This technique has also been applied in the treatment of malignant melanoma, and is potentially useful in other settings. Robotics in surgery Robotics is rapidly developing in surgery, although the word is slightly misused in this connection. each section of the paper. Because of the broad nature of the topics covered, we have generally cited good quality reviews rather than the original papers. Technological sea change Laparoscopy has been well established in gynaecology for many years, but the technique was adopted much more slowly in surgery. This is usually mainly because of the early limits of the technology. Gynaecologists used a purely optical telescope for illumination and visualisation and operated unassisted. With one hand around the telescope, the gynaecologist had only one hand to manipulate the viscera, and thus the technical repertoire was limited. The development of miniaturised television cameras that give an adequate image was key in the minimal access revolution. It allowed the assistant to have the same view as the surgeon. The assistant could therefore hold the camera (allowing the surgeon to operate with two hands) and retract the viscera to improve the access. Laparoscopic cholecystectomy was soon shown to be possible, and rapidly became the procedure of choice.2 The principles that were developed for laparoscopic cholecystectomy have now been applied to many other abdominal and thoracic operations. Recent advances Minimal access surgery has moved the focus of surgery towards ERK5-IN-1 reducing the morbidity of patients while maintaining quality of care Minimal access surgical techniques are now routine for cholecystectomy, Nissen fundoplication for gastro-oesophageal reflux disease, splenectomy, and adrenalectomy Use of sentinel node biopsy is minimising the morbidity associated with staging breast cancer Surgical robotics systems will enable a further revolution in minimally invasive techniques Future developments are likely to be fuelled by patient demand The importance of laparoscopic cholecystectomy was the cultural change it engendered rather than the operation it replaced. In terms of technique, the focus of attention shifted from the surgeon’s virtuosity to minimising the morbidity experienced by the patient.3 In a paper published in 1996 on laparoscopic adrenalectomy, the postoperative ERK5-IN-1 inpatient ERK5-IN-1 stay was decreased from 9.8 to 5.1 days.4 The next year, a second group reported a total inpatient stay as low as 2.4 days.5 Minimally invasive abdominal surgery Laparoscopic Nissen fundoplication Advances in the pharmacological management of gastro-oesophageal reflux disease have been accompanied by a surge of interest in surgical management of this condition. There are three reasons for this. Firstly, although the indications are that long term drug treatment is safe, it is very expensive. Estimated annual costs to the NHS for H2 antagonists and proton pump inhibitors for patients with gastro-oesophageal reflux disease are 60m and 90m respectively. Many of these patients could be treated by surgery. Secondly, gastro-oesophageal reflux disease is difficult to diagnose. Oesophageal manometry and pH monitoring are increasingly used to improve diagnostic accuracy. Better case selection will lead to better long term results from surgery. Thirdly, laparoscopic Nissen fundoplication has been shown to be technically feasible, safe, and effective and have a low rate of conversion to open surgery. 6 Although fundoplication is highly effective for controlling gastro-oesophageal reflux disease, it is unclear whether the cost savings of laparoscopic surgery over lifelong drug treatment justify the (admittedly much reduced) inconvenience and morbidity of surgery. These issues are about to be investigated in the UK collaborative gastro-oesophageal reflux disease trial run by the health service’s research unit at the University of Aberdeen (www.abdn.ac.uk/hsru/hta/reflux.hti). Minimal access techniques Established Laparoscopic cholecystectomy Diagnostic laparoscopy Laparoscopic appendicectomy Laparoscopic Nissen fundoplication Laparoscopic (or thoracoscopic) Heller’s myotomy25 Laparoscopic adrenalectomy Laparoscopic splenectomy Thoracoscopic sympathectomy Laparoscopic rectopexy26 Under evaluation Laparoscopic hernia repair Laparoscopic colectomy Laparoscopic nephrectomy for living related donor transplant Parathyroidectomy (guided with hand held gamma probe) Laparoscopic repair of duodenal perforation27 Prospects Sentinel node biopsy Hepatic resection Gastrectomy Inguinal hernia repair Inguinal hernia is common, and effective minimal access techniques have been developed. However, these techniques have not been adopted as widely as, for example, laparoscopic cholecystectomy. The first reason for this is that minimal access techniques were first advocated at the peak of a revolution in open surgical technique: the adoption of the open, tension-free mesh (Lichtenstein) repair.7 The Lichenstein repair was shown to have recurrence rates tenfold lower than those of the Shouldice repair, which was then the standard technique. The surgical community embraced the new technique,8 and further technical revolution was, unsurprisingly, met with scepticism. This scepticism was compounded by the fact that several techniques were proposed. The intraperitoneal on-lay mesh had.Minimal access techniques Established Laparoscopic cholecystectomy Diagnostic laparoscopy Laparoscopic appendicectomy Laparoscopic Nissen fundoplication Laparoscopic (or thoracoscopic) Heller’s myotomy25 Laparoscopic adrenalectomy Laparoscopic splenectomy Thoracoscopic sympathectomy Laparoscopic rectopexy26 Under evaluation Laparoscopic hernia repair Laparoscopic colectomy Laparoscopic nephrectomy for living related donor transplant Parathyroidectomy (guided with hand held gamma probe) Laparoscopic repair of duodenal perforation27 Prospects Sentinel node biopsy Hepatic resection Gastrectomy Inguinal hernia repair Inguinal hernia is common, and effective minimal access techniques have been developed. gynaecology for many years, but the technique was adopted much more slowly in surgery. This is mainly because of the early limits of the technology. Gynaecologists used a purely optical telescope for illumination and visualisation and operated unassisted. With one hand on the telescope, the gynaecologist had only one hand to manipulate the viscera, and thus the technical repertoire was limited. The development of miniaturised television cameras that give an adequate image was key in the minimal access revolution. It allowed the assistant to have the same view as Itga2 the surgeon. The assistant could therefore hold the camera (allowing the surgeon to operate with two hands) and retract the viscera to improve the access. Laparoscopic cholecystectomy was soon shown to be possible, and rapidly became the procedure of choice.2 The principles that were developed for laparoscopic cholecystectomy have now been applied to many other abdominal and thoracic operations. Recent advances Minimal access surgery has moved the focus of surgery towards reducing the morbidity of patients while maintaining quality of care Minimal access surgical techniques are now ERK5-IN-1 routine for cholecystectomy, Nissen fundoplication for gastro-oesophageal reflux disease, splenectomy, and adrenalectomy Use of sentinel node biopsy is minimising the morbidity associated with staging breast cancer Surgical robotics systems will enable a further revolution in minimally invasive techniques Future developments are likely to be fuelled by patient demand The importance of laparoscopic cholecystectomy was the cultural change it engendered rather than the operation it replaced. In terms of technique, the focus of attention shifted from the surgeon’s virtuosity to minimising the morbidity experienced by the patient.3 In a paper published in 1996 on laparoscopic adrenalectomy, the postoperative inpatient stay was decreased from 9.8 to 5.1 days.4 The next year, a second group reported a total inpatient stay as low as 2.4 days.5 Minimally invasive abdominal surgery Laparoscopic Nissen fundoplication Advances in the pharmacological management of gastro-oesophageal reflux disease have been accompanied by a surge of interest in surgical management of this condition. There are three reasons for this. Firstly, although the indications are that long term drug treatment is safe, it is very expensive. Estimated annual costs to the NHS for H2 antagonists and proton pump inhibitors for patients with gastro-oesophageal reflux disease are 60m and 90m respectively. Many of these patients could be treated by surgery. Secondly, gastro-oesophageal reflux disease is difficult to diagnose. Oesophageal manometry and pH monitoring are increasingly used to improve diagnostic accuracy. Better case selection will lead to better long term results from surgery. Thirdly, laparoscopic Nissen fundoplication has been shown to be technically feasible, safe, and effective and have a low rate of conversion to open surgery.6 Although fundoplication is highly effective for controlling gastro-oesophageal reflux disease, it is unclear whether the cost savings of laparoscopic surgery over lifelong drug treatment justify the (admittedly much reduced) inconvenience and morbidity of surgery. These issues are about to be investigated in the UK collaborative gastro-oesophageal reflux disease trial run by the health service’s research unit at the University of Aberdeen (www.abdn.ac.uk/hsru/hta/reflux.hti). Minimal access techniques Established Laparoscopic cholecystectomy Diagnostic laparoscopy Laparoscopic appendicectomy Laparoscopic Nissen fundoplication Laparoscopic (or thoracoscopic) Heller’s myotomy25 Laparoscopic adrenalectomy Laparoscopic splenectomy Thoracoscopic sympathectomy Laparoscopic rectopexy26 Under evaluation Laparoscopic hernia repair Laparoscopic colectomy Laparoscopic nephrectomy for living related donor transplant Parathyroidectomy (guided with handheld gamma probe) Laparoscopic fix of duodenal perforation27 Potential clients Sentinel node biopsy Hepatic resection Gastrectomy Inguinal hernia fix Inguinal hernia is normally common, and effective minimal gain access to techniques have already been created. However, these methods never have been followed as broadly as, for instance, laparoscopic cholecystectomy. The initial reason for that is that minimal gain access to techniques were initial advocated on the peak of the revolution in open up operative technique: the adoption from the open up, tension-free mesh (Lichtenstein) fix.7 The Lichenstein fix was proven to have recurrence prices tenfold less than those of the Shouldice fix, which was then your regular technique. The.