Why I hate the minimal access movement
Ok, maybe hate is too strong a word… I suppose I don’t really “hate” minimal access surgery, but rather the propaganda around a subject laced with soft secondary benefits whilst ignoring the primary aim for surgery.
Just because the access is smaller, it does not make what is done inside the body cavity less traumatic or invasive. If an equivalent procedure is performed, it will be as equally invasive. What saving is the “trauma” associated with a 4 inch versus an 8 inch sternotomy or the cumulative sum of 3 x 1.5 inch port sites versus a 8 inch limited thoracotomy, or a 6 inch limited thoracocomy and 2 x 1.5 inch port sites with VATS assistance versus 10 inch thoracotomy? If the procedure takes longer than conventional access surgery, would the duration of surgical trauma result in greater overall physiologic stress?
Many surgeons use the minimally invasive route as a self / institution promoting strategy hoping to gain more referrals and better patient acceptance for procedures where primary efficacy and safety are usually unconfirmed by randomised trials. Indeed, the primary aim is often forgotten in pursuit of surrogate marker to justify the performance of a possibly more expensive, less accessible, less complete and more compromising (during the initial learning curve) procedure. Why do most trials on VATS surgery for pneumothorax report pain and length of hospital stay instead of recurrence rates, and observation studies on minimal access revascularisation report pain and hospital stay instead of angiography graft patency, recurrence of angina and survival?
Reports of new techniques are often undertaken by enthusiasts in the field, who have a vested interested in proving what they are doing is better, and are often reviewers of papers related to these techniques, therefore how many papers critical to what they do would receive a good review?
My own views are that state of the art is not necessarily better, efficacy must be proven in the primary reasons for surgery before patients and referring physicians are “sold” the soft benefits of minimal access surgery.