Is Minimally Invasive Surgery at an Inflection Point?

General surgeons are likely to face the most challenges when deciding between laparoscopy and robotics as this specialty relies heavily on laparoscopes that can take advantage of larger operative space. But even within that field, common, high-volume procedures such as hernia repair may benefit from a robotic approach.

“There are studies to show that the learning curve for a laparoscopic inguinal hernia repair is longer than the learning curve for a robotic inguinal hernia repair,” said Dr. Higgins, who also specializes in minimally invasive hernia repair. “In addition, robotics may provide the ability to do more complex ventral hernia repairs in more ergonomically challenging positions in ways that you couldn’t do laparoscopically because you were limited by the technology.”

Hernia repair is an example of how robotic platforms provide an opportunity to perform complex procedures with an ergonomic tool. An element as fundamental as suturing can be transformed into a learned skill that comes more naturally to surgeons with this technology.

“As an MIS surgeon, I do laparoscopic suturing all the time, but it is easier to teach a resident how to do robotic suturing, because it makes more sense. You’re using wrists as opposed to straight stick suturing with laparoscopy. While an incredibly important skill, it is not realistic to say that everyone is going to be a master at advanced laparoscopic suturing,” Dr. Higgins said.

“The technology provides an opening for surgeons to give patients minimally invasive approaches that they may not have had if they didn’t feel comfortable or have the training or exposure to do it laparoscopically,” she added.

Dr. Larson underscored that laparoscopy has a higher skill floor than robotics, meaning that while current practitioners can operate at an expert level, robotic surgery provides additional opportunities for surgeons to be involved in MIS.

“The surgeons who do laparoscopy at the highest level are incredible technicians, but robotics helps to level out skill for people who aren’t as technically gifted. They can provide the same outcomes because of the technology,” he said. “We’re upskilling surgeons from the baseline. A rising tide lifts all boats, and to me, robotics is a rising tide that not only benefits the surgeons but significantly benefits patients.”

There also has been a tangible shift toward robotics in terms of the highest-quality research—randomized controlled trials.

“I’ve been doing robotic surgery since 2008, but we’re now just starting to see large, randomized control trials that demonstrate robotic superiority over laparoscopy,” Dr. Larson said, noting that at an individual institution level, some of these results started to filter out between 2012 and 2020.

Future Promise, Present Practicalities

While the future appears to be one where the robotic approach will take the lead for many surgical procedures, that transition presently is in its early stages.

To begin with, further studies need to be completed, and research needs to be released providing a higher level of certainty regarding the superiority of robotic or laparoscopic surgery outcomes across the spectrum of disciplines and procedures.

Looking at one of the most common surgical procedures around the world—cholecystectomy—as an example, current research presents a range of findings. Some indicate that the robotic approach incurs a significant increase in bile duct injury complication rate versus laparoscopic, while others show decreased complications, conversion to open procedures, and shorter hospital stays.^6,7

In this interim period, as additional outcomes research accumulates, one of the most significant questions is related to cost and how that affects availability and the financial practicality of robotic platforms. Robotic surgery is generally found to be a more expensive approach in terms of intraoperative activities and infrastructure,⁸ though there is a down trending of costs for robotics over time in certain disciplines such as bariatrics.⁹

Existing OR infrastructure, in particular, could prove to be another financial challenge.

“In terms of hospital resources, we have hundreds of operating rooms in at the Mayo Clinic, and each one of them has a laparoscopic tower. So, I can do laparoscopy in every single OR, but I can’t do robotics. That’s a huge frame shift for hospitals—so as laparoscopy diminishes, we’ll need to retool the operating room so that we can do robotics,” Dr. Larson said.

“I’m not saying just jettison all of our laparoscopic equipment in every OR in the US, but we need to start thinking about the entire ecosystem,” he said. While surgeons over time may “vote with their feet” and move toward robotics, there often are administrative and political considerations that are tied to funding the transition to the new technology.

Open Surgery and Future of Surgical Education

The current era of surgery is defined by MIS, and both patients and surgeons continue seeking operations that lead to easier recovery, fewer complications, and improved outcomes.

However, open surgery remains a necessary part of a surgeon’s toolkit. Areas such as trauma, major oncologic resection, and organ transplantation continue to be mainly performed through open surgery because of ingress and egress to the operative space, as well the need to manually manipulate large tissue or organs (although even in these, MIS is advancing¹⁰).

Another reality that any surgeon employing MIS for an operation may encounter is converting to open if a surgeon does not feel that they are able to manage an unforeseen challenge—scar tissue, bleeding, or complex anatomy—with a robotic or laparoscopic approach. Conversion to open across specialties is associated with detrimental outcomes for patients and hospitals compared with a procedure with no conversion.¹¹

So, whether through circumstance, preference, or necessity, open surgery will always need to be an option for delivering the highest-quality outcome possible for patients.

“As a minimally invasive surgeon, many of my procedures that I do are minimally invasive, but I also need to know its limitations,” Dr. Higgins said. “If a patient isn’t tolerating the insufflation from minimally invasive surgery, that’s not what’s best for the patient, and then you convert to open. You need to have all the tools in your toolbox. It’s not fair to patients for us to just know one way, and only that way.”

While mastery of open surgery is essential for comprehensive surgical competence, surgical residents are, statistically, performing fewer open operations in their course of their training.¹² Experienced surgeons recognize that for as much as surgery is continuing to shift toward MIS, a lack of skill with open surgery imperils patient safety.

The core knowledge imparted by open surgery training, including a tactile understanding of a patient’s unique anatomy and disease presentation, remains a critical underpinning for MIS.

To that end, residency training must continue pushing forward with including evolving MIS technology and techniques, while also allowing adequate exposure to open surgery.

“I emphasize to the residents to get as much exposure as they can to open operative cases, which is even more important today because it is becoming less common,” said Dr. Higgins, who also is the General Surgery Residency Program director at MCW.

“We stress that residents try to take advantage of being in those cases, even if you’re not the first assist surgeon or the most senior resident. Even if you’re a more junior resident, get exposure to as much as you can see,” she said.

For open surgery, exposure refers to understanding how a case is set up to begin with.

“If you’re seeing less open surgery, it’s difficult to really get comfortable with that. You may understand inguinal anatomy, but if you don’t know how to set up an open inguinal hernia repair, you’re not going to do right by the patient,” Dr. Higgins said.

A major part of contemporary surgical education, and an effective way to address growing gaps with open surgery experience, is surgical simulation. While wet labs and core curricula continue to grow around MIS, simulation provides a safe environment to grow skills in all surgical modalities and is becoming a critical part of residency training for surgery because of duty-hour restrictions and lessened operative experience for junior residents.

Simulation acts as an adjunct for resident training that should include robotic, laparoscopic, and open components. For both cases—setup for open surgery and using the powerful visualization and manipulation tools in the various forms of MIS—simulation has become a core part of residency training to bring trainees up to a level of proficiency that produces high-quality outcomes and provides patient safety.

“We never have our residents just jump in and start doing minimally invasive surgery. They all need to do a robotic training curriculum, they all need to complete a laparoscopic curriculum, and so on. Simulation is a must for training programs to introduce residents to the technology in a safe, protected environment before they perform these techniques on a patient,” Dr. Higgins said.

The conversations happening within MIS, open surgery, and surgical training are developing, and will expand well beyond the scope of this article. Within clinical care itself, evolving technology and the balance of current practicalities and future potential will require surgeons to take the lead and emerge from this inflection point in a way that ensures patients are receiving the best possible care.

Matthew Fox is the Digital Managing Editor in the ACS Division of Integrated Communications in Chicago, IL.

References

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