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CH A P T E R

10 Principles of minimal access surgery

Learning objectives
To understand:
• The principles of minimal access surgery • The perioperative assessment of patients undergoing
• The advantages and disadvantages of minimal access minimal access surgery
approaches • Novel advances in minimal access surgery and its
• The safety issues and indications for minimal access adjuncts
surgery • The application of artifcial intelligence to minimal access
surgery

DEFINITION Thoracoscopy
Minimal access surgery is a product of modern technology A rigid endoscope is introduced through an incision placed
and surgical innovation that aims to accomplish surgical ther- between the ribs to gain access to the thorax. In the majority
apeutic goals with minimal somatic and psychological trauma. of cases, specialist anaesthetic support is required to ensure
This type of surgery has reduced wound access trauma and isolation of the lung on the side of surgery, enabling the
is less disfguring than conventional techniques. It can ofer patient to be ventilated only on the non-operative side. This
cost-efectiveness to both health services and employers by is achieved through the use of right- or left-sided double
shortening operating times, shortening hospital stays, improv- lumen endotracheal tubes that comprise both a bronchial
ing operative precision compared with open surgery in some and a tracheal lumen. Usually there is no requirement for gas
(but not all) cases and allowing faster recuperation. insufation as the operating space is held open by the rigidity
of the thoracic cavity. In specifc cases, such as mediastinal
History of minimal access surgery tumour resection and diaphragmatic surgery, gas insufation
at low pressure (5–8 mmHg) may be applied. Further infor-
The frst experimental laparoscopic procedure was performed mation on the general principles of thoracoscopy are found
by Kelling in 1901. Jacobaeus performed the frst thoracoscopy in Chapter 60.
in 1910, again using a cystoscope; however, it took another
70 years before Steptoe in the UK developed laparoscopy
for treatment of infertility and Mouret performed the frst Single-incision minimal access surgery
video-laparoscopic cholecystectomy in 1987. Since laparo-
scopic techniques became widely adopted in the mid-1990s, Single-incision minimal access surgery has varied in popularity
minimal access surgery has developed into a multidisciplinary with both strong advocates and others who are sceptical of
approach that crosses all traditional specialty boundaries and any advantages. Single-incision laparoscopic surgery (SILS)
serves the patient as a whole and not specifc organ systems. involves insertion of all instrumentation through a multiple
channel port via a single incision at the umbilicus. The benefts
are that the incision, through a natural scar (the umbilicus), is
MINIMAL ACCESS APPROACHES virtually ‘scarless’ and that fewer port sites potentially reduces
pain and lessens the risks of port site bleeding and the potential
Laparoscopy for port site hernia.
A rigid endoscope is introduced through a port into the perito- SILS requires specially manufactured multichannel ports
neal cavity. Full details of laparoscopy including the principles and often roticulating instruments. It has most commonly been
of pneumoperitoneum can be found in Chapter 7. adopted in gallbladder and hernia surgery, although more

Georg Kelling, 1866–1945, surgeon, Dresden, Germany, performed the frst ‘celioscopy’ on a dog in 1901 using air insufation and a Nitze-cystoscope.
Hans Christian Jacobaeus, 1879–1937, physician, Karolinska Institutet, Sweden.
Patrick Christopher Steptoe, 1913–1988 gynaecologist, Oldham, UK, a pioneer of in vitro fertilisation.
Phillippe Mouret, 1938–2008, surgeon, Lyon, France.

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ve PART 1 | BASIC PRINCIPLES
Minimal access approaches 163

ve complex colon and rectal surgery can be performed. There

remains debate as to whether the increased procedural dif-
Arthroscopy and intra-articular joint
culty, steep learning curve and increased direct costs in terms surgery
of devices, instruments and operating time can be ofset by Arthroscopy was one of the earliest applications of endoscopic
signifcant clinical beneft. techniques, frst being applied in the knee as early as the 1930s.
Uniportal thoracic surgery requires less specialist equip- In the 1950s Watanabe developed arthroscopic techniques that
ment; many minor thoracic procedures are commonly per- have evolved such that shoulder, wrist, elbow and hip arthros-
formed using this technique. More complex resectional copy is now commonplace. Novel approaches to smaller joints
procedures are less commonly performed, largely because of such as the temporomandibular and metatarsal joints are being
technical complexity when compared with multiport tech- developed.
niques, which are on the whole very well tolerated.
Hybrid minimal access surgery
Endoluminal endoscopy and natural Hybrid surgery may utilise a combination of fexible and
orifice surgery straight stick endoscopic approaches or a combination of open
and endoscopic surgery.
Flexible or rigid endoscopes are introduced into hollow
organs or systems, such as the urinary tract, upper or lower Totally endoscopic hybrid approach
gastrointestinal tract and the respiratory and vascular systems. The diseased organ is visualised and treated by an assortment
Advances in endoluminal technology now enable more of endoluminal and extraluminal endoscopes and other
complex procedures to be completed endoscopically where imaging devices. In the abdomen, examples include the
previous transabdominal or transthoracic surgical resection combined laparo-endoscopic approach for the management
would have been advocated. Examples include endoscopic of biliary lithiasis, colonic polyp excision and several urological
submucosal resection of complex colonic polyps, transanal procedures, such as pyeloplasty and donor nephrectomy. In
endoscopic microsurgery and endobronchial laser resection of the thorax, navigational bronchoscopy with placement of
tracheal pathology. fducial markers has been employed as a means of marking
Natural orifce translumenal endoscopic surgery (NOTES) lung nodules that can then be resected via a minimal access
ofers the opportunity for ‘scar-free’ surgery by performing video-assisted approach. Cardiovascular surgeons have
entire procedures via natural body orifces. While these tech- for some time employed hybrid technologies to facilitate
niques have been applied in the pelvis, abdomen and thorax, catheter-based placement of cardiac valves, atrial devices and
technical limitations and safety concerns have limited adop- intravascular stents.
tion. Concern over closure of the visceral puncture site is the Hybrid techniques ofer improved visualisation, facilitating
principal issue that has prevented widespread uptake, as trans- the primary procedure to be carried out either via a smaller
gastric and transcolonic closure of peritoneal entry sites in a incision or a minimal access approach where otherwise open
safe manner remains problematic. In addition, there are sig- surgery would have been necessary. Such approaches may
nifcant cost and training implications that have limited more necessitate the availability of ‘hybrid’ theatre facilities, limit-
widespread adoption. ing this approach to tertiary centres where such technology is
available (Figure 10.1).
Perivisceral endoscopy Open and endoscopic hybrid approach
Body planes can be accessed even in the absence of a natural Hand-assisted laparoscopic surgery (HALS) is a well-developed
cavity. Examples are mediastinoscopy, retroperitoneoscopy technique. It involves the intra-abdominal placement of a
and retroperitoneal approaches to the kidney, aorta and
lumbar sympathetic chain. Some of these approaches have
been in place for many years (cervical mediastinoscopy was
frst performed in 1959); however, the availability of novel
videoscopes has enhanced visualisation, thus improving the
safety and accuracy of dissection.
Extraperitoneal approaches to the retroperitoneal organs,
as well as hernia repair, are now commonplace, further
decreasing morbidity associated with manipulation of the
visceral peritoneum. Other examples include subfascial
endoscopic perforator surgery for ligation of incompetent
perforating veins in varicose vein surgery and endoscopic
harvesting of the saphenous vein for use in coronary artery Figure 10.1 Modern hybrid theatre set-up (courtesy of Mr Kelvin Lau,
bypass grafting. Barts Thorax Centre, London, UK).

Masaki Watanabe, 1911–1995, orthopaedic surgeon, Tokyo, Japan, known as the ‘founder of modern arthroscopy’.

@ambidextrous_onc
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 PART 1 | BASIC PRINCIPLES
164 CHAPTER 10 Principles of minimal access surgery

hand or forearm through a minilaparotomy incision, while

pneumoperitoneum is maintained. In this way, the surgeon’s Summary box 10.1
hand can be used as in an open procedure. It can be used to
Advantages of minimal access surgery
palpate organs or tumours, refect organs atraumatically, retract
● Decrease in wound size
structures, identify vessels, dissect bluntly along a tissue plane
● Reduction in wound infection, dehiscence, bleeding, herniation
and provide fnger pressure to bleeding points, while proximal and nerve entrapment
control is achieved. This approach has been suggested to ofer ● Decrease in wound pain
technical and economic efciency when compared with a ● Improved mobility
totally laparoscopic approach, in some instances reducing both ● Decreased wound trauma
the number of laparoscopic ports and the number of instru- ● Decreased heat loss
ments required. Indeed, some advocates argue that if such ● Improved visualisation
an incision is necessary for extraction of the fnal specimen
then HALS does not signifcantly increase surgical trauma
over totally laparoscopic approaches. Furthermore, for those
trained in open surgery it may be easier to learn and perform LIMITATIONS OF MINIMAL ACCESS
than totally laparoscopic approaches, subsequently improving
patient safety. With the new generation of surgeons training SURGERY
in totally laparoscopic surgery it is likely that use of HALS Minimal access surgery has limitations. A number of these
will diminish, although it should remain part of the minimally have been addressed with advances in instrumentation and
invasive surgeon’s armamentarium. endoscopic systems; however, the basic principles remain.
Surgical robots further address a number of these limitations
but present novel challenges.
SURGICAL TRAUMA IN OPEN,
MINIMALLY INVASIVE AND Endoscopic surgery
ROBOTIC SURGERY Lack of three-dimensional vision
Most of the trauma of an open procedure is inficted because To perform minimal access surgery with safety, the surgeon
the surgeon must have a wound that is large enough to give must operate using an imaging system that provides a
adequate exposure for safe dissection at a target site. The two-dimensional (2D) representation of the operative site.
wound is often the cause of morbidity, including infection, The endoscope ofers a whole new anatomical landscape,
dehiscence, bleeding, herniation and nerve entrapment. which the surgeon must learn to navigate without the usual
Wound pain prolongs recovery time and, by reducing mobility, ‘open approach’ clues that make it easy to judge depth. The
contributes to an increased incidence of pulmonary atelectasis, instruments are longer and sometimes more complex to use
chest infection, paralytic ileus and deep venous thrombosis. than those commonly used in open surgery. This results in
Mechanical and human retractors cause additional trauma. the novice being faced with signifcant problems of hand–eye
Body wall retractors can infict localised damage that may be as coordination. There is a well-described learning curve for
painful as the wound itself. In contrast, during laparoscopy, the novice surgeons and experienced ‘open’ surgeons when adopt-
retraction is provided by the low-pressure pneumoperitoneum, ing the minimally invasive approach. Simulation training and
giving a difuse force applied gently and evenly over the whole mentoring are required to attain competence.
body wall, causing minimal trauma. Three-dimensional (3D) imaging systems are available but
Exposure of any body cavity to the atmosphere also causes are expensive and currently are not commonplace. Many sur-
morbidity through cooling and fuid loss by evaporation. The geons feel that endoscopic 3D technology does not yet ofer the
incidence of postsurgical adhesions is reduced by use of mini- technical enhancement necessary to improve safety. Indeed,
mally invasive approaches because there is less damage to del- 3D technology has been associated with ergonomic problems
icate serosal coverings. In the manual handling of intestinal such as headache without quantifable beneft in terms of accu-
loops, the surgeon and assistant disturb the peristaltic activity racy and time to perform directed tasks. Future improvements
of the gut and provoke adynamic ileus. in these systems carry the potential to enhance manipulative
While minimal access methods were initially established in ability in critical procedures, such as knot tying and dissection
elective surgery, the advantages have led to increased uptake of closely overlapping tissues. There are, however, some draw-
for a number of emergency surgical procedures, including backs, such as reduced display brightness and interference with
perforated viscus repair, such as omental patch repair of a normal vision because of the need to wear specially designed
peptic ulcer perforation, lavage of localised perforation of glasses for some systems. It is likely that brighter projection
diverticular disease, intrathoracic debridement of empyema displays will be developed; however, the need to wear glasses is
and pneumothorax and haemothorax surgery. More recently, not easily overcome. These factors currently limit stereoscopic
some experienced surgeons have chosen to employ minimal straight stick endoscopic surgery, which has largely been super-
access approaches to trauma situations for initial assessment seded by the development of robotic technology incorporating
and treatment in stable patients. 3D vision.

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Robotic surgery 165

Increased operative time they have the disadvantage of disrupting gross specimen
Minimal access surgery can be more technically demanding morphology and cannot be used in surgery for malignancy.
and slower to perform than conventional open surgery. On Typically, extraction is performed by enlarging one incision
occasion, a minimally invasive operation is so technically so as to facilitate removal without disruption to the specimen.
demanding that both patient and surgeon would be better Strategies to reduce surgical trauma have been considered.
served by conversion to an open procedure. Prolonged These include removal of lung via a subxiphoid approach so as
anaesthetic and operative times may negate a number of to reduce intercostal neuropraxia or natural orifce extraction
the benefcial efects of minimal access surgery and increase of abdominal resection specimens. However, such approaches
the risk of respiratory and wound complications as well as are themselves associated with diferent complications such as
compression neuropathy and venous thromboembolism. It is herniation and injury to structures outside the direct operative
vital for surgeons and patients to appreciate that the decision to feld.
convert to an open operation is not a complication but, instead, While tumour implantation and localisation at port sites
usually implies sound surgical judgement in favour of patient initially raised important questions about the future of the
safety. laparoscopic treatment of malignancy, large-scale trials have
shown concerns to be minimised by appropriate tissue han-
Control of bleeding and haemostasis dling, separating any tumours by bagging, irrigation and pro-
Haemostasis may be difcult to achieve endoscopically because tecting the extraction site.
blood may obscure the feld of vision with reduced image quality
Cost
owing to light absorption. Experienced surgeons may be able
to manage a degree of bleeding via an endoscopic approach; Initially high consumable costs and factors such as surgical
however, this requires a signifcant degree of experience and learning curve and high conversion rates led to increased
skill to be achieved safely. Such scenarios are also reliant on an costs of minimal access approaches compared with their open
experienced assistant able to reduce visual loss through optimal equivalents. This is now largely no longer the case for straight
camera positioning. It should be remembered that a situation stick endoscopic surgery such as laparoscopy and thoracoscopy.
of controlled conversion can easily become uncontrolled, Indeed, despite higher direct consumable costs, improvements
negating any beneft a minimally access approach would have in outcomes, hospital stay and general upscaling of the proce-
achieved. dural volume have resulted in improved cost-efectiveness for
Advanced electrosurgery/diathermy and laser technology many minimal access procedures.
have improved dissection precision and haemostatic efcacy Future reductions in the costs of image-processing technol-
in endoscopic surgery. Ultrasonic dissection and tissue fusion ogy will result in a wide range of transformed presentations
devices continue to evolve with incremental technical improve- becoming available. It should ultimately be possible for a sur-
ments and surgeons are increasingly familiar with their use. geon to access any view of the operative region accessible to a
Some devices now combine the functions of three or four sep- camera and present it stereoscopically in any size or orienta-
arate instruments, reducing the need for instrument exchanges tion, superimposed on past images taken in other modalities.
during a procedure. This fexibility, combined with the abil- Such augmented reality systems continue to improve and are
ity to provide a clean, smoke-free feld, facilitates dissection, discussed in more detail below.
improves haemostasis and reduces operating times.

Loss of tactile feedback Summary box 10.2

Minimal access surgery is associated with some loss of tactile
Limitations of minimal access surgery
feedback, although this is less with straight stick endoscopy than
● Lack of 3D vision
with robotic procedures. This is an area of ongoing research
● Loss of tactile feedback
in haptics and biofeedback systems. Early work suggested that
● Haemostasis
laparoscopic ultrasonography might be a substitute for the
● Extraction of large specimens
need to ‘feel’ in intraoperative decision-making. Rather than
● Learning curve and increased operative time
producing tactile feedback, endoscopic ultrasound provides a
● Cost
visual representation of structures that in open surgery would
● Reliance on new technologies
rely on palpation for accurate localisation and appraisal.
Widely used examples include appraisal of nodal disease in
cancer surgery and biliary tract exploration.

Tissue extraction ROBOTIC SURGERY

Large pieces of tissue, such as the lung or colon, may have to A robot is a mechanical device that performs automated phys-
be extracted from the body cavity following resection. In some ical tasks according to direct human supervision, a predefned
circumstances this signifcantly increases the surgical trauma program or a set of general guidelines, using artifcial intel-
of the procedure that could otherwise be carried out via two ligence (AI) technology. In surgery, robots can be used to
or three small port incisions. Although tissue ‘morcellators, assist surgeons to perform operative procedures, primarily in
mincers and liquidisers’ can be used in some circumstances, the form of automated camera systems and telemanipulator

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systems, thus resulting in the creation of a human–machine superseded by the advent of wider laparoscopy and thoracos-
interface. Reduced degrees of freedom of movement and copy, which became increasingly commonplace across during
difcult ergonomic positioning for the surgeon can limit the the 1990s and 2000s.
application of straight stick endoscopy to a number of special- In 1992, Computer Motion developed the AESOP (Auto-
ties owing to a loss in surgical precision. This has driven the mated Endoscopic System for Optimal Positioning) system,
uptake of robotic surgical systems, currently existing as two which mounted the endoscopic camera on a single robotic
main categories: arm, allowing the surgeon to control it remotely via voice com-
mand. The system was widely used in cholecystectomy and
● Teleoperated (master–slave) systems: a surgeon
hernia surgery and for harvesting the mammary conduit in
performs an operation via a robot and its robotic instru-
coronary artery bypass. This was followed by the development
ments through a televisual computerised platform (where
of the ZEUS robot in 1996, a master–slave teleoperated system
the surgeon is the master, i.e. the operator, and the robot is
that provided three robotic arms, one for the voice-controlled
the slave). This may be via onsite connections or remotely
endoscope and two further instrument arms. The surgeon was
through the internet or other digital channels – hence the
positioned at a remote console and the device was capable of
publicity of ‘operating on a patient from another country’
motion scaling and tremor correction, facilitating its use for
(such ‘remote’ operations are currently rarely performed
microsurgical procedures. ZEUS was used for the frst fully
but their existence is established).
endoscopic robotic surgical procedure, the reanastomosis of
● Active or semiactive systems: these are typically
a Fallopian tube in 1998. The frst remote surgical procedure
image-guided or pre-programmed. In active sys-
was performed in 2001, also utilising the ZEUS system. Here
tems, a surgical robot completes a pre-programmed surgical
a cholecystectomy was performed on a patient in Paris by a
task. This is guided by preoperative imaging and real-time
surgeon in New York, demonstrating the feasibility of remote
anatomical constraints and cues through the application
operating. ZEUS was discontinued in 2003 after the merger of
of in-built navigation systems. In semiactive systems, the
Computer Motion with Intuitive Surgical.
robotic device may be in part pre-programmed and in part
The current era of surgical robots is dominated by the da
surgeon driven.
Vinci® surgical system, which was frst approved for clinical use
in 2000. The system ofers a number of advantages, including
3D surgical vision, EndoWrist® precision instruments, tremor
History of robotic surgery reduction, motion scaling and improved ergonomics. The ini-
The frst documented clinical robotic procedure was a tial system was released in 1999 and provided three robotic
computed tomography (CT)-guided brain biopsy performed arms, one of which held the endoscope. This was upgraded to
in 1985 utilising the PUMA (Programmable Universal the da Vinci S (2006), the da Vinci Si (2009) and subsequently
Machine for Assembly) 560 system. This was followed by the the da Vinci Xi in 2014 (Figure 10.2). With each iteration
ROBODOC, a pre-programmed active robot that enabled came improvements in vision and instrumentation, along with
precise preparation of the femoral implant cavity during hip which came integrated fuorescence imaging. More recently,
replacement. The beneft of such a device was the ability to novel technologies include the development of a single port
perform tasks to a high degree of accuracy, thus minimising system (da Vinci SP), which combines multijointed wristed
error and variation. While this and other active surgical robots instrumentation with a wristed camera through a single port
demonstrated a number of advantages, they were largely to further improve dexterity and minimise surgical trauma.

(a) (b) (c)

Figure 10.2 The da Vinci Xi system: (a) surgeon console; (b) da Vinci Xi robot; (c) vision cart (courtesy of Intuitive Surgical).

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Robotic surgery 167

Advantages of robotic surgery to ft the individual profle of the operator, thus reducing phys-
ical stress and fatigue. The enclosed console system of many
Surgical robots have been considered to ofer many benefts, robotic systems also provides the advantage of surgical isolation
which have arisen as a result of new technology in lenses, from external distractions that may impact on the operator’s
cameras and computer software. Just as laparoscopic surgery concentration. The disadvantage is reduced awareness of
benefted from advances in light technology allowing the non-verbal communication, thus highlighting the importance
targeted transmission of light down tubing, robotic surgery of team training and regular verbal cues.
benefts from computer integration of mechanical (surgical)
arms that have paved the way for computer-integrated surgery. Motion compensation
Although not commonplace in current clinical practice, robotic
Vision surgical systems may in future provide motion compensation
Modern robotic camera systems ofer 3D high-defnition imag- to facilitate surgery on a moving target. Examples where this
ing, providing stereoscopic vision with true depth perception may be benefcial are in beating heart cardiac surgery, such as
that enhances the visualisation of tissue planes and key struc- coronary artery bypass grafting and mitral valve repair. In this
tures. Multiport systems typically employ a rigid endoscope setting, the increased dexterity of robotic surgery combined
with or without angulation. As with conventional endoscopes, with removing the need for cardioplegia and cross-clamping
angulation to 30° allows for a wider range of vision through may be particularly benefcial in terms of reducing the post-
manipulation of the camera position, which, in the case of operative infammatory response and improving its associated
robotic surgery, can be controlled by the surgeon at the console morbidity.
or, if required, by the assistant at the bedside. A reference
horizon is commonly provided to the surgeon at the console
system so as to maintain orientation throughout the procedure. Disadvantages of robotic surgery
More recently, modern single-port systems such as the da Vinci Cost
SP employ a wristed camera system that, in combination with
Robotic surgery remains more costly than minimally invasive
fully wristed instruments, may allow for operative triangulation
alternatives. Through upscaling of use between surgical
while at the same time maintaining a small, single skin incision.
specialties, the direct costs of purchasing a novel robotic system
Manoeuvrability, motion scaling and tremor can be partially ofset; however, consumable costs remain
high. When compared with open techniques, robotic surgical
suppression
procedures can reduce hospital stay, thus in part ofsetting
Improved manoeuvring as a result of the ‘robotic wrist’ this expenditure; however, it remains difcult to demonstrate
in some systems allows for up to seven degrees of freedom, signifcant improvement in length of stay or clinical outcomes
thus improving dexterity for the surgeon. This has particular when compared with other minimally invasive alternatives.
benefts in felds with signifcant space restraints such as Another consideration is the increased operating time and
transoral surgery, where conventional laparoscopy has limited overall learning curve requirement when establishing a robotic
applicability. Furthermore, the increased dexterity of surgical surgical programme. While some specialties have reported
robots may facilitate a minimal access approach to more shorter learning curves than in the early days of laparoscopic
complex procedures where the technical difculty of applying surgery, this is highly heterogeneous, across both specialties
conventional laparoscopy may be prohibitive. As the motion and practitioners. Furthermore, although shared interspecialty
of the surgeon’s hand is translated to the ‘slave’ motion of the
robotic arm, modern surgical robots are able to scale down
large external movements of the surgical hands to limited
internal movements. At the same time, the computer may flter
out tremor in the surgeon’s hands, thus ensuring stability of the
instrument tips and enhancing surgical precision.

Ergonomics
Although the advent of straight stick laparoscopic surgery
had many advantages for the patient, for the surgeon there
was a trade-of in terms of operative ergonomics. Increased
operative time in addition to unergonomic positioning can
result in signifcant physical discomfort for the surgeon. This is
particularly true in specialties such as bariatric surgery, where
the patient’s body habitus and the use of long, fulcrumed
instruments puts further strain on the surgeon’s back, neck and
upper arms. The advent of robotic surgery vastly improves
Figure 10.3 Robotic theatre set-up demonstrating the da Vinci Xi sys-
upon the ergonomic environment for the surgeon; in the case tem. The surgeon and trainee surgeon are positioned at joint consoles
of many of the current master–slave systems, allowing for the remote from the operating table with the surgical assistant and scrub
surgeon to be seated at a console remote from the operating nurse at the bedside (courtesy of Mr Tom Routledge, Guy’s and St
table (Figure 10.3). The console positioning can be optimised Thomas’ NHS Foundation Trust, London, UK).

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168 CHAPTER 10 Principles of minimal access surgery

use increases cost-efectiveness for the institution, it also conse- laparoscopic trocars so as to reduce consumable cost. This
quently reduces the access opportunities for each individual system also creates familiarity with conventional laparoscopy
user, potentially prolonging the learning curve. and facilitates hybrid techniques where this may be benefcial.
Surgery is enhanced though a 3D-HD system with the use of
3D glasses and eye-tracking camera control.
Uptake of robotic surgery As the feld of robotic surgery continues to expand and
Many surgical specialties have embraced robot-assisted innovate, there also remain a number of systems in devel-
techniques, including general surgery, cardiothoracic surgery, opment that are not yet approved for clinical use. Examples
urology, orthopaedics, ear, nose and throat surgery, gynaecol- similar to existing technologies include the Medtronic Hugo
ogy and paediatric surgery. Specialties that use microsurgical Robotic-Assisted Surgery (RAS) system, which was launched
techniques also beneft from this technology. Current robotic in late 2019. This modular system aims to provide a lower cost
systems were designed to ofer multifunctionality, including alternative by means of a more readily upgradeable model that
multianatomy and specialty capability in both operating may be used fexibly across surgical specialties and procedures.
theatre and remote environments. Currently, despite a small Moving forward, companies such as Verb Surgical strive to
number of reports of remote surgical procedures, robotic build on the currently dominant master–slave model, incorpo-
surgery remains focused on in-house operating. rating robotic autonomy and machine learning. While this may
in time revolutionise robotic surgery, such technologies remain
New entrants in the early phase of development.
In 2017, Intuitive Surgical released the da Vinci X, a low-cost
entry point in its robotic surgical portfolio that includes features
of the Xi while sacrifcing some fexibility in terms of multi- Direct robotic systems and hybrid
quadrant surgery. In the same year, Korean company Meere robotic surgery
gained a licence for the use of its surgical robot, the REVO-I, In addition to the remote master–slave platform design, direct
by the local Ministry for Food and Drug Safety. Similar to the robot systems also exist. Each of these systems ofers diferent
da Vinci, this four-arm robot is mounted on a single cart. The advantages to the operating surgeon, ranging from reducing the
surgeon is seated at an open vision cart and, by use of 3D glasses, need for assistants and providing better ergonomic operating
can achieve three-dimensional high-defnition (3D-HD) vision. positions to providing experienced guidance from surgeons not
In March 2019, CMR Surgical received a European CE mark physically present in the operating theatre. Examples include:
for its novel modular robot, the Versius (Figure 10.4). This
system incorporates individual cart-mounted modular robotic ● tremor suppression robots;
arms that can be confgured to ft the procedure and the ● active guidance systems;
operating room environment. The design difers from other ● articulated mechatronic devices;
robotic arms in that it aims to more closely mimic a human ● force control systems;
arm, improving freedom of port placement. Its vision cart ● haptic feedback devices.
similarly allows for ergonomic operating with 3D-HD vision,
through the use of 3D glasses. PERIOPERATIVE PLANNING FOR
Bridging the gap between laparoscopic and robotic surgery
the Senhance® robotic system received its CE mark in 2016. MINIMAL ACCESS SURGERY
In order to reduce cost and sustain familiarity with conven-
tional laparoscopy, the system uses independent robotic arms Preparation of the patient
mounted on separate carts that can be placed in accordance Although the patient may be in hospital for a shorter period,
with the procedure required. The system utilises reusable non- careful preoperative management is essential to minimise
wristed instruments that can be inserted through standard morbidity. Recognition of patient- or procedure-related factors
that may in turn complicate a minimal access approach is vital
to optimise outcomes.

History
Patients must be ft for general anaesthesia and open operation
if necessary. Potential coagulation disorders are particularly
dangerous in minimal access surgery where options for
haemostasis may be more limited. A prior history of surgical
intervention in the same area is vitally important and should
be carefully documented, so as to best predict factors such
as adhesions that may preclude a minimal access approach.
Previous oncological treatment can also create a more hostile
surgical environment and an appropriate threshold for conver-
sion to open access should be set prior to the procedure and
Figure 10.4 The Versius robotic system (courtesy of CMR Surgical). communicated clearly with the patient.

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General intraoperative principles 169

the patient has fasted and has recently emptied their bladder,
Summary box 10.3 particularly before creating pneumoperitoneum for minimal
access surgery approaches to the abdomen.
Preparation for minimal access surgery
● Overall ftness: cardiac arrhythmia, lung function, medications, Informed consent
allergies
● Previous surgery or oncological intervention: scars, adhesions
It is essential that the patient understands the nature of the
● Body habitus: obesity, skeletal deformity
procedure, the risks involved and, when appropriate, the
● Normal coagulation
alternatives that are available. A locally prepared explanatory
● Thromboprophylaxis
booklet concerning the minimal access procedure to be under-
● Informed consent
taken is extremely useful (Chapter 14). The patient should
● Operative diffculty is predicted when possible with appropriate
understand that the procedure may be converted to an open
risk model operation. Common complications should be mentioned, such
● Appropriate theatre time and facilities are available (especially as shoulder tip pain and minor surgical emphysema, as well
important for robotic cases) as rare but serious complications, such as inadvertent visceral
injury from trocar insertion or diathermy. Patients may also
have specifc questions or requests in terms of the application
of minimal access surgery. It is important to be considerate
Examination and address these. Some patients remain concerned about the
Routine preoperative physical examination is required as for application of technology, particularly robotics, to their care
any major operation. Although, in general, minimal access and it is important to ensure they understand and agree with
surgery allows quicker recovery, it may involve longer operat- the proposed surgical approach.
ing times and carbon dioxide insufation in both the chest and
abdomen may provoke cardiac arrhythmias. Severe chronic
obstructive airways disease and ischaemic heart disease may
THEATRE SET-UP AND TOOLS
be contraindications to a minimal access approach. Moderate Operating theatre design is key to efciency. Modern theatres
obesity does not increase operative difculty signifcantly, but are designed with moveable booms for video, diathermy and
morbid obesity may require specialist instrumentation and laparoscopic equipment with at least two high-resolution,
trocars. Patients with a particularly low body mass index and high-defnition (HD) or ultra-high-defnition (4K) monitors,
small body habitus may present separate challenges in terms a carbon dioxide supply and fow monitor and appropriate
of port placement, particularly when adopting a robotic audiovisual kit (Figure 10.1).
approach. Severe spinal deformity including kyphosis and Image quality is vital to the success of minimal access
scoliosis may present problems in terms of positioning as well surgery. New camera and lens technology allows the use of
as impact on overall recovery if there are associated problems smaller cameras while maintaining excellent resolution. Auto-
with sputum clearance and mobility. matic focusing and charge-coupled devices (CCDs) are used
to detect diferent levels of brightness and adjust for the best
Prophylaxis against thromboembolism image possible.
Venous stasis induced by the reverse Trendelenburg position Efcient teamwork is crucial for high-quality surgery and
during laparoscopic surgery coupled with prolonged duration quick yet safe turnover. This is particularly important in robotic
of operation are risk factors for deep vein thrombosis. Subcuta- surgery, where verbal interaction between all team members is
neous low-molecular-weight heparin and antithromboembolic paramount throughout the procedure. The robotic team must
stockings should be used routinely in addition to pneumatic carefully rehearse protocols for both controlled and uncon-
calf compression during the operation. Patients already taking trolled conversion in the event of emergency.
anticoagulation should have this stopped temporarily or, where
appropriate, be converted to intravenous or subcutaneous GENERAL INTRAOPERATIVE
heparin, depending on the underlying condition and local
thromboprophylaxis protocols. In most cases patients can PRINCIPLES
continue on aspirin when the benefts outweigh the slight Many minimal access procedures have a unique set of proce-
increase in bleeding potential. dural steps that may often be in a distinctly diferent sequence
from those of the open alternative.
Urinary catheters and nasogastric tubes Methods for creating a pneumoperitoneum are described
In the early days of minimal access surgery, routine bladder in Chapter 7. Preoperative evaluation is necessary to assess the
catheterisation and nasogastric intubation were advised. Most type and location of surgical scars and potential for perivisceral
surgeons now omit these in favour of enhanced recovery, adhesions. In the setting of redo surgery, trocar insertion may
which has demonstrated benefts in terms of both length of be complex and should be performed by an open approach
stay and morbidity outcomes. It remains essential to check that with direct visualisation on entry to the body cavity (abdomen

Friedrich Trendelenburg, 1844–1924, Professor of Surgery successively at Rostock (1875–1882), Bonn (1882–1895), Leipzig (1895–1911), Germany. The Tren-
delenburg position was frst described in 1885.

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170 CHAPTER 10 Principles of minimal access surgery

or thorax). Before trocar insertion, the introduction of a fn- When the bleeding vessel can be identifed and grasped, con-
gertip helps to ascertain penetration into the body cavity and trol may be achieved by clipping, stapling or use of an energy
allows adhesions to be gently removed from the entry site. The device, depending on vessel size. Occasionally suturing may
endoscopic camera may be used as a blunt dissector to tease be possible; however, this may be signifcantly more complex
adhesions gently away and form a tunnel towards the quad- via a minimal access approach. When the vessel is not identi-
rant where the operation is to take place. With experience, the fed, compression should be applied immediately with a blunt
surgeon learns to diferentiate visually between thick adhesions instrument, a cotton swab or with the adjacent organ. Good
that should be avoided and thin adhesions that would lead to suction and irrigation are of utmost importance. Once the
a window into a free area. area has been cleaned, pressure should be released gradually
In obese patients the location of some of the ports may to identify the site of bleeding. Insertion of an extra port may
need to be modifed and, in some instances, larger and lon- be required. There should be no delay in converting to an open
ger instruments may be necessary. It is important to recognise procedure when necessary. This is of particular importance in
this preoperatively to ensure that adequate measures are put robotic surgery as some or all of the robotic arms may need to
in place to ensure safe and efcient surgery when the patient be urgently undocked to facilitate the surgeon gaining bedside
arrives. It is also important to consider the weight and dimen- access to the patient. The bedside assistant should be confdent
sion restrictions of the operating table. In some cases, specialist to perform this process. It is sometimes appropriate for a single
operating tables will be required (Chapter 68). robotic arm to be left in place to help maintain pressure on the
bleeding vessel while direct access is achieved. Alternatively,
pressure may be maintained via an assistant port (if present),
Operative problems allowing the robot to be undocked completely and removed
from the surgical feld.
Intraoperative perforation of a viscus or
vascular injury Bleeding from organs encountered during surgery
Perforation of any viscus, such as bowel, is a potential hazard Excessive retraction can tear a visceral surface, resulting
that may occur inadvertently and go unrecognised or be of a in bleeding. This is particularly so in robotic surgery, where
severity that may require emergency conversion. The added instrument graspers have a small surface area, increasing
time required for this to take place may result in increased the potential for injury to retracted tissue. Here rolled swabs
blood loss and haemodynamic instability that would not have may be inserted into the surgical feld and held within the
occurred should the same injury have occurred in an open grasper, producing a larger surface for retraction and reducing
setting. With surgical experience, education, preparation and tissue injury. Surgicel® (absorbable fbrillar oxidised cellulose
patient selection many of these emergencies and their resultant polymer) or other clot-promoting strips, tissue glues or other
complications can be avoided. It is vital for the surgical team haemostatic agents may also be used to aid haemostasis, e.g.
to both recognise its own limitations and continually refect from the gallbladder bed during cholecystectomy.
throughout the procedure on the surgical progress and oper-
ative difculty. Bleeding from a trocar site
Bleeding from the trocar sites is usually treated by localised
Bleeding diathermy or applying upwards and lateral pressure with
Bleeding is the most common cause of conversion to open the trocar itself. Considerable bleeding may occur if a vessel
surgery. The impact of light absorption is particularly import- such as the inferior epigastric or intercostal artery is injured.
ant in robotic surgery, and regular haemostasis is paramount Haemostasis can be accomplished either by pressure or by
to facilitate dissection and surgical progress. Risk factors that suturing the bleeding site. Devices such as the EndoClose™
predispose to increased bleeding include: may also be used to apply transabdominal sutures under direct
laparoscopic view to close port sites that bleed.
● liver disease impacting on the production of vitamin
When a bleeding vessel cannot be easily identifed, mass
K-dependent clotting factors, e.g. cirrhosis, autoimmune
ligation of the vessel around the port site can be performed.
liver disease;
This manoeuvre is accomplished by extending the skin incision
● infammatory conditions (acute cholecystitis, diverticulitis);
by 3 mm at both ends of the bleeding trocar site wound. Two
● patients on anticoagulants;
fgure-of-eight sutures are placed in the path of the vessel at
● coagulation defects: these may be contraindications to both
both ends of the wound (Figure 10.5). Alternatively, pressure
open and minimal access surgery and require thorough dis-
can be applied using a Foley balloon catheter. The catheter
cussion with haematology colleagues to determine, where
is introduced into the abdominal cavity through the bleeding
possible, how to optimise the patient for surgery.
trocar site wound, the balloon is infated and traction is placed
Damage to a large vessel requires immediate assessment of on the catheter, which is bolstered in place to keep it under ten-
the magnitude and type of bleeding. It is paramount that as sion. The catheter is left in situ for 24 hours and then removed.
soon as bleeding is identifed this is communicated clearly to If signifcant continuous bleeding from the falciform lig-
all members of the theatre and anaesthetic team. There should ament occurs, haemostasis is achieved by percutaneously
be a relatively low threshold for early conversion; however, this inserting a large, straight needle at one side of the ligament.
will depend on the expertise of the operating team. It is per- A monoflament suture attached to the needle is passed into
tinent to achieve early control by whatever means necessary. the abdominal cavity and the needle is exited at the other side

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Postoperative care 171

of the ligament using a grasper. The loop is suspended and passage from recently coagulated, electrically isolated tissue.
compression is achieved. Maintaining compression throughout Bipolar diathermy is safer and should be used in preference
the procedure usually sufces. After the procedure has been to monopolar diathermy, especially in anatomically crowded
completed, the loop is removed under direct laparoscopic visu- areas. If monopolar diathermy is to be used, important safety
alisation to ensure complete haemostasis. measures include attainment of a perfect visual image, avoid-
ing excessive current application and meticulous attention to
Evacuation of blood clots insulation. Alternative methods of performing dissection, such
Careful haemostasis is important as even small, localised pools as the use of ultrasonic devices, may improve safety.
of blood or clot absorb light and can signifcantly impair the
surgical view. Carefully directed suction is usually sufcient in
open cases; however, suction may be problematic in laparo-
POSTOPERATIVE CARE
scopic and robotic procedures that are reliant on carbon diox- The postoperative care of patients after minimal access surgery
ide insufation to maintain the surgical feld. It is important is generally straightforward, with a low incidence of pain or
that suction is applied below a fuid level, or, if used in the other problems when compared with their open counterparts.
operative feld, only in short bursts as required. Should tissue It is a good general rule that if the patient develops a fever or
be inadvertently sucked into the end of the suction device, the tachycardia, or complains of severe pain at the operation site,
tubing can be kinked to allow the tissue to drop away before something is wrong and close observation or intervention is
removing. Rolled swabs or sponges can be used to remove blood necessary (see also Chapter 24).
from the surgical feld without need for suction (Figure 10.6).
These can also be used for gentle retraction, minimising tissue
damage and thus further reducing blood loss. Such swabs may
be inserted and removed via a 15-mm assistant port or in some (a)
cases a 12-mm robotic trocar with the port cap removed. Care
should be taken to avoid carbon dioxide loss during extraction.
Finally, the surgeon may choose to use a specially designed
robotic sucker that integrates with the robotic system. Alterna-
tively, non-wristed suction can be provided via an assistant port
if included in the operative set-up.

Principles of electrosurgery during

laparoscopic surgery
Inadvertent electrosurgical injuries during minimal access
surgery are potentially serious and are often unrecognised at the
time. The vast majority occur following the use of monopolar
diathermy. For conventional laparoscopy, the overall incidence
is thought to be between one and two cases per 1000 operations.
Injuries can occur through inadvertent touching or grasping
(b)
of tissue during current application; direct coupling between
tissue and a metal instrument that is touching the activated
probe; insulation breaks in the laparoscopic or robotic instru-
ments; direct sparking from the diathermy probe; or current

Figure 10.6 Use of rolled swabs for retraction of the lung during
pulmonary lobectomy (courtesy of Mr Tom Routledge, Guy’s and St
Figure 10.5 Management of bleeding from a surgical trocar site. Thomas’ NHS Foundation Trust, London, UK).

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172 CHAPTER 10 Principles of minimal access surgery

Nausea removed as soon as the operation is over and before the patient
regains consciousness. This is most commonly used in bariatric
About half of patients experience some degree of nausea after and oesophagogastric surgery, where a larger (32F or 34F) tube
minimal access surgery. It usually responds to an antiemetic, is used.
such as ondansetron, and settles within 12–24 hours. It is made
worse by opiate analgesics and these should be rationalised or
avoided where at all possible. Oral fluids
There is no signifcant ileus after minimal access surgery,
Shoulder tip pain except in abdominal resectional procedures, such as colectomy
or small bowel resection. Patients may resume oral fuids as
Patients should be warned about this preoperatively and soon as they are conscious; they usually do so 4–6 hours after
informed that the pain is referred from the diaphragm and that the end of the operation.
it is not due to a local problem in the shoulders. It can be at its
worst 24 hours after the operation. It usually settles within 2–3
days and is relieved by simple analgesics, such as paracetamol. Oral feeding
Provided that the patient has an appetite, a light meal can be
Port site pain and numbness taken 4–6 hours after the operation. Some patients remain
slightly nauseated at this stage, but almost all eat a normal
Pain in one or other of the port site wounds is not uncommon
breakfast on the morning after surgery. Subsequently a
and is worse if there is haematoma formation. It usually settles
balanced diet is recommended in most cases and where specifc
very rapidly. In the case of thoracoscopy, intercostal nerve
procedural recommendations are needed these should be
pain may be more common in those with smaller intercostal
clearly communicated to both the patient and relatives with
spaces. Nerve blockade by means of directed local anaesthesia
appropriate dietetic referral made.
is efective at reducing pain and the need for opiate medication
in the immediate postoperative period. Increasing pain after
2–3 days may be a sign of infection and, with concomitant Urinary catheter
signs, antibiotic therapy is occasionally required. Occasionally, The requirement for a urinary catheter depends on the opera-
herniation through a port may account for localised pain and tion. In shorter (<4 hours) minimal access procedures a urinary
should be considered, particularly if occurring late with a catheter is not usually required. If a urinary catheter has been
relevant preceding history (e.g. coughing). Failure of a patient placed in the bladder during an operation with likely short
to follow the expected recovery pathway should prompt senior stay, it can be removed before the patient regains conscious-
review with appropriate imaging and relook surgery if consid- ness if the procedure has been uneventful. Postoperatively it
ered necessary. is important to check that the patient has been able to pass
urine and empty their bladder without difculty. When there is
Analgesia uncertainty point-of-care bladder scanning can assess residual
bladder volume.
The type and extent of analgesic requirement will depend
on both the patient and procedural factors. Prior experience
of opiate analgesia may increase patient tolerance to similar Drains
agents, necessitating larger doses. There is also evidence
The use of postoperative drains depends on the operation
to suggest that those patients struggling with chronic pain
performed. Drain output should initially be documented at
preoperatively often present a more complex postoperative
least hourly or more regularly in the event of concern regard-
analgesic problem. The extent and region of surgery will
ing high drain output. Given the heterogeneity of drainage
also dictate the analgesic regimen. For example, even mini-
systems available it is paramount that nursing staf are familiar
mal access thoracic surgical procedures commonly require
with the system used. The exact location and size of any drains
patient-controlled opiate analgesia with or without local nerve
should be clearly documented in the operation notes and the
blockade (intercostal or paravertebral) in the initial 48 hours
tubing labelled accordingly. This avoids inadvertent removal
after surgery. This may be avoided for some abdominal surgery
of the wrong drain or confusion for the ward team. Continued
by careful use of non-steroidal agents and paracetamol. Opiate
blood loss from a drain is an indication for re-exploration and
analgesics cause nausea, impair gut motility and should be
should be immediately highlighted to the operating surgeon.
avoided unless the pain is very severe. When pain is dispropor-
tionate to the presenting problem, suspect a complication (see
also Chapter 23).
DISCHARGE FROM HOSPITAL
The discharge of patients is based on clinical indicators and
Orogastric or nasogastric tube the patient’s ftness for recuperating in a non-hospital environ-
An orogastric or nasogastric tube may be placed for some ment. One of the core drivers for the application of minimally
abdominal surgery if the stomach is distended and obscuring invasive surgery is an earlier recovery and therefore discharge
the view. It is not necessary in all cases and is very rarely used from hospital. Patients should not be discharged until they are
in other minimal access surgery. Where possible, it should be comfortable, have passed urine and are eating and drinking

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The future 173

with a peak wavelength of around 820–830 nm on illumination

Summary box 10.4 with near-infrared light. Through use of a specifcally designed
HD camera and software system with imposed pseudo-colour,
Principles of minimal access surgery
areas of diferential tissue density and vascular supply can be
● Meticulous care in the creation of a pneumoperitoneum
detected clearly without the need for digital palpation, thus
● Controlled dissection of adhesions
facilitating complete resection and clear surgical margins. Its
● Adequate exposure of operative feld
use is now well established in procedures such as minimal access
● Avoidance and control of bleeding
liver, lung, renal and prostatic resections, and its role in other
● Avoidance of organ injury
specialties such as colorectal surgery is also under investigation.
● Avoidance of diathermy damage
The technology can be integrated into both video-assisted and
● Vigilance in the postoperative period
robotic-assisted surgical procedures and is available within
the da Vinci Xi and X robotic surgical systems as the Firefy®
mode, which can be turned on as required from the surgical
console (Figure 10.7).
satisfactorily. They should be told that if they develop worsen- Another role for augmented reality in minimal access sur-
ing pain or other severe symptoms they should return to the gery is the overlay of imaging beside or directly onto the surgi-
hospital or to their general practitioner. Even for more major cal feld, ‘navigating’ the surgeon to the site of interest without
cases, some units have demonstrated safe and feasible protocols the need to look away from the patient to review imaging. Such
for a 23-hour stay. navigational techniques originated in image-guided diagnos-
tics, enabling identifcation of pathology in areas more difcult
Skin sutures to reach anatomically. Through increasing adoption of hybrid
theatre complexes, these approaches may be utilised for both
If non-absorbable sutures or skin staples have been used, they
diagnosis and treatment in a single setting. An example is the
can be removed from the port sites after 7–10 days.
use of navigational bronchoscopy to identify, diagnose and treat
difcult to reach or small lung nodules. Preoperative planning
Mobility and convalescence CT scan is reconstructed by specialist software. The result is a
Patients can get out of bed to go to the toilet as soon as they 3D ‘road map’ of the bronchial tree and a side-by-side picture
have recovered from the anaesthetic and they should be of real-time endobronchial images with those from the imag-
encouraged to do so. Such movements are remarkably pain ing system (Figure 10.8). The surgeon is then guided directly
free when compared with the mobility achieved after an open along the airway to the lesion of interest that can be biopsied
operation. Similarly, patients can cough actively and clear with on-site frozen section. Where the lesion is resectable but
bronchial secretions, and this helps to diminish the incidence difcult to localise, a fducial marker may be placed to enable
of chest infections. localisation under fuoroscopy guidance in a second-stage pro-
cedure performed in a hybrid theatre (Figure 10.9). Where
resection is not possible, ablation or other treatment may be
FURTHER DEVELOPMENTS ofered in the same setting, both reducing surgical invasiveness
and increasing the provision of curative surgery to patients
Augmented reality and minimal access who may not otherwise be candidates for resection.
An area of interest is the application of head-mounted dis-
surgical adjuncts plays and eyeglasses to minimal access surgery. Although the
The future of minimal access surgery will almost certainly majority of applications remain in the realm of simulation and
feature more advanced applications of adjuncts to facilitate training, the promise of real-time image guidance by means
anatomical recognition and the localisation of pathology. of multiplanar or imaging overlay of the surgeon’s view is par-
These are becoming commonplace in both video-assisted and ticularly attractive. Head-mounted displays may also provide
robotic-assisted procedures. data display or communication tools, reducing the need for
the surgeon to look away from the operative feld and allow
Augmented reality real-time guidance by a trainer or proctor. To date, clinical
Augmented reality by defnition comprises the fusion of application is limited owing to time lag, the need for high-speed
projected computerised images with a real environment. In wireless Internet or Bluetooth connection and device weight
surgery, this involves the application of real-time imaging or and battery life; application to minimal access surgery remains
other data overlaid via computer processing software onto the under development.
surgical feld. Such technology may be particularly benefcial in
minimal access surgery where the localisation of pathology and
identifcation of anatomy may be more difcult than in open THE FUTURE
surgery because of the lack of digital palpation of the relevant Minimal access surgery has changed surgical practice; however,
structures. At an elementary level, examples include the use it has not changed the nature of disease. The basic principles of
of indocyanine green for immunofuorescent localisation of good surgery still apply, including appropriate case selection,
tumours as well as vascular, bronchial or lymphatic structures. excellent exposure, adequate retraction and a high level of
When bound to plasma proteins, indocyanine green emits light technical expertise. Endoscopic and robotic surgery training is

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174 CHAPTER 10 Principles of minimal access surgery

Figure 10.7 Robotic-assisted lung segmentectomy utilising indocyanine green administered endobronchially to highlight the segment for resec-
tion. (a) Robotic dissection of the superior (S6) segment. (b) Indocyanine green immunofuorescence of the marked segment, enabling clear
identifcation of the area for resection.

Figure 10.8 Navigational bronchoscopy. Split screen image demonstrating real-time endobronchial imaging adjacent to a virtual bronchoscope
image and a three-dimensional map of the lesion and bronchial tree (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, UK).

key to allow the specialty to progress. The pioneers of yesterday systems should be adaptable for international exposure so that
have to teach the surgeons of tomorrow not only the technical these techniques can be disseminated worldwide.
and dexterous skills required but also the decision-making and The predominant video and digital component of these
innovative skills necessary for the feld to continue to evolve. new techniques opens the door for simulation approaches for
Training is often perceived as difcult, as trainers have less training in these modalities, which have demonstrated benefts
control over the trainees at the time of surgery and caseloads in reducing learning curves and in turn are aimed at improv-
may be smaller, especially in centres where laparoscopic and ing patient outcomes. The ultimate goal for this educational
robotic procedures are not common. However, trainees now approach is to develop expert surgeons through the ‘totally
rightly expect exposure to these procedures, and training safe’ and ‘risk-free’ environment of simulation before they

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The future 175

in a preclinical setting, the STAR (Smart Tissue Autonomous

Robot) robotic system has demonstrated superiority over
human surgeons in porcine bowel anastomosis.
Translation of such laboratory-based experiments to real-
world surgery is not simple. Application requires detailed
understanding of surgical workfow and integration of com-
plex data. To provide a fully comprehensive, annotated train-
ing data set on which deep learning may be established, all
devices and systems in the dynamic operating environment
must be integrated, including operating room set-up, tool and
camera usage and the variable patient and procedural factors.
In addition there are complex questions in terms of data pro-
tection and confdentiality, not to mention the ethical consider-
ations and accountability of autonomous or semi-autonomous
robotic surgeons. The most promising elements of AI inte-
gration into minimal access surgery remain enhanced object
Figure 10.9 Image-guided video-assisted thoracoscopic surgery with
detection, speech recognition, video characterisation and
the use of a navigationally placed fducial marker to guide tumour integration with next-generation technologies. Real-time met-
resection (courtesy of Mr Kelvin Lau, Barts Thorax Centre, London, abolic profling and tissue-level diagnosis may diferentiate
UK). between cancerous and non-cancerous tissues on the basis of
their metabolic signature. An example is the iKnife, which uses
actually have to operate on patients. Indeed, both videoscopic a rapid evaporative ionisation mass spectrometric (REIMS)
and robotic platforms now have established simulation pro- technique to report tissue histology in real time by analysing
grams that are a prerequisite for surgical trainees. Modern aerosolised tissue during electrosurgical dissection.
robotic simulation modules are able to create an environment Artifcially intelligent systems also hold potential to dramat-
that mirrors console use (face validity) and subsequently pro- ically improve the fdelity of simulation training in minimal
vide hierarchical training compatible with the user’s expertise. access surgery, through the creation of a ‘real-world’ training
The combination of simulation with profciency-based ‘mas- environment based on the vast data accrued in their develop-
tery’ training may be the key to optimising the impact that sim- ment. Such data may be used to create a dynamic simulation
ulation may have on the surgical learning curve and remains environment for any procedure, much more akin to that of
the subject of research in a range of surgical specialties. ‘real-life’ surgery. This holds potential for a stepwise tutorial
With widespread uptake of minimal access surgery, train- system similar to that of bedside teaching, with objective feed-
ees are now facing a new problem owing to lack of experience back provided against standardised profciency benchmarks
in open surgery. Surgeons must have sufcient open surgical that can be easily integrated into national training programmes.
experience to feel comfortable converting cases in the event One major obstacle for minimally invasive technology
of difculty or emergency. A minimal access approach to a remains the cost efciency and device fnancing in an increas-
particular procedure may difer signifcantly in the order of ingly rationed global healthcare environment; this is an issue
operative steps and dissection technique. It is therefore vital that will require surgical liaison with hospital management and
that the new generation of surgeons continues to receive train- national policy providers. Surgeons need to continue to have
ing in open surgery so that they can apply either technique as a dialogue, discussing their experiences and ideas in order to
appropriate. efectively progress minimal access surgery and continue to
Advances in robotic surgery lend themselves to further adopt novel technology. As technological advancements are
AI integration, with potential advantages such as providing adopted, carefully designed outcomes research is required to
enhanced clinical decision support, warning of deviations provide a clear evidence base to support changes to clinical
from optimal workfow or detecting and overlaying potentially practice. In this way the comparative efectiveness of novel
at-risk structures. In this way, artifcially intelligent systems may minimal access technologies will be better understood in terms
streamline procedural technique, reduce error and improve of both clinical outcomes and cost-efectiveness, allowing
patient outcomes. Intelligent operating theatres may provide selection of those with the greatest potential to provide lasting
automated optimisation of a wide range of ergonomic features improvements in patient care.
such as table positioning, lighting and temperature, further
facilitating procedural efciency and efectiveness. In turn, The cleaner and gentler the act of operation, the less the
more advanced artifcial systems may also develop a degree of patient suffers, the smoother and quicker his convales-
supervised autonomy whereby basic surgical procedures can cence, the more exquisite his healed wound.
be independently performed by the robotic system. Indeed,
Berkeley George Andrew Moynihan (1920)

Berkeley George Andrew Moynihan (Lord Moynihan), 1865–1936, Professor of Clinical Surgery, Leeds, UK. Moynihan felt that English surgeons knew
little about the work of their colleagues both at home and abroad. Therefore, in 1909, he established a small travelling club which in 1929 became the Moynihan
Chirurgical Club. It still exists today. He took a leading part in founding the British Journal of Surgery in 1913 and became the frst chairman of the editorial committee
until his death.

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