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KEY POINTS

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  1. Minimally invasive surgery describes a philosophical approach to surgery in which access trauma is minimized without compromising the quality of the surgical procedure.

  2. The carbon dioxide pneumoperitoneum used for laparoscopy induces some unique pathophysiologic consequences.

  3. Robotic surgery has been most valuable in the pelvis for performance of minimally invasive prostatectomy and gynecologic and fertility procedures.

  4. Natural orifice transluminal endoscopic surgery represents a new opportunity to develop truly scar-free surgery.

  5. Single-incision laparoscopic surgery reduces the amount of abdominal wall trauma but presents unique challenges to the traditional tenets of laparoscopic ergonomics.

  6. Laparoscopy during pregnancy is best performed in the second trimester and is safe if appropriate monitoring is performed.

  7. Laparoscopic surgery for cancer is also appropriate if good tissue handling techniques are maintained.

  8. Training for laparoscopy requires practice outside of the operating room in a simulation laboratory.

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INTRODUCTION

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Minimally invasive surgery describes an area of surgery that crosses all traditional disciplines, from general surgery to neurosurgery. It is not a discipline unto itself, but more a philosophy of surgery, a way of thinking. Minimally invasive surgery is a means of performing major operations through small incisions, often using miniaturized, high-tech imaging systems, to minimize the trauma of surgical exposure. Some believe that the term minimal access surgery more accurately describes the small incisions generally necessary to gain access to surgical sites in high-tech surgery, but John Wickham’s term minimally invasive surgery (MIS) is widely used because it describes the paradox of postmodern high-tech surgery—small holes, big operations.

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Robotic surgery today is practiced using a single platform (Intuitive, Inc., Sunnyvale, CA) and should better be termed computer-enhanced surgery because the term robotics assumes autonomous action that is not a feature of the da Vinci robotic system. Instead, the da Vinci robot couples an ergonomic workstation that features stereoptic video imaging and intuitive micromanipulators (surgeon side) with a set of arms delivering specialized laparoscopic instruments enhanced with more degrees of freedom than are allowed by laparoscopic surgery alone (patient side). A computer between the surgeon side and patient side removes surgical tremor and scales motion to allow precise microsurgery, which is helpful for microdissection and difficult anastomoses.

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Single-incision laparoscopic surgery (SILS), also called laparoendoscopic single-site surgery (LESS), is a recent addition to the armamentarium of the minimally invasive surgeon. As ­public awareness has grown, so too has its spread outside of larger institutions. SILS challenges the well-established paradigm of standard laparoscopic surgery by placing multiple trocars within the fascia at the umbilicus or through a single multichannel trocar at the umbilicus. The manipulation of tightly spaced instruments across the fulcrum of the abdominal wall requires that the surgeon either operate in a crossed hands fashion or use specialized curved instruments to avoid clashing outside the body while working intra-abdominally. The primary advantage of SILS is the reduction to one surgical scar. Greater efficacy, safety, and cost savings have yet to be ...

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