Book Review

Minimally Invasive Surgery and New Technology

N Engl J Med 1995; 332:1039April 13, 1995

Article

Minimally Invasive Surgery and New Technology
Edited by Felicien M. Steichen and Roger Welter. 762 pp., illustrated. St. Louis, Quality Medical, 1994. $130. ISBN: 0-942219-51-1

Few surgical disciplines have been untouched by the advent of minimally invasive therapy. In the five or six years since laparoscopic cholecystectomy was popularized, virtually every branch of surgery has tested the hypothesis that minimal-access surgery could have results comparable to those of open surgery, with less short-term morbidity. And if the number of new procedures has increased exponentially, so too has the number of publications about them.

This book is one of these new textbooks and deserves particular praise for its broad appeal and focus. It contains the proceedings of the Second International Congress on New Technology and Advanced Techniques in Surgery, held in Luxembourg in the fall of 1992. The book was at once outdated, because this field changes rapidly; nonetheless, it gives the reader an important account of minimally invasive surgery during its infancy and a valuable glimpse toward the horizon of this new and exciting field. As preparations are made for the next congress, it is important to look back over the past two years and assess the place of minimal-access therapy in the management of surgical disease.

Written accounts of proceedings are typically eclectic, representing the variety of presenters and styles. Thus, the chapters in this book vary considerably. Furthermore, the 1992 congress was heavily weighted toward Europe, and there is a continental flavor throughout. The two editors, however, come from both sides of the Atlantic: Professor Steichen is a distinguished U.S. surgeon who was instrumental in introducing and popularizing stapler techniques here, and Professor Welter is the emeritus director of the Princess Marie-Astrid Hospital of Luxembourg.

The book is long (more than 750 pages, including the index) and covers the state of the art as it was in 1992. Moreover, it is protean, looking not only at minimal-access surgery but also at areas in which new techniques have made substantial inroads into the management of surgical disease. That is a key point, for in the past two years the field of minimally invasive surgery has changed remarkably. Nonetheless, the changes that have occurred have been evolutionary rather than revolutionary, and much that is found in this book serves as the background against which expansion has occurred in the intervening years. There are important sections on areas such as laser surgery, argon-beam techniques, and the physics of electrosurgery. Naturally, a large portion of the book is devoted to laparoscopic surgery of the biliary tract, but in addition it covers important evolving areas in traditional surgery, such as innovative anastomotic techniques, neoadjuvant therapy for rectal cancer, the use of biologic sealants for visceral fistulae, and the ethics of technology. Moreover, the chapters on minimal-access surgery are not confined to the abdomen, but also include the thorax, the retroperitoneum, and the vascular system.

The phrase “paradigm shift” is often used to describe minimal-access surgery, but unfortunately it is also used to describe any of a host of changes that occur in daily life. Therefore, it has become somewhat hackneyed. Yet in the sense in which the historian of science Thomas Kuhn initially used the term — to describe the painful changes that often occur when a radically new scientific concept replaces long-held beliefs — minimal-access surgery truly is a paradigm shift. It is hard to overestimate the importance of the development of laparoscopic cholecystectomy and the subsequent adaptation of this technique to a host of other intraabdominal, pelvic, retroperitoneal, and thoracic diseases. It will surely stand with the three other radical surgical changes that the past hundred years have witnessed: anesthesia, antisepsis, and organ transplantation. Furthermore, this shift has come not from academic medical centers but from community surgeons, and it has been fired by consumer demand rather than the insistence of the medical hierarchy. Consumers, fed a partially digested menu of high technology by the Defense Department, Hollywood, and MTV, saw in minimal-access surgery what was not immediately evident to the profession: that surgical cures could be relatively painless and that medicine need not taste bitter.

Despite the popularization of minimal-access surgery and the clamor for it by the public, surgeons who have taken up the standard have found an entirely new world of technical difficulty, one that, though based on the Halstedian tenets of surgery, demands new skills, new perceptions, and an appreciation of the inherent wrinkles in space and dimension that confound entry into a two-dimensional world. This legerdemain requires patience, persistence, and an appreciation of the way our minds interpret the world around us. Once these are achieved, however, the surgeon sees and does things in ways never before imagined.

This book is a substantial foundation in the new surgical world, a thorough presentation of the state of the art, and a glimpse of what is to come. As such, it should become an important part of the library of anyone interested in minimal-access surgery, regardless of subspecialty.

David C. Brooks, M.D.
Brigham and Women's Hospital, Boston, MA 02115