Spotlight on … minimally invasive surgery

The latter part of the 20th century saw many media reports of ‘psychic healers’ in the Philippines who claimed to remove organs without instruments or pain, while leaving no scars. This has nothing to do with the science and practice of surgery, but the fact that it captivated the attention of media and the public highlights the dream of surgery with no pain, no scar and no recovery time. Minimally invasive surgery (MIS), which promises fewer scars, less pain and shorter recovery time, has been widely covered in TOG articles over the last two decades. Considering how common heavy menstrual bleeding is, it was no surprise to find that endometrial ablation was one of the earliest applications of MIS. As early as 2000, TOG published a review of endometrial ablation techniques by David Parkin (TOG 2000;2:35–8). The article described two hysteroscopic and two second-generation techniques. By 2007, an update entitled ‘Current minimal access techniques in the treatment of heavy menstrual bleeding’ included over eight second-generation techniques (TOG 2007;9:223–32). Ten years later in 2017, the topic was revisited in the first of a two-part article covering surgical management of heavy menstrual bleeding (TOG 2017;19:37–45). By then, the focus had shifted to cover some of the long-term issues, such as the acceptability of various techniques, post-ablation syndrome and contraception after ablation. MIS for fibroids was covered in 2016 (TOG 2016;18:33–42) in a review of evidence-based management of uterine fibroids. The article provided a concise, well-illustrated description of hysteroscopic myomectomy with only a brief mention of the laparoscopic approach. Two years later, a full article was dedicated to laparoscopic myomectomy (TOG 2018;20:261–8). As the role of laparoscopy in management of endometriosis expanded from diagnosis to treatment, a review entitled ‘New techniques in managing endometriosis’ was published in the ‘New Developments’ section of the Journal in 2004 (TOG 2004;6:33–5). While the article briefly discussed some of the surgical aspects of management of endometriosis, the full scope of laparoscopic surgery for endometriosis was covered in 2007 and featured many interesting photographs (TOG 2007;9:147–52). Later on, two articles were crucial in directing the attention to the bigger picture. Firstly, Laborda et al. discussed the threshold for laparoscopy in pelvic pain within the diagnostic armamentarium (TOG 2010;12:7–12). Later, Hoo and colleagues described the therapeutic role of laparoscopic surgery in managing endometriosis-related pain within the context of a multifaceted approach (TOG 2017;19:131–8). As for any new technology, the safety profile and risk management strategy had to be defined. In its first ever issue, TOG published a review about avoiding complications of laparoscopic approach, concentrating on safe entry technique (TOG 1999;1:34–6). In 2001, Gregory Kalu and Jeremy Wright published ‘Laparoscopic surgery and the law’ (TOG 2001;3:141–6). The article highlighted how the potential for litigation in cases of laparoscopic surgery was high compared with ‘classical’ surgery, despite the fact laparoscopy had more favourable complication figures. With increasing the scope of using laparoscopic approach to include complicated procedures, the incidence of urinary tract injuries increased. In 2014, Minas and colleagues summarised available methods for prevention, recognition and management of urinary tract injuries in laparoscopic gynaecological surgery (TOG 2014;16:19–28). In 2015, Quinn and Moohan addressed the safety of MIS from a different angle. They reviewed the role of optimal ergonomics of laparoscopic surgery in minimising its risks on the surgeons’ musculoskeletal system (TOG 2015;17:77–82). As training is an essential part of safe MIS practice, the availability of training in laparoscopic management of ectopic pregnancy was the focus of a discussion paper (TOG 2006;8:251–5). Ten years later, in one of my favourite articles, the authors outlined the contemporary understanding of the process of learning psychomotor skills in laparoscopic surgery, with some fascinating insights into the way surgeons acquire such skills (TOG 2016;18:53–63). From surgical management of polycystic ovary syndrome (TOG 2000;2:17–20) and optimising assisted conception treatments (TOG 2013;15:91–8) to urogynaecology (TOG 2018;20:101–8), the role of laparoscopic surgery in different subspecialties was covered in TOG articles. Even maternity care had its share of MIS, with Gibb and Saridogan describing the technique of laparoscopic cervical cerclage for extreme preterm birth as part of their review of the role of abdominal cerclage (TOG 2016;18:117–25). Over the years, new horizons were covered by TOG articles, while some of the reviewed trends have seen the sun set on their time. Robot-assisted surgery in gynaecology was reviewed in 2011 (TOG 2011;13:183–8) and revisited in 2016 (TOG 2016;18:221–9). These two articles presented a balanced appraisal of the new technology as well a brief description of the techniques involved. By contrast, updates on hysteroscopic sterilisation (TOG 2017;19:227–35) represented what may prove to be the obituary of some trends in female sterilisation, after the discontinuation of some these techniques in many countries. An online collection of all TOG articles on minimally invasive surgery is available at onlinetog.org.