Minimally Invasive Surgery
If your doctor has recommended surgery, it’s natural to feel anxious about it. But minimally invasive (also known as laparoscopic or keyhole) procedures are making many surgeries dramatically safer and more tolerable. Instead of a large incision at the treatment site, the surgeon makes one or more very small incisions, and inserts slender instruments and a tiny camera to help visualize progress on a monitor. In some cases, the patient goes home with only bandages to cover the wounds.
“Almost every surgeon at Yale Medicine performs some type of minimally invasive surgery,” says Nita Ahuja, MD, chair of Yale Medicine Surgery and chief of surgery for Yale New Haven Hospital. “Of course, there may always be situations where the most effective way to perform a surgery will be through a larger incision. But minimally invasive approaches are an important tool in our toolbox now. They can be far easier on the patient, causing less tissue damage, fewer complications, and minimal pain and scarring. Patients recover quickly and leave the hospital sooner.”
How is minimally invasive surgery performed?
Typically, the surgeon will make one or more small incisions, which are called “ports.” The exact size of the ports will vary according to the procedure. Unlike an open surgery, the surgeon typically will not need to make extensive cuts through skin, muscle, tissue, and nerves.
The surgeon then works through the ports, inserting short, narrow tubes called trochars. The next step is to insert surgical instruments, along with tiny video camera equipment, through the ports. The surgeon manipulates the instruments to perform the surgery, while watching video pictures sent back from the camera on a monitor.
Depending on your procedure, there may be other differences in how a minimally invasive surgery is performed. For example, if you are having abdominal surgery, the surgeon will send carbon dioxide gas into your abdomen through a trochar to expand the area and provide room to operate.
Because minimally invasive surgery does not provide direct access to the surgical site in the same way as traditional open surgery, the procedure may be more complex for the surgeon. In some cases, it may take longer to perform.
What types of surgery are minimally invasive?
Surgeons are using minimally invasive approaches to diagnose and/or treat many cancers, abdominal issues such as appendicitis or gallbladder problems, hip and knee replacements, hiatal hernia repair, some heart surgeries, lung surgeries, and weight loss surgeries, among other types of procedures. A variety of terms are used to describe the various minimally invasive approaches:
Arthroscopic surgery: An orthopedic surgeon inserts a thin, flexible fiber optic video camera called an arthroscope through an incision the size of a buttonhole, near a joint (such as the knee), to examine, diagnose, and sometimes repair joint damage.
Bronchoscopy: A flexible tube with a light and a camera, called a bronchoscope, is inserted through the nose or mouth to look inside lung airways. Bronchoscopy helps to evaluate and diagnose lung problems, assess blockages, obtain samples of tissue or fluid, and help remove a foreign body.
Endoscopy: A small, flexible tube with a light and a camera lens at the end (endoscope) is used to examine the inside of the digestive tract. Tissue samples from inside the digestive tract may also be taken for examination and testing.
Hysteroscopy: A small, narrow telescope (a hysteroscope) is inserted through the vagina to allow visualization of the inside of the uterine cavity without the need for any incisions. This is often done to evaluate uterine bleeding. Specialized hysteroscopes are also used for treatment in some cases, such as the removal of fibroids, polyps, or scar tissue.
Laparoscopy: This was one of the first types of minimally invasive surgery. It involves making tiny incisions and inserting a tube with a light and a camera (the laparoscope) on its end. The camera sends live pictures to a video monitor, which allows the surgeon to visualize the anatomy as he or she performs complex surgeries with minimal trauma to the patient. Laparoscopy can also be used for diagnostic purposes, to examine organs, check for abnormalities, or take tissue samples.
Natural orifice transluminal endoscopic surgery (NOTES): This is a surgery that allows access to the abdominal cavity through natural orifices, such as the oral, rectal, or vaginal openings, with little to no scarring.
Parathyroidectomy: This technique removes abnormal parathyroid glands through an incision at the front of the neck, under local anesthesia, often on an outpatient basis.
Robotic: The surgeon sits at a console, tracking his or her progress using a 3D image on a monitor, while operating controls to maneuver robotic arms that will perform the surgery. While robotic surgery is new, it has proven useful for treating areas of the body that are difficult to navigate, such as the head and neck or genital areas. Use of the robotic arms allows surgeons to work with more precision and dexterity.
Sigmoidoscopy: A small, flexible tube with a light and a camera lens at the end (endoscope) is used to examine the rectum and sigmoid colon.
Video-assisted thoracoscopic surgery (VATS): A tiny camera (thoracoscope) and surgical instruments are inserted through small incisions in the chest to diagnose and treat problems affecting the lung, esophagus, and other areas in the chest.
What are the benefits and risks of minimally invasive surgery?
For patients, a minimally invasive surgical approach has many advantages over traditional, open surgeries:
- Less trauma, because the surgeon typically does not cut through muscles and other tissue to reach the surgical site
- Shorter and potentially no hospital stays, since some procedures can be done on an outpatient basis
- Less scarring
- Safety, because there is less blood loss and lower risk of infection
- Fewer complications
- Quick recovery, depending on the surgery. Minimally invasive approaches can often reduce a recovery that would have taken weeks down to a few days.
However, minimally invasive surgery is still surgery, even if the risks are lower. Side effects and complications can include bleeding, infection, and injury to organs. In the hands of an experienced surgeon who has performed a particular operation often, complications tend to be rare. But it’s still important to talk to your surgeon about any risks associated with your particular operation.
Are there certain patients who benefit from minimally invasive surgery?
Minimally invasive surgeries have advantages for obese patients, because operations that involve long incisions on a large amount of subcutaneous tissue are more likely to lead to infections or other problems.
These surgeries may also be more tolerable for people who have chronic pain issues, and for whom a large incision may result in more medicine to manage the pain, something that typically can be avoided with minimally invasive surgery.
Elderly people may also benefit from small incisions, because it means they don’t need to recover in bed as long and are likelier to avoid complications like blood clots in the legs as a result.
When is minimally invasive surgery not an option?
Every patient is unique, and so is every medical problem. There are some cases when open surgery is the better approach. For instance, it may be necessary when the surgeon needs to make an incision large enough to expose the tissue and structures that need to be operated on directly.
Some surgeries, such as complex thoracic aneurysm repairs, simply can’t be done effectively through small incisions. In other situations, a surgeon may plan a minimally invasive operation, but then find it necessary to switch to an open procedure for better visualization of the area being operated on. But this varies widely by specialty, so it’s important to talk to your doctor about your options.
How is Yale Medicine unique in the use of minimally invasive surgery?
Yale Medicine’s world-class surgeons and specialists offer the most advanced, minimally invasive surgeries for the most complex and routine cases. “We have treated many patients with minimally invasive approaches after they were told elsewhere that their problem was inoperable,” Dr. Ahuja says.
However, Yale Medicine surgeons also believe it’s important to remember that minimally invasive surgery is a treatment tool—and one of many. “Every patient is different and our surgeons are constantly learning and innovating,” Dr. Ahuja says. “The most important thing is that you have a team of specialists who have access to all of the latest tools and techniques, and who can help you understand the pros and cons of all the approaches available to you. Then, you can choose the tool that is best for you, whether that is a minimally invasive surgery or another approach.”