Minimally invasive surgery.

During the last 10 years, minimally invasive surgery has influenced the techniques used in every specialty of surgical medicine. This development has not only led to the replacement of conventional procedures with minimally invasive ones, but has also stimulated surgeons to reevaluate conventional approaches with regard to perioperative parameters such as pain medication. However, two major drawbacks have emerged with the introduction of this new technique: firstly, the prolonged learning curve for most surgeons, in comparison with the learning process in open surgery; and secondly, increased costs due to investment in the equipment required and the use of disposable instruments, as well as longer operating times. In the various health-care systems around the world, these increased costs are not always compensated for by shorter hospital stays. This review focuses on major areas of indication for minimally invasive surgery in the gastrointestinal tract. These include functional disorders of the upper and lower gastrointestinal tract, obesity surgery, minimally invasive techniques in gastric and hepatobiliary surgery and in other solid organs, and laparoscopic colorectal surgery. The shortening of the hospitalization period has led to increasing use of outpatient laparoscopic surgery, and many centers specializing in day-care surgery are using these techniques. The frontiers are being pushed even further, as the size of the instruments is reduced to achieve better cosmetic results. Clinical research has also focused on the topic of expanding the indications for minimally invasive approaches in the elderly and in high-risk patients, to take advantage of the shorter hospital stays and reduced surgical trauma that are possible. A considerable amount of basic research has been carried out on the stress response during and after minimally invasive procedures, and an improved immune response with the minimally invasive approach has been observed, leading to better results after extensive oncological procedures. Robotic surgery and telesurgery involve new computer-aided methods that allow greater precision in surgical technique, as well as offering an opportunity to supply surgical skill and expertise remotely, over long distances. Minimally invasive surgical techniques are thus now fully established in routine use, and the indications are continuing to expand.