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Basic Surgical Science

It can safely be said that a paradigm shift has occurred in the world of general surgery over the last decade and a half. The introduction of video laparoscopic methods for cholecystectomy was followed, rapidly, by the development of minimally invasive methods for “advanced” procedures such as fundoplication, splenectomy, adrenalectomy, colectomy, nephrectomy, and gastric bypass, among others. The abdomen is not the only place where this revolution has occurred. Thoracoscopic pulmonary lobectomy and minimally invasive parathyroid procedures have also been developed and introduced. The surgical methods themselves, as well as all aspects of the technology utilized to carry out these operations, have evolved and continue to evolve at a breakneck pace. It is fairly safe to say that little or none of the equipment that we presently use is the same as was used back in 1992 or even 1995. Advances in the design and construction of ports, instruments, laparoscopes, and light sources have increased the surgeon’s ability to perform minimally invasive operations. The surgical landscape is forever changed and it is not clear at all just what the scene will look like a decade hence. What has fueled this gargantuan collective expenditure of energy, brainpower, money, and time? The answer is the ability to perform complex operations in ways that dramatically reduce the overall tissue trauma incurred during surgery. What is the clinical benefit of decreasing abdominal wall injury, and how do we judge these new methods? Different surgical methods have traditionally been evaluated by comparing the shortand longterm clinical results. This is certainly the case in regards to open and laparoscopic methods, where length of stay, severity and duration of pain, pain medication requirement, and return of bowel function, as well as tolerance of diet, have commonly been assessed and analyzed. The recurrence rates of inguinal hernia repair and the clinical impact of closed versus open fundoplication have also been determined and contrasted. In the setting of malignancy, as is the case with laparoscopic-assisted colectomy for cancer, the long-term survival as well as the local and distant recurrence rates are determined and compared. Indeed, clinical outcome is, in the end, the final acid test for a new surgical technique or approach. However, there is much more to be learned and many more questions to be asked of both the new and old surgical methods that we use.