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Springer, Cham

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10.1002/chir.20721

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What Is Minimally Invasive Surgery and How Do You Learn It?

Authors: Aaron G. Rosenberg,

Publish Date: 2015
Volume: , Issue:, Pages: 1-11
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Abstract

Innovation in surgery is not new and should not be unexpected. As an example, the history of total joint replacement has demonstrated continuous evolution, and the relatively high complication rates associated with early prostheses and techniques eventually led to the improvement of implants and refinement of the surgical procedures. Gradual adoption of these improvements and their eventual diffusion into the surgical community led to improved success and increased rates of implantation [1]. Increased surgical experience was eventually accompanied by more rapid surgical performance and then by the development of standardized hospitalization protocols, which eventually led to more rapid rehabilitation and return to function. These benefits are well accepted and can be seen as helping contribute to the establishment of a more “consumer-driven” and medical practice.Innovation in surgery is not new and should not be unexpected. As an example, the history of total joint replacement has demonstrated continuous evolution, and the relatively high complication rates associated with early prostheses and techniques eventually led to the improvement of implants and refinement of the surgical procedures. Gradual adoption of these improvements and their eventual diffusion into the surgical community led to improved success and increased rates of implantation [1]. Increased surgical experience was eventually accompanied by more rapid surgical performance and then by the development of standardized hospitalization protocols, which eventually led to more rapid rehabilitation and return to function. These benefits are well accepted and can be seen as helping contribute to the establishment of a more “consumer-driven” and medical practice.Most surgeons would agree that as experience guides the surgeon to more accurate incision placement, more precise dissection, and more skillful mobilization of structure, the need for wide exposure diminishes. Indeed, less invasiveness appears to be a hallmark of experience gained with a given procedure. From a historical perspective, this appears to be true of total hip replacement. The operation as initially described by Charnley required trochanteric osteotomy. The osteotomy served several purposes: generous exposure, access to the intramedullary canal for proper component placement and cement pressurization, and the ability of the surgeon to “tension” the abductors to improve stability. However, over time, it became apparent that trochanteric nonunion and retained trochanteric hardware could be problematic. In attempts to minimize these problems, some worked to develop improved techniques for trochanteric fixation. However, others went in a different direction, eventually demonstrating that the operation could be performed quite adequately without osteotomy. Many purists complained that this was not the Charnley operation and that the benefits of trochanteric osteotomy were lost. Yet the eventual acceptance of the nonosteotomy approaches by almost all surgeons performing primary total hip arthroplasty (THA) in the vast majority of circumstances would attest to the fact that osteotomy was not required to achieve the result that had come to be expected.These developments led to the popularity of the posterior approach to the hip for THA. Initially, the gluteus maximus tendon insertion into the posterolateral femur was routinely taken down to obtain adequate exposure of the acetabulum. Indeed, the generous exposure provided by this release was needed to adequately control acetabular component position, to reduce bleeding for cement interdigitation, and to allow pressurization of acetabular cement. However, this generous exposure was associated with a higher dislocation rate than was seen with the trochanteric osteotomy technique. But with the advent of improved component design (offset) and better understanding of component positioning, as well as the introduction of cementless techniques, less exposure was needed in the majority of cases. Eventually, careful closure of the posterior structures also led to a significant reduction in the dislocation rate [2]. Seen in this example is a finding typically noted in the close examination of most evolutionary processes: initial benefits are obtained at some expense in the form of new or different complications or alterations in the complication rate. Further modifications are then required to overcome the new problems that arise from the adaptation of the innovation. The study of the factors that lead to the adoption (and alterations) of innovations has been extensively studied by Rogers and is well described in his landmark work, the Diffusion of Innovation [3].It would be fair to say that almost all surgical techniques improve over time by leading to less invasive approaches, which are frequently adopted only reluctantly by the surgical community. For skeptics, it is instructive to review the career of Dr. Kurt Semm [6]. His reports of surgical techniques were shouted down at professional meetings and his lectures were greeted with “laughter, derision, and suspicion.” He was forbidden to publish by his dean, and his first papers submitted were rejected because they were “unethical.” The President of the German Surgical Society demanded that his license be revoked and he be barred from practice. His associates at the University of Kiel asked him to have psychological testing because his ideas were considered so radical. Despite this opprobrium, he invented 80 patented surgical devices, published more than 1,000 scientific papers, and developed dozens of new techniques. His obituary in the British Medical Journal hailed him as “the father of laparoscopic surgery.” Who today would choose a standard open cholecystectomy over the benefits of the laparoscopic approach?Hip replacement is currently being performed by a variety of minimalist modifications of the standard hip approaches as well as by nontraditional approaches. Knee replacement is similarly being attempted through shorter incisions with various arthrotomy approaches. The proponents of all call them minimally invasive, but this term has really become a catchall and has no specificity or agreed-upon meaning.The purported benefits of these techniques include earlier, more rapid, and more complete recovery of function, less perioperative bleeding, and improved cosmesis. There has been, to date, few data by other than those proponents of specific techniques to substantiate any of these potential benefits. Of course, these purported benefits must be weighed against their potential to change the nature and/or incidence of complications that may arise secondary to the modifications of these approaches.There is general consensus that adoption of new techniques initially results in a greater incidence of complications. This is the so-called learning curve [7, 8], well known to all surgeons learning a new procedure. Whether this learning curve is extended or contracted has been shown to depend on both individual and the systemic features of the operation [9].


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