An Interview with Dr. Gustavo Carvalho, Bariatric Surgeon, Universidade de Pernambuco

HI Sarah, at first I’d like to say thank you, it is for me not only great honor but a great pleasure to work with you again in this interview, and I hope I can be of some help not only to give my sincere opinion but also to share my enthusiasm about Minilaparoscopy, that is possibly one of the most sub used great technique of minimally invasive surgery.

1. What is unique about the development of the new "mini-lap"?

 The low friction trocars were really a game changer for us, allowing us to tie knots and dissect tissue with an unmatched precision. Current Mini trocars we are using now, is called low friction, and unlike their ancestors from the 90s, do not have a sealing membrane or a valve (Low Friction). They have very low friction between trocar and forceps, therefore almost no force is needed to move the instruments inside the trocars. The possible increase in CO2leak was a huge reason for criticism at that time, but actually we measured ii, and it is so small – less than 0.1 l/min - that it does not impose any real consequence in the performance of the procedure. Its also nice to observe that many current technical limitations of MINI are being resolved by the efforts of the industry in crafting more resistant, with less chance to bend and higher performance instruments. The second point that we must stress about our new mini technique is that we have almost no use for the mini 3mm optics, especially for doing routine cases like cholecytectomies and inguinal hernias. For the third point we must not forget the fact that there are no 3mm clip appliers or stapling devices for mini. To solve this limitation, we have been always emphasizing the importance of the correct use of monopolar and bipolar electrosurgery, as well as the use of intracorporeal knots. Several procedures like appendectomy, inguinal hernia repair, anti-reflux procedures and of course our killer procedure mini-cholecystectomy are really suitable for the mini technique that we call clipless – it is overall much simpler and most efficient than the regular mini, that imposes a need to change optics in order to place clips - as we do not use the mini optics and consequently we can’t and don’t need to exchange the scope from 10 to 3mm and vice-versa just to put clips in the cystic duct and cystic artery - changing optics makes the procedure not only boring and time consuming but also more expensive as the mini-optics are expensive and not really long living. Mini clipless has been a real advancement for us. Wehave been performing this technique of Clipless cholecystectomy since 2000 and for that we have used just a standard 10-mm scope, we have been following very rigid standard principles, and after 16 years of experience we have done over 2.100 MINI Clipless cholecystectomies, without mortality, significant hemorrhage, cbd injuries or conversion to open surgery, when necessary, in few cases we have converted to regular laparoscopy – by placing 1 to 3 5mm trocars – that can undoubtedly confirm the safety of the mini clipless procedure. Currently, MINI Clipless is, depending on the settings, an ambulatorial procedure or a 1-day surgery, very safe, with all the advantages of laparoscopy, highly reproducible, cost effective, and with great aesthetic appeal leading to highly satisfied patient !

2.      How is it different from the old mini lap?

Ok Sarah, for that question let me take as an example the case of mini-clipless cholecystectomy: besides the fact that we use low friction trocars, what gives us much better dexterity and make our knot tying easier and quicker, not only when compared with regular laparoscopy but also when we compare it with the minis with regular trocars, we also have the advantage use a totally new generation of mini instruments, longer, much better crafted and with much stronger and durable material, when we compare them with the old instruments from the 90’s.

Still there are 5 points that must be emphasized in our technique that makes it a really simple and standard procedure, now being reproduced in several countries around the world.

1) Only one 11mm Trocar is used and its scar is hidden inside the navel, three other low friction mini-ports are used for inserting mini instruments.

2) As only one 10mm optics is used there is no necessity for boring and time consuming 3mm optics exchange, therefore we must tie knots.

3) Cystic duct is securely closed with surgical knots

4) Cystic Artery is safely sealed by electrocautery, strict principles must be followed for safe cauterization of cystic artery.

5) Gallbladder is always retrieved in a BAG, increasing safety for preventing contamination of the umbilical wound, also avoiding the necessity to exchange the optics.  

Considering that NOTES cholecystectomy is still experimental, although hybrid transvaginal cholecystectomy is gaining popularity in clinical practice and single port is still a nonstandard approach, with significant technical challenges, and a not stablished safety profile, Mini´s approach almost identical to the standard laparoscopic technique offers significant benefits without exposing patients to unecessary postoperative complications, therefore being the logical choice of evolution for a routine elective cholecystectomy.

3.      How do you think your new development will impact mini lap as it becomes more established in the industry?

In the last few years, mini has evolved from a mere surgical curiosity to a really useful and advantageous technique, and is currently being used more and more in many center around the world to perform a wide variety of surgical procedures in different surgical areas, such as colorectal, gynecologic, pediatric, urologic and general surgery, always in a safe and reproducible manner. The transition from traditional laparoscopy to Mini is really very smooth and easy for the general surgeon who is already well trained in laparoscopy. There is still however, a need to get familiarized with the mini-instruments and to learn some tips and tricks, for that, to supply that training, industry can be really helpful, as an untrained surgeon can jeopardize the technique for not using the instruments in the correct way, possibly damaging the instruments and the patient.

Another aspect that is important to mention is that mini is a cost saving procedure, Since low-friction mini-trocars and other mini instruments are reusable and now long lasting, Mini can lead to a significant cost reduction, since the high cost use of disposable equipment is avoided. On the other hand, the burden of clip appliers and staplers not existing for Mini procedures, reduces even more the total cost of different procedures. In the specific case ofcholecystectomy, not using clips not only saves money, but also surgical time since scope exchange is not necessary. In the case of inguinal hernia TEP repair, no balloon dissection is used and Mini-TEP is considerably faster compared to regular laparoscopic TEP repair. In mini appendectomy a knot is easily tied at the base, and no staplers are needed to be used in most of the cases. Staplers and clips are costly equipment, mini procedures, in general, do not use them, the advantages in cost effectiveness of mini procedures have been reported in surgical literature for different procedures calling the attention a paper published by Chekan at JSLS in 2013 when he found that mini cholecystectomy is more than 200 dollars cheaper than an average laparoscopic conventional chole. Considering that over 700.000 lap-choles are performed every year in USA, the adoption of mini besides all the advantages for the patients would imply in an economy of at least 140.000.000 USD, and those cases were not clipless, imagine if those cases could have been done clipless the economy would possibly be even higher.

4.      What do you see is the future for mini lap?

Even though mini has been among us for more than 20 years, we must say that the game is just starting for mini now, we believe in a bright future for mini in a not very long time from now. Unlike other new access methods like NOTES, Robotics and single-port, MINI reigns for its simplicity, offering increased dexterity, delicacy, and precision, without significantly adding extra costs and at the same time, maintaining the triangulation that is already an important stablished advantage of standard laparoscopy. As surgeons we all know that surgical precision has always been dear to our hearts. All those new developments will have a huge impact on mini as it will be progressively more standard and widespread as an efficient and cost effective surgical tool. Mini is more and more occupying the space that would in the long run be occupied by robots, but because of money shortage, that space is being occupied by minis. We will see from now, more and more, the most critical parts of a complicated laparoscopic procedure being done by minis, like a cbd exploration or reconstruction after a biliary procedure, or pyeloplasty, or a ureteral reconstruction, or tubal anastomosis, and believe me cosmetics will not be the reason, but true reason will be to use the proper instrument for the proper task. Imagine that a small needle for a 5-0 or 6-0 thread is better handled by a 3.0mm needle holder than with a 5mm needle holder. The surgeon who performs open surgery do not use the same instrument for different scale tasks. When they close the abdomen, which is a brutal task they use bigger and stronger needle holder and forceps, but when they are performing a very delicate anastomosis like a cbd or vascular suturing they switch theirs instruments for more delicate and proper ones. Why an endoscopic-surgeon must use only 5mm and 10mm instruments during a whole lap procedure. We believe that in a near future for example during a pacreatoduodenectomy a surgeon will switch to a robot to perform the more delicate anastomosis in a much more precise way, but for the surgeon who do not have enough resources to invest in a robot, still he will have the choice to do better by using mini instruments. In the long run mini would be considered the poor man robot. In the near future mini will be recognized not only as a tool with cosmetic advantages but with all the real advantages: besides being a simple and standard procedure, it gives the patient much less wall damage, is cost effective, have improved visualization and dexterity, keeping a safety profile compatible to standard laparoscopy, all those advantages that mini can provide goes far beyond cosmesis, the only proven advantage of single port so far!

5.      What other new things are you working on?

Most of our new plans now includes the development of new mini tools, and applying mini in even more advanced procedures, that will make mini even more attractive. Also we are pushing mini to the limits, doing now all advanced surgeries and procedures that we believe are much better performed by mini than regular LAP. We are now also working very hard in sending the mini message to the world, so more surgeons around the world will be able to understand that mini has much more to offer than just a pretty face, and cosmesis is just a good side effect of mini. When surgeons are able to understand that message they will be able to enjoy the real benefits of mini. We are also collaborating with many important surgical societies, like SOBRACIL, SLS and ELSA among others. We also are trying very hard to keep mini on the media and to make it even more attractive for surgeons and patients. We have recently started a facebook group named mini friends, and so far it is a great success being accessed regularly by more than 2300 surgeons around the world, who are interested in minimally invasive surgery, very interesting discussions including videos, pictures, questionings and case reports are being discussed frequently there, and for that we believe facebook is an amazing tool. We believe mini is now mature, but the real message of mini still need to be spoken and for that we once more thank you SARAH for the opportunity!

Gustavo Carvalho, M.D., is a laparoscopic/bariatric surgeon in Recife, Brazil, with subspecialties in minimally invasive surgery. He is a Society of Laparoendoscopic Surgeons (SLS) faculty member and recognized as a pioneer in mini-laparoscopy.