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1.  Minilaparotomically Assisted Vaginal Hysterectomy 
Journal of Korean Medical Science  2004;19(2):263-268.
Endoscopic hysterectomy is increasingly selected as a current trend to minimize invasion, tissue trauma and early recovery. However it has disadvantages of the difficulty to learn and needs expensive equipments. So we developed a new minimally invasive method of vaginal hysterectomy-minilaparotomically assisted vaginal hysterectomy (MAVH) in order to complement the current laparoscopic surgery. The principle of MAVH is based on suprapubic minilaparotomical incision and uterine elevator that allows access and maximal exposure of the pelvic anatomy and an easy approach to the surrounding anatomy enabling division of round ligaments, Fallopian tubes, tuboovarian ligaments, and dissection of bladder peritoneum. After then, the vaginal phase of MAVH is done by the traditional vaginal hysterectomy. We enrolled 75 consecutive cases and in 73 cases thereof MAVH was accomplished successfully. The technique of MAVH is simple and easy to learn and it involves a small incision causing less pain and complications. This practice does not require expensive equipments. MAVH is considered as a safe and effective alternative method for abdominal hysterectomy in most cases.
doi:10.3346/jkms.2004.19.2.263
PMCID: PMC2822309  PMID: 15082901
Minilaparotomically Assisted Vaginal Hysterectomy (MAVH); Laparoscopic Surgery; Laparo-scopy; Leiomyoma; Endometriosis
2.  Vibrating Interventional Device Detection Using Real-Time 3-D Color Doppler 
Ultrasound image guidance of interventional devices during minimally invasive surgery provides the clinician with improved soft tissue contrast while reducing ionizing radiation exposure. One problem with ultrasound image guidance is poor visualization of the device tip during the clinical procedure. We have described previously guidance of several interventional devices using a real-time 3-D (RT3-D) ultrasound system with 3-D color Doppler combined with the ColorMark technology. We then developed an analytical model for a vibrating needle to maximize the tip vibrations and improve the reliability and sensitivity of our technique. In this paper, we use the analytical model and improved radiofrequency (RF) and color Doppler filters to detect two different vibrating devices in water tank experiments as well as in an in vivo canine experiment. We performed water tank experiments with four different 3-D transducers: a 5 MHz transesophageal (TEE) probe, a 5 MHz transthoracic (TTE) probe, a 5 MHz intracardiac catheter (ICE) transducer, and a 2.5 MHz commercial TTE probe. Each transducer was used to scan an aortic graft suspended in the water tank. An atrial septal puncture needle and an endomyocardial biopsy forceps, each vibrating at 1.3 kHz, were inserted into the vascular graft and were tracked using 3-D color Doppler. Improved RF and wall filters increased the detected color Doppler sensitivity by 14 dB. In three simultaneous planes from the in vivo 3-D scan, we identified both the septal puncture needle and the biopsy forceps within the right atrium using the 2.5 MHz probe. A new display filter was used to suppress the unwanted flash artifact associated with physiological motion.
doi:10.1109/TUFFC.2008.798
PMCID: PMC2639786  PMID: 18599423
3.  A novel technique for pediatric femoral locked submuscular plate removal: the ‘push-pull’ technique 
Submuscular and minimally invasive plate insertion is gaining popularity reducing the need for large open approaches and resulting in a smaller operative ‘footprint.’ With pediatric fractures and titanium implants, fibrous and osseous ingrowth to the implant and osseous implant integration may interfere with implant removal. Therefore, the small minimally invasive implant insertion procedure may require a large maximally invasive exposure for implant removal after fracture healing. To reduce soft tissue damage, bleeding, scarring, and pain associated with implant removal, a minimally invasive procedure utilizing the pre-existing incisions while controlling the implant is efficient and beneficial. The surgical technique is described, and a case series of 21 treated pediatric femoral fractures illustrates the successful performance of the procedure and its limitations.
doi:10.1186/1749-799X-8-21
PMCID: PMC3711786  PMID: 23844650
4.  Thoracoscopic treatment of benign esophageal tumors 
Introduction
Gastrointestinal stromal tumors are among the most frequent mesenchymal tumors of the gastrointestinal tract; the incidence of these tumors in the esophagus is less than 5%. Prognosis depends on localization, size, mitotic activity and possible invasion of surrounding structures. Minimally invasive surgery may be maximally utilized for removal of these tumors from the esophageal wall. This operation is usually performed thoracoscopically or laparoscopically and using the “rendez-vous” method – with endoscopic navigation.
Aim
To evaluate a set of patients with benign tumor of the esophagus who were operated on at the First Department of Surgery from 2006 to 2011.
Material and methods
In the years 2006-2011 a total of 11 patients with benign tumors of the esophagus underwent operation.
Results
Of the 11 patients with esophageal tumor, 5 were diagnosed with gastrointestinal stromal tumor, 5 with leiomyoma and in one patient the lesion was described as heterotopy of the pancreas. We used the minimally invasive rendez-vous method with endoscopic navigation in 9 cases. All patients healed primarily and were released from hospital on the 4th-7th day. These patients are being followed up as outpatients and recurrence of the tumor has not been observed in any of them.
Conclusions
Minimally invasive treatment of benign tumors of the esophageal wall is considered to the method of choice. Due to possible complications and the need for subsequent therapy in some patients, these procedures should be centralized to departments with experience in esophageal, thoracic and minimally invasive surgery.
doi:10.5114/wiitm.2011.30817
PMCID: PMC3557729  PMID: 23362430
esophagus; esophageal tumor; thoracoscopy; benign tumor
5.  Minimally invasive approach for redo mitral valve surgery 
Journal of Thoracic Disease  2013;5(Suppl 6):S686-S693.
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining “mitral valve” with the following terms: ‘minimally invasive’, ‘reoperation’, and ‘alternative approach’. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed “mini” thoracotomy or “port access”. The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.
doi:10.3978/j.issn.2072-1439.2013.10.12
PMCID: PMC3831839  PMID: 24251029
Mitral valve; reoperation; minimally invasive approach
6.  Use of a radiopaque localizer grid to reduce radiation exposure 
Background
Minimally invasive spine surgery requires placement of the skin incision at an ideal location in the patient's back by the surgeon. However, numerous fluoroscopic x-ray images are sometimes required to find the site of entry, thereby exposing patients and Operating Room personnel to additional radiation. To minimize this exposure, a radiopaque localizer grid was devised to increase planning efficiency and reduce radiation exposure.
Results
The radiopaque localizer grid was utilized to plan the point of entry for minimally invasive spine surgery. Use of the grid allowed the surgeon to accurately pinpoint the ideal entry point for the procedure with just one or two fluoroscopic X-ray images.
Conclusions
The reusable localizer grid is a simple and practical device that may be utilized to more efficiently plan an entry site on the skin, thus reducing radiation exposure. This device or a modified version may be utilized for any procedure involving the spine.
doi:10.1186/1750-1164-5-6
PMCID: PMC3177900  PMID: 21827694
Radiation; Exposure; Minimally Invasive; Spine Surgery; Localization; Innovation; Grid
7.  Minimally invasive aortic valve replacement surgery through lower half sternotomy 
Journal of Thoracic Disease  2013;5(Suppl 6):S658-S661.
Less invasive approaches to aortic valve surgery frequently rely upon the development of new technology and instrumentation. While not suitable for every patient requiring an aortic valve procedure, these less invasive operations can offer certain clinical benefits and are becoming an important part of the modern cardiothoracic surgeon’s skillset. A lower partial sternotomy approach provides excellent visualization of the operative field, efficient execution of the operation and many of the benefits of minimally invasive surgery. Importantly, the lower partial sternotomy requires no new or unusual instruments and presents a familiar view to the surgeon. The technique, therefore, lends itself well to being adapted and utilized quickly with a potentially shorter “learning curve” for maximal surgical flexibility and patient benefit.
doi:10.3978/j.issn.2072-1439.2013.09.22
PMCID: PMC3831833  PMID: 24251024
Aortic valve replacement; lower partial sternotomy; minimally invasive surgery
8.  Robotic-Assisted Minimally Invasive Surgery for Gynecologic and Urologic Oncology 
Executive Summary
Objective
An application was received to review the evidence on the ‘The Da Vinci Surgical System’ for the treatment of gynecologic malignancies (e.g. endometrial and cervical cancers). Limitations to the current standard of care include the lack of trained physicians on minimally invasive surgery and limited access to minimally invasive surgery for patients. The potential benefits of ‘The Da Vinci Surgical System’ include improved technical manipulation and physician uptake leading to increased surgeries, and treatment and management of these cancers.
The demand for robotic surgery for the treatment and management of prostate cancer has been increasing due to its alleged benefits of recovery of erectile function and urinary continence, two important factors of men’s health. The potential technical benefits of robotic surgery leading to improved patient functional outcomes are surgical precision and vision.
Clinical Need
Uterine and cervical cancers represent 5.4% (4,400 of 81,700) and 1.6% (1,300 of 81,700), respectively, of incident cases of cancer among female cancers in Canada. Uterine cancer, otherwise referred to as endometrial cancer is cancer of the lining of the uterus. The most common treatment option for endometrial cancer is removing the cancer through surgery. A surgical option is the removal of the uterus and cervix through a small incision in the abdomen using a laparoscope which is referred to as total laparoscopic hysterectomy. Risk factors that increase the risk of endometrial cancer include taking estrogen replacement therapy after menopause, being obese, early age at menarche, late age at menopause, being nulliparous, having had high-dose radiation to the pelvis, and use of tamoxifen.
Cervical cancer occurs at the lower narrow end of the uterus. There are more treatment options for cervical cancer compared to endometrial cancer, however total laparoscopic hysterectomy is also a treatment option. Risk factors that increase the risk for cervical cancer are multiple sexual partners, early sexual activity, infection with the human papillomavirus, and cigarette smoking, whereas barrier-type of contraception as a risk factor decreases the risk of cervical cancer.
Prostate cancer is ranked first in men in Canada in terms of the number of new cases among all male cancers (25,500 of 89,300 or 28.6%). The impact on men who develop prostate cancer is substantial given the potential for erectile dysfunction and urinary incontinence. Prostate cancer arises within the prostate gland, which resides in the male reproductive system and near the bladder. Radical retropubic prostatectomy is the gold standard treatment for localized prostate cancer. Prostate cancer affects men above 60 years of age. Other risk factors include a family history of prostate cancer, being of African descent, being obese, consuming a diet high in fat, physical inactivity, and working with cadium.
The Da Vinci Surgical System
The Da Vinci Surgical System is a robotic device. There are four main components to the system: 1) the surgeon’s console, where the surgeon sits and views a magnified three-dimensional image of the surgical field; 2) patient side-cart, which sits beside the patient and consists of three instrument arms and one endoscope arm; 3) detachable instruments (endowrist instruments and intuitive masters), which simulate fine motor human movements. The hand movements of the surgeon’s hands at the surgeon’s console are translated into smaller ones by the robotic device and are acted out by the attached instruments; 4) three-dimensional vision system: the camera unit or endoscope arm. The main advantages of use of the robotic device are: 1) the precision of the instrument and improved dexterity due to the use of “wristed” instruments; 2) three-dimensional imaging, with improved ability to locate blood vessels, nerves and tissues; 3) the surgeon’s console, which reduces fatigue accompanied with conventional laparoscopy surgery and allows for tremor-free manipulation. The main disadvantages of use of the robotic device are the costs including instrument costs ($2.6 million in US dollars), cost per use ($200 per use), the costs associated with training surgeons and operating room personnel, and the lack of tactile feedback, with the trade-off being increased visual feedback.
Research Questions
For endometrial and cervical cancers,
1. What is the effectiveness of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
2. What are the incremental costs of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
For prostate cancer,
3. What is the effectiveness of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
4. What are the incremental costs of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
Research Methods
Literature Search
Search Strategy
A literature search was performed on May 12, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, Wiley Cochrane, CINAHL, Centre for Reviews and Dissemination/International Agency for Health Technology Assessment for studies published from January 1, 2000 until May 12, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low or very low according to GRADE methodology.
Inclusion Criteria
English language articles (January 1, 2000-May 12, 2010)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a primary data source (e.g. obtained in a clinical setting)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a secondary data source (e.g. hospital- or population-based registries)
Study design and methods must be clearly described
Health technology assessments, systematic reviews, randomized controlled trials, non-randomized controlled trials and/or cohort studies, case-case studies, regardless of sample size, cost-effectiveness studies
Exclusion Criteria
Duplicate publications (with the more recent publication on the same study population included)
Non-English papers
Animal or in-vitro studies
Case reports or case series without a referent or comparison group
Studies on long-term survival which may be affected by treatment
Studies that do not examine the cancers (e.g. advanced disease) or outcomes of interest
Outcomes of Interest
For endometrial and cervical cancers,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Number of complications*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of conversions to laparotomy*
Number of lymph nodes recovered
For prostate cancer,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Amount of morphine use/pain*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of transfusions*
- Duration of catheterization
- Number of complications*
- Number of anastomotic strictures*
Number of lymph nodes recovered
Oncologic factors
- Proportion of positive surgical margins
Long-term outcomes
- Urinary continence
- Erectile function
Summary of Findings
Robotic use for gynecologic oncology compared to:
Laparotomy: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations.
The beneficial effect of robotic surgery was shown in pooled analysis for complications, owing to increased sample size.
More work is needed to clarify the role of complications in terms of safety, including improved study designs, analysis and measurement.
Laparoscopy: benefits of robotic surgery in terms of shorter length of hospitalization, less blood loss and fewer conversions to laparotomy likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for length of hospitalizations and blood loss is low.
Fewer conversions to laparotomy indicate clinical effectiveness in terms of reduced morbidity.
Robotic use for urologic oncology, specifically prostate cancer, compared to:
Retropubic surgery: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss/fewer individuals requiring transfusions. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations. There was a beneficial effect in terms of decreased positive surgical margins and erectile dysfunction. These results indicate clinical effectiveness in terms of improved cancer control and functional outcomes, respectively, in the context of study design limitations.
Surgeon skill had an impact on cancer control and functional outcomes.
The results for complications were inconsistent when measured as either total number of complications, pain management or anastomosis. There is some suggestion that robotic surgery is safe with respect to less post-operative pain management required compared to retropubic surgery, however improved study design and measurement of complications need to be further addressed.
Clinical significance of significant findings for length of hospitalizations is low.
Laparoscopy: benefits of robotic surgery in terms of less blood loss and fewer individuals requiring transfusions likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for blood loss is low.
The potential link between less blood loss, improved visualization and improved functional outcomes is an important consideration for use of robotics.
All studies included were observational in nature and therefore the results must be interpreted cautiously.
Economic Analysis
The objective of this project was to assess the economic impact of robotic-assisted laparoscopy (RAL) for endometrial, cervical, and prostate cancers in the province of Ontario.
A budget impact analysis was undertaken to report direct costs associated with open surgery (OS), endoscopic laparoscopy (EL) and robotic-assisted laparoscopy (RAL) based on clinical literature review outcomes, to report a budget impact in the province based on volumes and costs from administrative data sets, and to project a future impact of RAL in Ontario. A cost-effectiveness analysis was not conducted because of the low quality evidence from the clinical literature review.
Hospital costs were obtained from the Ontario Case Costing Initiative (OCCI) for the appropriate Canadian Classification of Health Intervention (CCI) codes restricted to selective ICD-10 diagnostic codes after consultation with experts in the field. Physician fees were obtained from the Ontario Schedule of Benefits (OSB) after consultation with experts in the field. Fees were costed based on operation times reported in the clinical literature for the procedures being investigated. Volumes of procedures were obtained from the Ministry of Health and Long-Term Care (MOHLTC) administrative databases.
Direct costs associated with RAL, EL and OS included professional fees, hospital costs (including disposable instruments), radiotherapy costs associated with positive surgical margins in prostate cancer and conversion to OS in gynecological cancer. The total cost per case was higher for RAL than EL and OS for both gynecological and prostate cancers. There is also an acquisition cost associated with RAL. After conversation with the only supplier in Canada, hospitals are looking to spend an initial 3.6M to acquire the robotic surgical system
Previous volumes of OS and EL procedures were used to project volumes into Years 1-3 using a linear mathematical expression. Burden of OS and EL hysterectomies and prostatectomies was calculated by multiplying the number of cases for that year by the cost/case of the procedure.
The number of procedures is expected to increase in the next three years based on historical data. RAL is expected to capture this market by 65% after consultation with experts. If it’s assumed that RAL will capture the current market in Ontario by 65%, the net impact is expected to be by Year 3, 3.1M for hysterectomy and 6.7M for prostatectomy procedures respectively in the province.
RAL has diffused in the province with four surgical systems in place in Ontario, two in Toronto and two in London. RAL is a more expensive technology on a per case basis due to more expensive robot specific instrumentation and physician labour reflected by increased OR time reported in the clinical literature. There is also an upfront cost to acquire the machine and maintenance contract. RAL is expected to capture the market at 65% with project net impacts by Year 3 of 3.1M and 6.7M for hysterectomy and prostatectomy respectively.
PMCID: PMC3382308  PMID: 23074405
9.  Minimally invasive versus conventional exposure for total hip arthroplasty: a systematic review and meta-analysis of clinical and radiological outcomes 
International Orthopaedics  2010;35(2):173-184.
Over the past decade, minimally invasive surgery has gained popularity as a means of optimising early postoperative rehabilitation and increasing patient satisfaction and cosmesis following total hip arthroplasty (THA). However, this surgical exposure has also been associated with increased risk of iatrogenic nerve injury and implant mal-positioning due to limited visibility compared to conventionally larger surgical incisions. The purpose of this meta-analysis was to compare the outcomes of these two surgical exposures. A systematic review of the published and unpublished literature was conducted to include all randomised and non-randomised controlled trials comparing the clinical and radiological outcomes of minimally invasive and conventional THA procedures. In total, 28 studies met the eligibility criteria and included 2,849 hips, i.e. 1,428 minimally invasive compared to 1,421 conventional THAs. The meta-analysis of the current evidence base showed that minimally invasive THA is associated with a significantly increased risk of transient lateral femoral cutaneous nerve palsy (p = 0.006) with no significantly better outcome.
doi:10.1007/s00264-010-1075-8
PMCID: PMC3032108  PMID: 20559827
10.  Minimally Invasive Subvastus Approach: Improving the Results of Total Knee Arthroplasty: A Prospective, Randomized Trial 
Background
Minimally invasive knee arthroplasty seeks to diminish the problems of traditional extensile exposures aiming for more rapid rehabilitation of patients after surgery.
Questions/purposes
To determine if the subvastus approach results in less perioperative pain and blood loss, shorter hospital stay, and improved function at both early and long-term followup.
Methods
One hundred patients were enrolled in a prospective, randomized trial. Fifty were operated on using a minimally invasive subvastus approach and the other 50 by a conventional, peripatellar approach. Minimum followup was 3 years. A repeated-measures analysis of variance was used to compare the Knee Society score and range of motion during followup.
Results
The minimally invasive approach resulted in greater perioperative bleeding but no increase in transfusions. No differences were found in postoperative pain between groups nor did hospital stay show any differences. The range of motion on the third day after surgery was greater in the minimally invasive group. No differences were found in surgical time, femoral or tibial component orientation or outliers, or complication rates. Both Knee Society score and range of motion were superior using the minimally invasive subvastus approach during followup out to 36 months.
Conclusions
The minimally invasive subvastus approach can result in improved long-term Knee Society scores and range of motion of total knee arthroplasty without increased risk of component malalignment, surgical time, or complication rate.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-009-1160-8
PMCID: PMC2853674  PMID: 19911245
11.  Overview of single-port laparoscopic surgery for colorectal cancers: Past, present, and the future 
Single-port laparoscopic surgery (SPLS) is implemented through a tailored minimal single incision through which a number of laparoscopic instruments access. Introduction of operation-customized port system, utilization of a camera without a separate external light, and instruments with different lengths has brought the favorable environment for SPLS. However, performing SPLS still creates several hardships compared to multiport laparoscopic surgery; a single-port system inevitably leads to clashing of surgical instruments due to crowding. To overcome such difficulties, investigators has developed novel concepts and maneuvers, including the concept of inverse triangulation and the maneuvers of pivoting, spreading out dissection, hanging suture, and transluminal traction. The final destination of SPLS is expected to be a completely seamless operation, maximizing the minimal invasiveness. Specimen extraction through the umbilicus can undermine cosmesis by inducing a larger incision. Therefore, hybrid laparoscopic technique, which combined laparoscopic surgical technique with natural orifice specimen extraction (NOSE) - i.e., transvaginal or transanal route-, has been developed. SPLS and NOSE seemed to be the best combination in pursuit of minimal invasiveness. In the near future, robotic SPLS with natural orifice transluminal endoscopic surgery’s way of specimen extraction seems to be pursued. It is expected to provide a completely or nearly complete seamless operation regardless of location of the lesion in the abdomen.
doi:10.3748/wjg.v20.i4.997
PMCID: PMC3921551  PMID: 24574772
Colorectal neoplasms; Colectomy; Laparoscopy; Natural orifice endoscopic surgery; Single-port laparoscopic surgery
12.  The history and evolution of surgical instruments. VI. The surgical blade: from finger nail to ultrasound. 
Elective surgery requires planned incisions and incisions require appropriate blades. In the prehistoric era, division of the umbilical cord and other minor procedures were probably undertaken with human teeth and nails, and later with plant, animal and mineral substitutes, as witnessed by studies of primitive societies still surviving or recently extinct. More efficient metallic blades appeared in historic times and ultimately generated five specific shapes which are analysed in detail. Today, as minimally invasive techniques, endoscopes, laser and ultrasound sources evolve, many hallowed incisions of surgical access diminish in length or disappear entirely. In historical terms, elective surgery of the twentieth century will be recalled as an interlude characterised by maximally invasive incisions.
Images
PMCID: PMC2502426  PMID: 7486768
13.  Minimal Incision Congenital Cardiac Surgery 
Minimally invasive techniques have had limited application in congenital cardiac surgery, primarily due to the complexity of the defects, small working area, and the fact that most defects require exposure to intracardiac structures. Advances in cannula design and instrumentation have allowed application of minimal incision techniques but in most cases, cardiopulmonary bypass is still required. Image guided surgery, which uses non-invasive imaging to guide intracardiac procedures, holds the promise of permitting performance of reconstructive surgery in the beating heart in children.
doi:10.1053/j.semtcvs.2007.12.004
PMCID: PMC2440728  PMID: 18395631
14.  The golden age of minimally invasive cardiothoracic surgery: current and future perspectives 
Future cardiology  2011;7(3):333-346.
Over the past decade, minimally invasive cardiothoracic surgery (MICS) has grown in popularity. This growth has been driven, in part, by a desire to translate many of the observed benefits of minimal access surgery, such as decreased pain and reduced surgical trauma, to the cardiac surgical arena. Initial enthusiasm for MICS was tempered by concerns over reduced surgical exposure in highly complex operations and the potential for prolonged operative times and patient safety. With innovations in perfusion techniques, refinement of transthoracic echocardiography and the development of specialized surgical instruments and robotic technology, cardiac surgery was provided with the necessary tools to progress to less invasive approaches. However, much of the early literature on MICS focused on technical reports or small case series. The safety and feasibility of MICS have been demonstrated, yet questions remain regarding the relative efficacy of MICS over traditional sternotomy approaches. Recently, there has been a growth in the body of published literature on MICS long-term outcomes, with most reports suggesting that major cardiac operations that have traditionally been performed through a median sternotomy can be performed through a variety of minimally invasive approaches with equivalent safety and durability. In this article, we examine the technological advancements that have made MICS possible and provide an update on the major areas of cardiac surgery where MICS has demonstrated the most growth, with consideration of current and future directions.
doi:10.2217/fca.11.23
PMCID: PMC3134935  PMID: 21627475
minimally invasive cardiothoracic surgery; outcomes
15.  Thoracoscopic confirmation of correct seating of minimaly-invasive rapid-deployment aortic bioprosthesis 
There is a growing interest in minimally invasive access for aortic valve surgery. The upper hemi-sternotomy provides good aortic valve exposure, with numerous possible advantages. Nevertheless, some surgeons remain skeptical about limited access surgery because it is technically more demanding. Sutureless and rapid-deployment bioprostheses could alleviate these concerns by improving ease of implantation.
We herein describe the use of video-assisted visualization to verify the position of the balloon-expandable frame during rapid aortic valve deployment.
Sutureless and rapid-deployment bioprostheses improve implantation and make it easy to increase minimally invasive access for aortic valve surgery.
doi:10.12659/MSM.889094
PMCID: PMC3781200  PMID: 24045538
aortic valve; minimally invasive surgery; sutureless aortic valves
16.  A Compact Modular Teleoperated Robotic System for Laparoscopic Surgery 
Compared with traditional open surgery, minimally invasive surgical procedures reduce patient trauma and recovery time, but the dexterity of the surgeon in laparoscopic surgery is reduced owing to the small incisions, long instruments and limited indirect visibility of the operative site inside the patient. Robotic surgical systems, teleoperated by surgeons from a master control console with joystick-type manipulation interfaces, have been commercially developed yet their adoption into standard practice may be limited owing to their size, complexity, cost and time-consuming setup, maintenance and sterilization procedures. The goal of our research is to improve the effectiveness of robot-assisted surgery by developing much smaller, simpler, modular, teleoperated robotic manipulator systems for minimally invasive surgery.
doi:10.1177/0278364909104276
PMCID: PMC3130619  PMID: 21743765
robotic surgery; minimally invasive surgery; laparascopy; teleoperation
17.  From the Idea to Its Realization: The Evolution of Minimally Invasive Techniques in Neurosurgery 
Minimally Invasive Surgery  2013;2013:171369.
Minimally invasive techniques in neurosurgery evolved in two steps. Many minimally invasive concepts like neuronavigation, endoscopy, or frame based stereotaxy were developed by the pioneers of neurosurgery, but it took decades till further technical developments made the realization and broad clinical application of these early ideas safe and possible. This thesis will be demonstrated by giving examples of the evolution of four minimally invasive techiques: neuronavigation, transsphenoidal pituitary surgery, neuroendoscopy and stereotaxy. The reasons for their early failure and also the crucial steps for the rediscovery of these minimally invasive techniques will be analysed. In the 80th of the 20th century endoscopy became increasingly applied in different surgical fields. The abdominal surgeons coined as first for their endoscopic procedures the term minimally invasive surgery in contrast to open surgery. In neurrosurgery the term minimally invasive surgery stood not in opposiotion to open procedures but was understood as a general concept and philosophy using the modern technology such as neuronavigation, endoscopy and planing computer workstations with the aim to make the procedures less traumatic.
doi:10.1155/2013/171369
PMCID: PMC3877623  PMID: 24455231
18.  Minimally Invasive Mitral Valve Procedures: The Current State 
Minimally Invasive Surgery  2013;2013:679276.
Since its early days, cardiac surgery has typically involved large incisions with complete access to the heart and the great vessels. After the popularization of the minimally invasive techniques in general surgery, cardiac surgeons began to experiment with minimal access techniques in the early 1990s. Although the goals of minimally invasive cardiac surgery (MICS) are fairly well established as decreased pain, shorter hospital stay, accelerated recuperation, improved cosmesis, and cost effectiveness, a strict definition of minimally invasive cardiac surgery has been more elusive. Minimally invasive cardiac surgery started with mitral valve procedures and then gradually expanded towards other valve procedures, coronary artery bypass grafting, and various types of simple congenital heart procedures. In this paper, the authors attempt to focus on the evolution, techniques, results, and the future perspective of minimally invasive mitral valve surgery (MIMVS).
doi:10.1155/2013/679276
PMCID: PMC3870135  PMID: 24382998
19.  Multiple parallel skin markers for minimal incision lumbar disc surgery; a technical note 
Background
Spinal surgery depends on accurate localization to prevent incorrect surgical approaches. The trend towards minimally invasive surgery that minimizes surgical exposure and reduces postoperative pain increasingly requires surgeons to accurately determine the operative level before an incision is made. Preoperative localization with a C-arm image intensifier is popular, but the exposure of both patients and theatre staff to radiation is a disadvantage, as well as being time-consuming.
Methods
We describe a simple surgical tool developed to help localize exact spinal levels in conjunction with a simple AP X-ray film immediately before surgery. Multiple parallel skin markers were made using a circular oven rack comprising multiple 1.5 cm spaced parallel wires attached to a circular outside rim. The longest line was placed on the line of the postero-superior iliac spine (PSIS) over the junction of the L5-S1 region.
Results and conclusions
Based on the film taken, the incision can be accurately made at the intended level. The incision wound can be minimized to 3.0 cm even when using conventional disc surgery instruments.
doi:10.1186/1471-2474-5-8
PMCID: PMC394334  PMID: 15113431
20.  Multidisciplinary Teams in the Management of Rectal Cancer 
ABSTRACT
A myriad of advances in the treatment of rectal cancer have been achieved over the last few decades. The introduction of total mesorectal excision (TME) has resulted in significant improvements in local recurrence. Surgical education on the technique has made it the standard of care. Radiation and chemotherapy combined with TME have improved results even further with stage II and III cancers. Sphincter-sparing techniques, reservoir procedures, local treatment advances, minimally invasive techniques, surgery for metastatic disease, newer chemotherapies, and extended resections for locally advanced and recurrent lesions, have all benefited the patient with rectal cancer. The goal and responsibility of colorectal surgeons treating rectal cancer patients is to understand and coordinate the wide variety of modalities available to optimize survival, minimize morbidity, and maximize quality of life for those with this difficult problem. Coordination of specialists in this time of evolution in rectal cancer treatment becomes more important than ever. Here the authors briefly review the role of the multidisciplinary team, discuss a model multidisciplinary team approach and look at evidence supporting team use as we begin this issue devoted to the multidisciplinary management of rectal cancer.
doi:10.1055/s-2007-984858
PMCID: PMC2789504  PMID: 20011195
Multidisciplinary teams; rectal cancer; tumor board; total mesorectal excision
21.  Recent advances of robotic surgery and single port laparoscopy in gynecologic oncology 
Journal of Gynecologic Oncology  2009;20(3):137-144.
Two innovative approaches in minimally invasive surgery that have been introduced recently are the da Vinci robotic platform and single port laparoscopic surgery (SPLS). Robotic surgery has many advantages such as 3-dimensional view, the wrist like motion of the robotic arm and ergonomically comfortable position for the surgeon. Numerous literatures have demonstrated the feasibility of robotic surgery in gynecologic oncology. However, further research should be performed to demonstrate the superiority of robotic surgery compared to conventional laparoscopy. Additionally, cost reduction of robotic surgery is needed to adopt robotic surgery into gynecologic oncology worldwide. SPLS has several possible benefits including reduced operative complications, reduced postoperative pain, and better cosmetic results compared to conventional laparoscopy. Although several authors have indicated that SPLS is a feasible approach for gynecologic surgery, there have been few reports demonstrating the potential advantages over conventional laparoscopy. Moreover, technical difficulties of SPLS still exist. Therefore, the advantages of a single port approach compared to conventional laparoscope should be evaluated with comparative study, and further technologic development for SPLS is also needed. These two progressive technologies take the lead in the development of MIS and further studies should be performed to evaluate the benefits of robot surgery and SPLS.
doi:10.3802/jgo.2009.20.3.137
PMCID: PMC2757556  PMID: 19809546
Minimal surgical procedure; Endometrial neoplasm; Cervical neoplasm; Laparoscopic surgery
22.  A multidisciplinary evidence-based guideline for minimally invasive surgery. 
Gynecological Surgery  2012;9(3):271-282.
The Dutch Society for Endoscopic Surgery together with the Dutch Society of Obstetrics and Gynecology initiated a multidisciplinary working group to develop a guideline on minimally invasive surgery to formulate multidisciplinary agreements for minimally invasive surgery aiming towards better patient care and safety. The guideline development group consisted of general surgeons, gynecologists, an anesthesiologist, and urologist authorized by their scientific professional association. Two advisors in evidence-based guideline development supported the group. The guideline was developed using the “Appraisal of Guidelines for Research and Evaluation” instrument. Clinically important aspects were identified and discussed. The best available evidence on these aspects was gathered by systematic review. Recommendations for clinical practice were formulated based on the evidence and a consensus of expert opinion. The guideline was externally reviewed by members of the participating scientific associations and their feedback was integrated. Identified important topics were: laparoscopic entry techniques, intra-abdominal pressure, trocar use, electrosurgical techniques, prevention of trocar site herniation, patient positioning, anesthesiology, perioperative care, patient information, multidisciplinary user consultation, and complication registration. The text of each topic contains an introduction with an explanation of the problem and a summary of the current literature. Each topic was discussed, considerations were evaluated and recommendations were formulated. The development of a guideline on a multidisciplinary level facilitated a broad and rich discussion, which resulted in a very complete and implementable guideline.
doi:10.1007/s10397-012-0731-y
PMCID: PMC3401300  PMID: 22837735
Guideline; Minimally invasive surgery; Multidisciplinary; Laparoscopy; Access; Entry; Pneumoperitoneum
23.  Surgeon Perceptions of Minimally Invasive Spine Surgery 
SAS journal  2008;2(3):145.
Background
Interest in minimally invasive surgery (MIS) of the spine has driven the development of new and innovative techniques to treat an ever wider range of spinal disorders. Despite these new advances, spine surgeons have been slow in adopting MIS into their clinical practice. This study aims to provide a better understanding of the factors that have led to limited incorporation of these procedures into their practices.
Methods
Eighty-seven spine surgeons completed a questionnaire related to their perceptions of MIS. Respondents were asked to comment on their perceptions regarding the limitations and advantages of minimally invasive spine surgery. Survey results were then analyzed for both overall opinions and opinions based on the amount of MIS utilization in the respondents’ current practices.
Results
The top 3 identified limitations of MIS of the spine were technical difficulty, lack of convenient training opportunities, and radiation exposure. Of these respondents, spine surgeons experienced in MIS were concerned more with radiation exposure than the lack of training opportunities. In contrast, spine surgeons with little MIS experience cited the lack of training opportunities as the most significant limitation. There was little concern related to the limited proven clinical efficacy of MIS of the spine.
Discussion
Technical factors, training opportunities, and radiation exposure appear to be the major obstacles to MIS of the spine. Most spine surgeons believe that MIS leads to faster return to daily activities, better long-term function, and decreased hospitalization. This may explain why most surgeons did not cite a lack of proven efficacy as a major limitation to MIS.
These findings indicate that the widespread adoption of MIS of the spine will likely be driven through relatively simple means, such as improved training programs that strive to decrease the technical difficulty and limit radiation exposure of these procedures. It is unlikely that extensive clinical data alone, without such improved training programs, will be sufficient to drive widespread use of minimally invasive spine surgery.
doi:10.1016/S1935-9810(08)70032-X
PMCID: PMC2817980  PMID: 20148184
Surgeon perceptions; minimally invasive spine surgery; survey; limitations
24.  Combined ablation of atrial fibrillation and minimally invasive mitral valve surgery: a case report 
A partial lower inverted J sternotomy and an extended transseptal incision provide excellent exposure for minimally invasive mitral valve surgery. However, the extended trasnsseptal incision causes dividing the sinus node artery, which may result in conduction system disturbance and need for permanent pacemaker implantation. Therefore, there is a challenge in the patient who requires concomitant ablation for atrial fibrillation because of possible conduction system disturbance caused by extended transseptal incision. We describe a new strategy for combined ablation of atrial fibrillation with minimally invasive cardiac surgery by a transseptal approach to the mitral valve through a partial lower sternotomy incision. Cryoablation was performed using a T-shaped cryoprobe with a lesion set of pulmonary vein isolation and ablation of the left and right isthmus in performing mitral annuloplasty, tricuspid annuloplasty, and atrial septal defect closure through a limited sternotomy incision. This technique might minimize possible conduction system disturbance and provide good surgical result for the patients who undergo mitral valve surgery and ablation of atrial fibrillation.
doi:10.1186/1749-8090-5-79
PMCID: PMC2958893  PMID: 20937138
25.  Clinical review: What are the best hemodynamic targets for noncardiac surgical patients? 
Critical Care  2013;17(2):210.
Perioperative hemodynamic optimization, or goal-directed therapy (GDT), has been show to significantly decrease complications and risk of death in high-risk patients undergoing noncardiac surgery. An important aim of GDT is to prevent an imbalance between oxygen delivery and oxygen consumption in order to avoid the development of multiple organ dysfunction. The utilization of cardiac output monitoring in the perioperative period has been shown to improve outcomes if integrated into a GDT strategy. GDT guided by dynamic predictors of fluid responsiveness or functional hemodynamics with minimally invasive cardiac output monitoring is suitable for the majority of patients undergoing major surgery with expected significant volume shifts due to bleeding or other significant intravascular volume losses. For patients at higher risk of complications and death, such as those with advanced age and limited cardiorespiratory reserve, the addition of dobutamine or dopexamine to the treatment algorithm, to maximize oxygen delivery, is associated with better outcomes.
doi:10.1186/cc11861
PMCID: PMC3672542  PMID: 23672840

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