Minimal access surgery--the renaissance of gastric surgery?

Peptic ulcer surgery has been revitalized by the introduction of minimal access techniques for surgery of chronic and perforated peptic ulcer. A wide range of vagotomies, including truncal vagotomy, anterior lesser curve seromyotomy with posterior truncal vagotomy and proximal gastric vagotomy, have been performed laparoscopically. Short-term (two-24 month) follow-up of laparoscopic anterior seromyotomy with posterior truncal vagotomy cases has been promising, but long-term follow-up is required to confirm these early good results. Laparoscopic repair of perforated peptic ulcers has also been described. Initial reports of laparoscopic gastrojejunostomy and Billroth II partial gastrectomy have also appeared. These procedures are technically very demanding and are currently being performed in only a few "centers of excellence" around the world. Cost-benefit analyses of medical treatment with proton-pump inhibitors versus laparoscopic vagotomy are necessary to determine which form of treatment is more economical in the long run. Criteria for patient selection need to be defined and substantiated by audit of outcome.