Minimally invasive mitral surgery: dangerous to dabble.

The introduction of any new surgical technique is fraught with dangers and difficulties, and in cardiac surgery, these potential negative outcomes are magnified by inherent small margins for error. Buxton's law states that it is always too early for rigorous evaluation (of a new technique) until, unfortunately, it is suddenly too late (1). This insightful statement was used to describe the phenomenon to often seen in the introduction of new technologies or procedures in medicine. There is a natural reluctance to subject new techniques to standardized assessment too early in the introductory phase in an attempt to avoid negatively biased results while operator learning is still occurring (2). Over the last two or three decades, this phenomenon has been described as the learning curve and has most often been applied to minimally invasive surgery of all specialties, including general surgery, gynecology, and cardiothoracic surgery. Buxton's concern was justified, because by the time the procedure has become well practiced, there is a reluctance to subject it to rigorous trials on the argument that this will deny the latest, and perhaps greatest, treatment to patients. Whereas each argument, pre-emptive assessment, or delaying access is valid in isolation, the combination is a dangerous system to follow because it prevents rigorous evaluation and denies best practice.