Why have we embraced minimally invasive surgery and ignored enhanced recovery after surgery?

There has been a lot of enthusiasm about minimally invasive surgery (MIS) in the surgical community in recent times. Some of the main reasons for this are an unmatched appeal to patients, doctors and healthcare systems alike. Push from the industry also serves as an important reason for its popularity. 'Enhanced recovery after surgery' (ERAS) is a programme of implementing multimodal interventions in the perioperative period to promote faster recovery. Even though MIS is an important component of ERAS protocols, the latter has not seen the reception the former has received. In this article, the authors present their personal viewpoint on the matter. The authors intend to highlight issues surrounding an increasing emphasis on MIS and to caution against the MIS operative technique superseding comprehensive perioperative care.

The field of surgery is moving ahead at a rapid pace in the 21st century. It may be said with sufficient confidence that surgery has become safer today than ever before. Large incisions are being replaced by 'keyholes'. Tubes can be inserted from almost any opening in the body for diagnostic or therapeutic purposes. Surgeons are moving from the side of the patient to remote terminals in operating rooms. The master (surgeon) has a new slave (the robot). Evolution in surgical methodology has aimed to make surgery as minimally invasive as possible. This is due to an understanding that minimal interruption of the patient's physiology offers him/her the best chance at a faster recovery after surgery. The development of minimally invasive surgery (MIS) has been possible due to technological advances in instrument development. There is a fascinating amount of technology at the disposal of a surgeon today. However, the current understanding and adoption of MIS has become a matter of intense debate for some in the surgical community. There are a few who believe that recently the emphasis on MIS has superseded the delivery of comprehensive perioperative care. The criticism is that MIS techniques are only one part of the patient care system and should not become the focus of surgical practice.

In recent times, another concept in providing comprehensive patient care is 'enhanced recovery after surgery' (ERAS). It essentially involves resolving the pathologic process in a patient by minimal interruption of normal physiology or with minimal deviation. This in turn gives the patient a chance of a faster recovery and may also result in fewer complications in the postoperative period. Professor Henrik Kehlet described this programme as comprising multimodal interventions in the perioperative care of a patient to hasten recovery.[1] Most of the research in the field has been done in Europe. Even though this concept is almost two decades old, it has not seen widespread application in India. There are very few examples of studies from India that have dealt with ERAS.[23] A survey conducted by the authors also showed that even though awareness regarding ERAS is not low, implementation of practices in India is poor.[4] This is so in spite of convincing evidence regarding the efficacy of ERAS. There can hardly be any debate that MIS is a vital component of an ERAS programme. However, an ERAS programme actually consists of much more.[1] ERAS has been shown to improve recovery when compared to MIS alone in traditional settings. In fact, it has been seen that MIS may not confer significant additional benefit when applied within an ERAS programme.[5] Hence the question that begs to be asked is, why have we embraced MIS but not ERAS?

There can hardly be any debate that MIS has revolutionised the field of surgery. Even in early comparative studies it had been noted to not only reduce recovery time and improve outcomes but also improve quality of life indicators, when compared to open surgery.[6] It is a common misconception that MIS sufficiently enhances recovery such that other interventions in perioperative care may not matter. The popularity of MIS is due to reasons involving patients, doctors and the industry. Smaller incisions, less pain and the absence of disfiguring scars make these procedures more acceptable to patients. Surgeons reportedly prefer MIS as, in addition to the above, it reduces recovery time and decreases the risk of complications such as wound dehiscence, incisional hernia and bowel adhesions.[7] Aggressive marketing and promotion of equipment by the industry also contributes to its popularity.

There may, however, be a few other reasons for the current popularity of MIS. MIS generates intrigue and adulation in trainee and senior surgeons alike. Surgeons are enamoured by the technical capability that MIS offers. It also has an appeal to the proverbial 'alpha' in every surgeon. The bravado of performing a spectacular surgery may easily overcome the sensibility of performing safer albeit 'boring' surgery. The fact that some surgeons call themselves 'laparoscopic' surgeons or MIS specialists bears testimony to the appeal of MIS amongst surgeons. Traditional specialties were formed on the basis of organ systems (e.g., colorectal, hepatobiliary surgery) or diseases (e.g., surgical oncology) that a surgeon/physician treated. Never has a method of performing surgery been given the status of a sub-specialty. There are fellowships offered in laparoscopy training; on the other hand, it is assumed that the surgical trainee will learn about perioperative care while training. The peer pressure to learn MIS techniques may make it highly desirable to master this skill, sometimes at any cost. In India, many surgeons have learned 'on the job' and have had no formal training in MIS as a result of this peer pressure. On the other hand, there is almost no emphasis on comprehensive perioperative care during training. Many a time, unknowingly, an attitude that 'surgeons are responsible only for the intraoperative course of the patient' is reinforced in the mind of the surgical trainee. It is assumed that the role of the perioperative care provider will be performed partly by the anaesthesiologist and partly by an intensivist. More trainees are worried about whether they will be able to perform a laparoscopic cholecystectomy independently by the end of their training than about providing comprehensive perioperative care.

A lot of surgical training takes place through mentorship. Role models play an important part in the development of a surgical trainee. They leave a huge impression and shape the careers of young surgeons. This influence has been largely underestimated. It is truly debatable how many surgeons can actually fill the role of a comprehensive care provider. However, there is no dearth of 'laparoscopic surgeons' in India. They become role models for young surgeons and fascination with MIS is only propagated. The mood of the surgical community can also be judged from the popularity of innumerable conferences and programs where surgeons' show-case advanced laparoscopic skills. A difficult case that warrants advanced laparoscopy meets with a round of applause. It bears testimony to the fact that senior surgeons and trainees alike are enamoured by laparoscopy. There are only few conferences on comprehensive perioperative care and they usually have only a handful of surgeons in the audience. It might be even more surprising to know out of the handfuls who attend, how many are invited and how many appear voluntarily.

In the atmosphere of enthusiasm generated around MIS, some caution may be warranted. MIS has a few limitations. It is disappointing that even with its widespread adoption the practice of MIS is still not regulated. The techniques may be practised by any surgeon irrespective of training and skill. The learning curve to techniques involved may be small for some surgeries but is steep for others. This may give rise to complications, the exact magnitude of which is rarely discussed but not uncommonly experienced. It may also be inappropriate to think of MIS as the end of open surgery. In patients presenting with anaesthetic challenges or a compromised cardiopulmonary status, performing open surgery may be a safer or even the only option. When laparoscopic procedures are converted to open procedures, for whatever indication, skills learnt at open surgery are indispensible to manage complications or complete the operation. There are instances where the differences between MIS and open surgeries may actually be reduced or even disappear, such as within ERAS programmes.[8] In some instances, such as gastrointestinal or colorectal malignancy, MIS has been found to produce equivalent oncologic outcomes when compared to open surgery.[9] Even though enthusiasts may use this to justify the use of MIS in such cases, it may also be concluded that open surgery is equally efficacious.

The introduction of MIS has been a huge leap forward in the modern surgical era. It may be wise, however, to not let it become the focus of healthcare delivery to surgical patients. The principles of safe surgery and comprehensive perioperative care should take precedence over technical prowess. Surgical decision-making may factor in the use of MIS to the patient's advantage. However, it should be immune to the bias that may arise due to the appeal of MIS to the surgeon. The only safeguard to this at this time may be a conscientious surgeon who puts patient welfare above all else at all times.

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Conflicts of Interest

There are no conflicts of interest.