Extent of minimal access surgery

Minimal access surgery has crossed all traditional boundaries of specialities and disciplines. Shared, borrowed and overlapping technologies and information are encouraging a multi­disciplinary approach which serves the whole patient rather than a specific organ system. Broadly speaking, minimal access techniques can be categorised as follows.

Laparoscopy

A rigid endoscope is introduced through a metal sleeve into the peritoneal cavity which has been previously inflated with carbon dioxide to produce a pneumoperitoneum. There is little doubt that laparoscopic cholecystectomy has revolutionised the surgical management of cholelithiasis and has become the mainstay of management of uncomplicated gall­stone disease. With improved instruments and more experience, it is likely that other advanced procedures, currently regarded as controversial, will also become fully accepted.

Thoracoscopy

A rigid endoscope is introduced through an incision in the chest to gain access to the thoracic contents. Many feel that the benefits of thoracoscopy will prove to be even greater than those of laparoscopy.

Endoluminal endoscopy

Flexible or rigid endoscopes are introduced into hollow organs or systems, such as the urinary tract, upper or lower gastrointestinal tract, and respiratory and vascular systems.

Perivisceral endoscopy

Body planes can be accessed even in the absence of a natural cavity. Examples are mediastinoscopy, retroperitoneoscopy and retroperitoneal approaches to the kidney, aorta and lumbar sympathetic chain. Other more recent examples include subfascial ligation of incompetent perforating veins in varicose vein surgery.

Arthroscopy and intra-articular joint surgery

Orthopaedic surgeons have long used arthroscopic access to the knee, and have now moved their attention to other joints including the shoulder, wrist, elbow and hip.

Combined approach

The diseased organ is visualised and treated by an assortment of endoluminal and extraluminal endoscopes and other imaging devices.