What Is Minimally Invasive Surgery and How Do You Learn It?

Abstract

Innovation in surgery is not new and should not be unexpected. As an example, the history of total joint replacement has demonstrated continuous evolution, and the relatively high complication rates associated with early prostheses and techniques eventually led to the improvement of implants and refinement of the surgical procedures. Gradual adoption of these improvements and their eventual diffusion into the surgical community led to improved success and increased rates of implantation. Increased surgical experience was eventually accompanied by more rapid surgical performance and then by the development of standardized hospitalization protocols, which eventually led to more rapid rehabilitation and return to function. These benefits are well accepted and can be seen as helping contribute to the establishment of a more “consumer driven” and medical practice.

Most surgeons would agree that as experience guides the surgeon to more accurate incision placement, more precise dissection, and more skillful mobilization of structure, the need for wide exposure diminishes. Indeed, less invasiveness appears to be a hallmark of experience gained with a given procedure. From a historical perspective, this appears to be true of total hip replacement. The operation as initially described by Charnley required trochanteric osteotomy. The osteotomy served several purposes: generous exposure, access to the intramedullary canal for proper component placement and cement pressurization, and the ability of the surgeon to “tension” the abductors to improve stability. However, over time, it became apparent that trochanteric nonunion and retained trochanteric hardware could be proble­matic. In attempts to minimize these problems, some worked to develop improved techniques for trochanteric fixation. However, others went in a different direction, eventually demonstrating that the operation could be performed quite adequately without osteotomy. Many purists comp­lained that this was not the Charnley operation, and that the benefits of trochanteric osteotomy were lost. Yet the eventual acceptance of the nonosteotomy approaches by almost all surgeons performing primary total hip arthroplasty (THA) in the vast majority of circumstances would attest to the fact that osteotomy was not required to achieve the result that had come to be expected.