Minimal access is the buzzword in paediatric surgery. It essentially means performing a procedure without cutting open the body wall. While the principles and the basic steps of each surgery remain the same, special instruments are used which reach the organ in question via tiny, key hole incisions or through a natural orifice. Minimal access surgery includes:
Endoscopic surgery, which is a procedure performed inside a hollow organ (eg the urethra, the urinary bladder, the stomach, the ureters, even the kidney) through an optical instrument inserted through a natural orifice such as the urethral meatus or the mouth.
Laparoscopic and thoracoscopic surgery – in this type of surgery, long, fine instruments are inserted through the body wall to reach the organ that needs surgery. The surgeon uses a fine telescope with a camera to look inside. The term laparoscopic means that the surgery is done in the abdomen while the term thoracoscopic means that the surgery is being done in the chest.
Robot assisted surgery: this is the latest advancement in minimal access surgery in children. In this type of surgery, the surgeon uses robotic arms to perform key hole surgery. The robot is completely controlled by the surgeon, and all surgical decisions are made by the surgeon. The robot overcomes the most serious limitation of laparoscopy, which is freedom of movement. Laparoscopic instruments are like long sticks which are manoeuvred by the surgeon on one end to manipulate the organ on the other end. Robotic instruments have a complex assembly of miniature pulleys and joints at the tip which allow nearly as much movement as the human wrist. This makes it easier for the surgeon to perform complex reconstructive procedures through key hole incisions.
What surgeries can be performed by minimal access?
The list of procedures that can be performed with minimal access is exhaustive. In today’s world, nearly every type of surgery has been performed with minimal access. Whether or not a patient can undergo such a procedure depends on a number of considerations. For instance, many minimal access procedures require the body cavity to be filled with a gas, usually carbon dioxide. Patients with a compromised heart or severely affected lungs may not be able to withstand this carbon dioxide. Extremely small patients such as premature infants, besides having very delicate physiology, may be physically too small to accommodate the minimal access instruments. The feasibility of removing a tumour by minimal access depends on the size, location and behaviour of the tumour. In general, a minimal access procedure takes more time to perform than an open procedure.
However, the advantages of minimal access are not insignificant. This technique minimises the scarring in the muscles of the body wall, which is advantageous in the growing child. Since the incisions are smaller, the pain and the consequent need for painkillers are greatly reduced. Although operative time increases, recovery and return to routine activities are hastened. And of course, the cosmetic outcome of a keyhole incision is much better than that of a large incision.
All in all, a patient who is a candidate for minimal-access surgery should receive one. That said, the technique should not be misused.
