As the world sought the 'Holy Grail' of scarless surgery, minimizing access seemed to be the natural path to follow, and minilaparoscopy (MINI) was considered to be a natural advancement of standard laparoscopy. It aims at minimizing surgical trauma by further reducing the diameter of standard instruments, without compromising range of motion, triangulation or safety. Several different terms have been coined to address this sophisticated reduced-port technique, which is characterized by the use of instruments 3 mm or less in diameter: acuscopic surgery, minilaparoscopy, needlescopic surgery and microlaparoscopy. The early adoption of MINI was mostly inhibited by the limitations of first-generation instruments, especially with respect to functionality, cost and durability. Furthermore, mini cholecystectomy demanded the use of mini optics, which suffered from poor imaging quality and a short lifetime of the scopes. Newer-generation mini instruments have mitigated these issues through the use of improved effector tips, better insulation, strength and durability, and superior optics. During the early MINI years, surgeons clipped most structures, but sturdy mini clip appliers were either unavailable or did not hold the requisite-size clips. Clipping with MINI required the use of a standard clip applier and the scope had to be changed several times during a procedure, making MINI not only more complicated but also boring and time-consuming. The development and popularization of the clipless technique allowed the surgeon to get free from the expensive and cumbersome minilaparoscopic clip appliers, and replace clips with knots. The marked improvements in instrumentation and the development of the clipless technique have occurred simultaneously with the development of NOTES, LESS and Robotic surgery, which may have contributed to a greater push towards MINI. MINI has been proven to offer more than just better cosmesis. Other advantages include better visualization of the surgical field and, with the development of precisely engineered low-friction trocars, which enhance surgical precision during dynamic and delicate tasks (knotting and suturing small structures), less stress and higher efficiency, which makes the procedure easier to perform. Furthermore, transmission of electro cautery through mini instruments has led to less lateral spread of electric current and subsequent less tissue trauma. For more than 20 years, our team has successfully used minilaparoscopy. Even with the rising popularity of robotic surgery, which still uses 8 mm instruments, minilaparoscopy remains an attractive option that is far from becoming obsolete.

Background: Inguinal hernia repair has been a controversial area in surgical practice. Its complexity is reflected by the fact that numerous different procedures including both open and laparoscopic techniques are in use today. Laparoscopic totally extraperitoneal (TEP) repair is preferred over transabdominal pre-peritoneal repair as the peritoneum is not breached and also due to fewer intra-abdominal complications. This is the most elegant technique but rather difficult to perform. Aim: The purpose of this study was to describe Dulucq's technique for inguinal hernia repair and the use of three-dimensional mesh without fixation in laparoscopic TEP inguinal hernioplasty. Methods: Surgical technique of laparoscopic TEP inguinal hernia repair is detailed in the text. Results: A total of 945 hernia repairs were included in the study. The hernias were repaired by Dulucq's technique. Mean operative time was 45 min in unilateral hernia and 65 min in bilateral hernia. There were no serious complications. Conclusion: The laparoscopic TEP hernioplasty by Dulucq's technique is feasible with fewer intra-abdominal complications. The dissection must always be done with the same stages with minimal monopolar diathermy and patient in a slight Trendelenburg position.

This reason for this editorial arose following the publication in Surgical Endoscopy: Biomolecular inflammatory response to surgical energy usage in laparoscopic surgery: results of a randomized study [1]. This RCT is interesting in attempting to quantify the inflammatory response produced by laparoscopic cholecystectomy (LC), conducted with use of electrosurgical dissection (ED) and compared to dissection without use of electrosurgery [1]. Whilst we can no more than agree with the authors on most of their findings, we consider some issues need addressing. In essence by this RCT, the authors conclude that during an LC, the inflammatory response to surgical trauma is significantly greater when ED, on the basis of a sequential increase in IL-6 and TNF-a levels. What is of some concerns to us and other readers of this publication is that the clinical significance, indeed consequence of this rise in cytokines is not addressed by the authors. At our institution, we perform LC with regular use of ED using minilaparoscopic approach, including cauterization of the cystic artery. In a series of more than 2000 patients (Table 1) with strict adherence to the well-known principles governing safe ED [2], we have not encountered any CBD injury and not observed any objective adverse effect of ED which delayed recovery, with the vast majority of these patients being discharged within the first 24 h after their operation, and without any major complaint [3–5]. The development of high-frequency electrocautery by Cushing and Bovie [6], allowed surgeons to dissect and cut living tissues with minimal bleeding and great precision. It’s interesting that like Cushing, most of us never really did learn the physics behind one of the most important technical improvements in modern surgery. But undoubtedly Cushing knew well enough that objectively reducing blood loss with precise hemostasis, electrosurgery allowed him to operate more safely in patients with tumors that had been previously deemed inoperable, as well as on those suffering from different kinds of neurosurgical diseases [6, 7]. The high temperature and lateral spread of of electric current—particularly when monopolar mode is used—can produce collateral tissue damage. It is true that monopolar current when applied at 60 W for 1 s exhibits a mean critical spread of 3.5 mm; but the spread exceeds 20 mm when applied for 2 s or more [8]. Thus, compared to short bursts, a more prolonged continuous current may increase the extent of collateral damage. Electro-thermal damage can result from unrecognized energy transfer within the operative field or from stray currents beyond the operative field (so called ‘off screen injuries’). Stray currents can result due to insulation failure, direct coupling or capacitive coupling. The entire surgical team should have a sound knowledge of the biophysics of electrosurgery, the basis of equipment, general tissue effects and be aware of the importance of good surgical Editorial invited by Prof. Dr. Sir Alfred Cuschieri.

Background and Objectives: Current treatments for overweight adults include reduced-calorie diet, exercise, behavior modification, and selective use of medications. Many achieve suboptimal results with these measures and progress to obesity. Whether the intragastric balloon (IGB), a reversible device approved for treatment of obesity, is a safe and effective option in overweight adults is less well studied. We conducted a study to prospectively analyze the safety and effectiveness of IGB in overweight adults, to compare the results to a simultaneously studied cohort of obese patients, and to share procedural tips for safe IGB placement and removal. Methods: One hundred thirty-nine patients were evaluated in this prospective, nonrandomized study. Twenty-six overweight [body mass index (BMI), 26–30)] and 113 obese (BMI > 30) patients underwent outpatient, endoscopic IGB placement under intravenous sedation. The IGB was filled with a 550–900 mL (average, 640 mL) solution of saline, radiological contrast, and methylene blue, with an approximate final proportion of 65:2:1. The patients were followed up at 1–2 weeks and then monthly for 6 months. At 6 months, they underwent IGB removal via an esophageal overtube to optimize safety, and then they were observed for 6 more months. Results: IGB time was 190 ± 36 d in the overweight patients and 192 ± 43 d in the obese patients. Symptoms of IGB intolerance included nausea and pain, which were transiently present in 50–95% of patients for several days, and necessitated early IGB removal in 6% of patients. There were no procedure-related complications and no IGB-related esophagitis, erosion, perforation, or obstruction. The percentage of excess weight loss (EWL%) was 96 ± 54% in the overweight group and 41 ± 26% in the obese group (P < 0.001). Conclusion: In overweight adults failing standard treatments, IGB placement for 6 months had an acceptable safety profile and excellent weight loss.

Background and Objectives: Inguinal hernia repair is among the most common procedures performed worldwide and the laparoscopic totally extraperitoneal (TEP) approach is a recognized and effective surgical technique. Although technically advantageous because of the option of no mesh fixation and no need for creation of a peritoneal flap resulting, in less postoperative pain and faster recovery, TEP has not achieved the popularity it deserves, mainly because of its complexity and steep learning curve. Minilaparoscopy was first described in the 1990s and has recently gained significantly from better instrumentation that may increase TEP's effectiveness and acceptance. We performed a prospective study, to analyze the outcomes of minilaparoscopy in pain and operative time when compared to the conventional laparoscopic technique in hernia repair.Methods: Fifty-eight laparoscopic inguinal hernia repairs were performed: 36 by traditional laparoscopic technique and 22 by minilaparoscopic instruments (mini). A study protocol was applied prospectively for data collection. Variables analyzed were early postoperative pain (at hour 6 after procedure), pain at discharge, use of on-demand analgesics, and operative time.Results: The mini group presented reduced early postoperative pain and operative time. The present study also suggests less postoperative pain at discharge with mini procedures, although this difference was not statistically significant. No difference between the groups regarding on-demand use of analgesics was found.Conclusions: This study corroborates findings in previously published papers that have shown the feasibility of minilaparoscopy in laparoscopic TEP hernia repair and its benefits regarding postoperative pain, operative time, and aesthetic outcomes.

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 23, No. 8 Letter to the EditorMinilaparoscopic Surgery—Not Just a Pretty Face! What Can Be Found Beyond the Esthetics Reasons?Gustavo L. Carvalho, Leandro Totti Cavazzola, and Prashanth RaoGustavo L. CarvalhoOswaldo Cruz University Hospital and UNIPECLIN, Faculty of Medical Sciences, University of Pernambuco, Recife, Brazil.Search for more papers by this author, Leandro Totti CavazzolaFederal University of Rio Grande do Sul, Porto Alegre, Brazil.Search for more papers by this author, and Prashanth RaoGlobal Hospitals & Mamata Hospital, Mumbai, India.Search for more papers by this authorPublished Online:31 Jul 2013https://doi.org/10.1089/lap.2013.0147AboutSectionsView articleView Full TextPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited ByA SAGES technology and value assessment and pediatric committee evaluation of mini-laparoscopic instrumentation19 August 2022 | Surgical Endoscopy, Vol. 36, No. 10Inguinal Hernia Repair with Mini-laparoscopic Instruments24 November 2018Pediatric laparoscopic cholecystectomy with 2.3 mm Percutaneous Surgical System (MiniLap®): A new frontier for pediatric mini laparoscopy?Journal of Pediatric Surgery Case Reports, Vol. 6MINILAPAROSCOPIC APPENDECTOMYABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo), Vol. 29, No. 1Transjejunal Extraction of Gallbladder After Mini-Laparoscopic Cholecystectomy in Patients with Previous Roux-en-Y Gastric Bypass: A Small Case Series Cuneyt Kayaalp, Ali Tardu, Mehmet Ali Yagci, and Fatih Sumer2 July 2015 | Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol. 25, No. 7Mini-laparoscopic live donor nephrectomy with the use of 3-mm instruments and laparoscope3 September 2014 | World Journal of Urology, Vol. 33, No. 5 Volume 23Issue 8Aug 2013 InformationCopyright 2013, Mary Ann Liebert, Inc.To cite this article:Gustavo L. Carvalho, Leandro Totti Cavazzola, and Prashanth Rao.Minilaparoscopic Surgery—Not Just a Pretty Face! What Can Be Found Beyond the Esthetics Reasons?.Journal of Laparoendoscopic & Advanced Surgical Techniques.Aug 2013.710-713.http://doi.org/10.1089/lap.2013.0147Published in Volume: 23 Issue 8: July 31, 2013Online Ahead of Print:June 21, 2013PDF download