Em mais um editorial, os Drs. Leandro Cavazzola do Rio Grande do Sul e Gustavo Carvalho de Pernambuco novamente discutem o tema das novas tecnologias aplicadas a cirurgia minimamente invasiva. Desta vez, abordam as preferências dos pacientes e sua percepção sobre estas novas técnicas.
Publicada no Surgical Endoscopy, o artigo nos ajuda a entender um pouco mais a evolução da cirurgia neste século XXI.
Who should decide the best minimally invasive approach? Should we listen to our patients?
Leandro Totti Cavazzola • Gustavo Lopes de Carvalho • Jose Sérgio Nascimento Silva
We read with special interest the article entitled Patient Preferences for New Techniques: Should We Invest in New Approaches? by Rao et al. [1] published online 19 May 2010. This definitely well-designed article with an interesting methodology tried to question people about minimally invasive surgery considering their different educational backgrounds. Nevertheless, we cannot help disagreeing with some important points stated by Rao et al. [1].
An important issue stated in this paper is the assumption that single-port surgery involves the same principles as those currently recognized widely as foundational to ‘‘regular laparoscopic surgery.’’ As we stated in previous communications, single-port procedures are not regular laparoscopic surgery and therefore should be performed only by experienced laparoscopic surgeons with specific training in the animal lab before they are applied to human cases. Loss of triangulation (even with articulating instruments), collision of instruments, and important ergonomic concerns show that, although similar, this type of procedure (laparoendoscopic single-site surgery) implies different training and demands much more effort than regular laparoscopy [2].
Therefore, needlescopic surgery should be considered not only the most similar alternative to regular laparoscopic surgery, but also the technique offering better cosmetic results than laparoscopy. However, this option was forgotten by the authors and not presented to the individuals interviewed [3]. In addition, after working with all the devices available on the market and even considering single-incision surgery as proposed by Podolsky and Curcillo [4], we find it difficult understand that these procedures can be performed through a 12-mm incision because the minimal diameter of current ports is in the range of a 25-mm incision [4, 5]. Another point is that as incision size is increased, the rates of incisional hernia and infection should rise proportionally [6–8].
We congratulate the journal and Rao et al. [1] for stating that we should always ask the main individual interested in our minimally invasive surgical techniques: the patient [9–11]. As a matter of further contribution, we suggest that this type of survey should be reproduced adding needlescopic surgery, a currently established and well-studied alternative that should be offered as a surgical approach option to the interviewers, including pictures of postoperative cases to illustrate the difference among the surgical access scars [3]. It could definitely help patients to think better about their decision [12].
Despite the apparent widespread enthusiasm for minimally invasive procedures worldwide in recent years, their value extends beyond the demonstrated or potential clinical benefits [13]. In addition, economic considerations of patients, surgeons, and hospitals are prominent factors in this debate and should influence the adoption of these innovative minimally invasive surgical procedures in our daily practice.
Finally, we should never forget Henry Ford’s famous quotation about customers, which we must extrapolate to our patients: ‘‘If I had asked people what they wanted, they would have said faster horses.’’ People are commonly resistant to change. Surely we should always have the patients’ opinion, but we also should continue trying to find innovative strategies to diminish surgical trauma and give our patients better minimally invasive options with the least possible morbidity and risk [7, 13].
References
1. Rao AS, Kynaston J, MacDonald ER, Ahmeduld I (2010) Patient preferences for new techniques: should we invest in new
approaches? Surg Endosc [Epub ahead of print]. doi:10.1007/ s00464-010-1078-y
2. Muller EM, Cavazzola LT, Machado Grossi JV, Mariano MB, Morales C, Brun M (2010) Training for laparoendocopic singlesite surgery (LESS). Int J Surg 8:64–68
3. Carvalho GL, Silva FW, Silva JS, de Albuquerque PP, Coelho Rde M, Vilaca TG, Lacerda CM (2009) Needlescopic clipless cholecystectomy as an efficient, safe, and cost-effective alternative with diminutive scars: the first 1,000 cases. Surg Laparosc Endosc Percutan Tech 19:368–372
4. Podolsky ER, Curcillo PG (2010) Reduced-port surgery: preservation of the critical view in single-port-access cholecystectomy. Surg Endosc [Epub ahead of print]. doi:10.1007/s00464-010-1081-3
5. Rivas H, Varela E, Scott D (2010) Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients. Surg Endosc 24:1403–1412
6. Jones KB Jr, Afram JD, Benotti PN, Capella RF, Cooper CG, Flanagan L, Hendrick S, Howell LM, Jaroch MT, Kole K, Lirio OC, Sapala JA, Schuhknecht MP, Shapiro RP, Sweet WA, Wood MH (2006) Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 16:721–727
7. de Carvalho GL, Cavazzola LT (2010) Can mathematic formulas help us with our patients. Surg Endosc [Epub ahead of print]. doi: 10.1007/s00464-010-1065-3
8. Blinman T (2010) Incisions do not simply sum. Surg Endosc [Epub ahead of print]. doi:10.1007/s00464-009-0854-z
9. Peterson CY, Ramamoorthy S, Andrews B, Horgan S, Talamini M, Chock A (2009) Women’s positive perception of transvaginal NOTES surgery. Surg Endosc 23:1770–1774
10. Becerra Garcia FC, Romo-Medrano Mora KE (2010) Our perception of ‘‘women’s positive perception of transvaginal NOTES surgery’’: let the voices be heard, not just counted. Surg Endosc 24:1226–1228
11. Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009) Natural orifice surgery: initial clinical experience. Surg Endosc 23:1512–1518
12. Ross SB, Morton CA, Boyle R (2010) Citizen perceptions of LESS surgery and NOTES: the impact of age, gender, and BMI. Program and abstracts of The Society for Surgery of the Alimentary Tract (SSAT), 1–5 May 2010, New Orleans, LA
(Abstract 795)
13. Detry O, Nsadi B, Kohnen L (2010) Natural orifice transluminal endoscopic surgery (NOTES): when a step forward may be a step too soon or too far. Surg Endosc 24:1213–1214.
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