal usually still need bigger wound. For complex reconstruction, open surgery still is the gold standard.
Secondly, the time spent on the surgery and learning curve involved in mastering the necessary skill is the bar before contempating new approach. For example, in robotic surgery requiring wide movement of target operation site, e.g. removing a lung tumour. The time spent on setting up the robotic arms and concentrating on relevant structure tilt the balance favoring traditional Thoracosocpic resection rather than Robot assisted minimally invasive surgery. Learning curve is indeed the major concern for both the surgeon and the patient. For patient demanding the less practiced minimally invasive surgery, he or she must do good research to go to surgeon with good track record in other new surgical appraoach so that the relative time for learning cujrve is small.
Risk of bleeding in going minimal invasive. The extent of surgery dose not become smaller even if minimally invasive surgery. However, paradoxically, minimally invasive surgery to some extent increase the safety margin because hemostasis is better and picture is clear on optically ideal magnified view. Good surgical tecnique can circumvent the absence of tactile sensation and degree of freedom of long through the hole instrument. Yet, from time to time. Heavy bleeding as a result of small wound surgery approach is never short of examples. Years and years and time after time. Patients' interest is at risk for unjustified minimally access for complex surgery or absence of good surpervision and help in steps moving away from conventional surgery. No compromise of safety should be allowed for surgeons choosing small wound or non invasive approach.
Pooling of cases may be difficult for less common patholgy. In another words, minimally invasive surgery may not be vivable if the encountered pathology is rare or the referral basis of that centre is small. Like so mnay audit report, in rare pathology, the surgical outcome is in direct proportion to the case volume. But in ususal pathogy like gallstone or hernia., the difference between small centre and big referral centre is negligible.
In short, I really support the current trend of going minimally invasive in every possible operation. But still I believe it needs right time, right place and last but not least the right occasion (patient and skill mix). Otherwise, I believe in the old saying that it is safer to detour a usual path to guarantee arrival than to risk for new route. And, old dogs usually learn new tricks slow but can play it safe after skill acquirment.
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