Scarless Surgery: Advancements in Incision Techniques

Introduction

Minimally invasive surgery has greatly changed how we treat urologic diseases, and our active use of laparoscopy has led to better surgical results. The adoption of surgical robotics has taken this shift to the next level, putting urology at the forefront of innovation in minimally invasive procedures. However, challenges have emerged, including the requirement for specialized training and the associated costs of implementing new technology. In the late 1980s, laparoscopic cholecystectomy was first performed but was initially embraced by only a few surgeons. Early studies indicated that laparoscopy did not bring significant benefits to patients and could even increase costs and potential harm. Despite this, the public, influenced by the media and industry, insisted on having this innovative procedure. Consequently, the rapid spread and establishment of laparoscopic cholecystectomy as the current standard was largely driven by public demand. Therefore, apart from evaluating outcomes and improving instruments, a critical factor for any new surgical procedure is the patients' demand and perception of the techniques involved. This article aims to offer a comprehensive summary of scarless surgery and the recent advancements in minimally invasive surgery.

What Is Scarless Surgery?

Scarless surgery refers to minimally invasive surgery in which advanced incision techniques are used. Scarless procedures, like endoluminal procedures, take place inside organs without any external incisions. Natural orifice transluminal endoscopic surgery (Notes) involves making a small incision in an internal organ. Examples of endoluminal procedures include treating GERD with fundoplication, reducing the stomach pouch for obesity, and addressing achalasia in the esophagus. NOTES encompasses accessing internal organs through small internal incisions, like reaching the gallbladder behind the uterus. The Minimal Access Surgery Program offers single-port surgery, where specialized laparoscopic instruments are inserted through a single incision in the navel. This technique is used for gallbladder removal, sleeve gastrectomy for weight loss, and appendectomy. Single port surgery yields a better cosmetic result compared to traditional minimally invasive procedures, and the recuperation times for abdominal minimum access procedures are comparable. The program's multidisciplinary team, including gastroenterologists, surgeons, interventional endoscopists, and gynecologists, collaborates to perform various surgeries. Current procedures available include retro-uterine gallbladder removal, single port gallbladder removal, single port appendectomy, endoscopic treatment for GERD, endoscopic revision of obesity surgery, and single port/endogastric sleeve gastrectomy for obesity. Additionally, endogastric stomach plication is offered for weight loss.

What Are the Advancements in Incision Techniques?

Advancements in incision techniques for scarless surgery include:

• Natural Orifice Transluminal Endoscopic Surgery (NOTES): NOTES involves accessing internal organs through natural body openings (such as the mouth, vagina, or rectum) rather than making external incisions. This approach minimizes visible scarring.

• Transgastric and Transvaginal Approaches: Surgeons utilize the stomach (transgastric) or vagina (transvaginal) as entry points for instruments, avoiding external incisions and reducing the need for abdominal access.

• Single-Port Laparoscopy: Single-port laparoscopy, also known as single-incision laparoscopic surgery (SILS), involves making a single small incision through which multiple instruments can be inserted. This approach aims to reduce scarring compared to traditional multi-port laparoscopy.

• Natural Orifice Appendectomy: Procedures like transgastric appendectomy explore the possibility of removing the appendix through natural orifices, potentially eliminating the need for external incisions.

• Advanced Flexible Endoscopy: Flexible endoscopy has advanced to allow more intricate procedures to be performed internally, reducing the need for external incisions. Instruments can be navigated through natural body openings with improved precision.

• Robotic Surgery: Robotic-assisted surgery offers enhanced precision and dexterity, enabling surgeons to carry out difficult procedures through smaller incisions. This can contribute to minimizing visible scars.

• Hybrid Procedures: Hybrid procedures combine endoscopic techniques with laparoscopic or robotic assistance, providing a flexible approach to address specific patient needs while minimizing external incisions.

• Improved Closure Techniques: Advances in closure techniques, such as the use of self-absorbing sutures or closure devices, contribute to better wound healing and reduced scarring.

• Peroral Endoscopic Myotomy (POEM): Developed for treating achalasia, POEM involves making an incision internally through the mouth to access and treat the esophagus, eliminating the need for external incisions.

• Intraluminal and Intragastric Procedures: Procedures like intraluminal flexible endoscopy and intragastric interventions explore options for performing surgeries entirely within the gastrointestinal tract, reducing the need for external access points.

It is important to note that while scarless surgery aims to minimize visible scarring, the choice of technique depends on the specific procedure, patient characteristics, and surgeon expertise. Technological and methodological developments continue to influence the landscape of scarless surgery, providing patients with less invasive options and improved cosmetic outcomes.

What Are the Advantages of Scarless Surgery?

The following are the advantages of scarless surgery:

• Cosmetic Benefit - Scarless surgery gives no scars on the surgery site, which leads to an enhanced look even after surgery. Since the incision is made inside the body, there is no visibility of scars or incision marks outside the body.

• Reduced Pain - Due to the minimal invasion technique, the patient experiences less pain.

• Quicker Recovery - Scarless surgery allows rapid healing and helps in quicker recovery.

• Minimal Blood Loss - There is minimal blood loss during surgery due to an advanced incision technique. This gives an advantage to patients who are at increased risk of difficulties as a result of blood loss.

• Less Chance of Infection - Due to fewer external excision there is less chance of exposure to infection.

• Improved Quality of Life - Faster recovery, less pain, and scarless surgical sites lead to less disturbance to the patient’s daily routine, which results in enhanced quality of life.

Conclusion

The idea behind scarless procedures involves consistently reducing the invasiveness of diagnostic and therapeutic methods. It builds on the successes of flexible gastroenterological endoscopy and minimally invasive surgery, aiming to combine their benefits synergistically. Animal experiments have shown promising results for various interventions in the peritoneal and retroperitoneal space. However, further studies and technological advancements are needed to demonstrate the practicality and superiority of this concept in terms of medical outcomes and efficiency compared to current procedures. It's conceivable that scarless procedures could replace individual minimally invasive surgical techniques or even open up new areas of application. Beyond methodological advancements, creating appropriate organizational, infrastructure, and training structures is essential. If successful, the concept of scarless procedures could pave an attractive path into the future for numerous medical applications.