We have witnessed three major medical revolutions, which can be called patient friendly. One was asepsis, the second was anaesthesia and the most recent is minimal access surgery, otherwise also called minimally invasive surgery, keyhole surgery or laparoscopic surgery. Earlier it was necessary for surgeons to make a large muscle cutting incision to enter the abdominal cavity because it was important to have both the working hands inside the abdomen for manipulation. The large incision was also needed to let the light inside the body to visualize the organs for the surgical procedure. Developments in electronic engineering like the miniaturized camera and telescopes made it possible to visualize the insides of the body, and hence, endoscopy was developed. In due course of time, a very reliable system of illumination was developed and surgeons could operate on patients without opening the abdominal or chest cavity.
As the new century unfolds, we are in the midst of a second surgical revolution, based on advances in imaging techniques, in particular fibre-optics and microchip cameras. These have led to magnified images of the contents of the abdominal and chest cavities and the insides of many viscera. Projected on to large screens, sometimes with three-dimensional imagery, these developments, combined with the production of small instruments and miniaturised stapling machines, have allowed the development of minimal access and endoscopic surgery.
In laparoscopy, few small punctures are made in the abdomen or chest varying from 2-10 mm through which ports are used for introduction of various instruments and energy sources. From one port, a camera mounted telescope is put inside the abdomen and this also carries a bright light for illumination. Images of the various organs are projected on the TV monitor and the organs are manipulated according to the need of the operations. Through these small ports, various types of needles, sutures can be passed into the abdomen for various operations.
The biggest advantage of minimal access surgery is the reduced post operative pain that can be easily managed with a few pain killer tablets. The operation produces tiny scars and the cosmetic results are excellent. Patients may be discharged within few hours of surgery and resume their normal activities within 3-4 days after the operation.
Minimal access surgery has been criticized for its high cost. However, if one calculates the overall economics of this surgical procedure, it works out to be cheaper because of the early resumption of work and minimum discomfort. Many of the complications like wound infection and scar hernias are rarely seen with this surgery. It was also believed, in the past, that this is surgery for the affluent. However, we strongly feel that this may be more important for poor people who are required to resume work soon after the operation.
The advent of laparoscopic cholecystectomy (key hole removal of gall bladder) led to rapid and impressive dissemination of knowledge and has prompted many advances. Indeed, as Blaise Pascal stated "imagination disposes off everything; it creates beauty, justice and happiness, which is everything in the world". This imagination applied to surgery has expanded the horizons of the general surgeons into the new field of minimal access surgery.
At a time when new technologies are being increasingly developed at an increasing rate, it is important for surgeons to evaluate critically, not only the effectiveness, but also the cost-effectiveness and influence on quality of life of new technologies. We are fortunate to be living in a time when advances in other sciences can be adapted for use in surgery. The skeptical surgeon is one who will always question whether a new technology is an advance on the existing technology, and if it is, whether it is cost-effective.
It is heartening to note that the surgical fraternity in India has kept pace and indeed, taken a lead in several aspects to advance the frontiers of minimal access surgery. This speaks volumes for the technical brilliance, innovativeness and innate adaptability of Indian surgeons and industry, which normally function under severe financial and resource constraints.
Financial and budgetary constraints have impeded the large-scale spread of the new technology to the peripheral areas in the country. Many surgeons were skeptical, and rightly so, before accepting minimal access surgery. Rigid and conditioned mindsets were reluctant to embrace newer ideas because that meant entering the 'learning curve' again. However, the overwhelming benefits and patient friendliness ensured that minimal access surgery took firm roots all over the country.
Some of the more commonly performed operations in India today by minimal access surgery are surgery for gallstones, appendicitis and diagnostic laparoscopy. With increasing expertise, more and more operations are being performed and it is estimated that an overwhelming majority of operations being performed conventionally by long incisions will be performed by minimal access in the next decade.