A New Stage of Surgical Treatment: Super Minimally Invasive Surgery

The evolution of surgical techniques has seen significant advancements over the years, transitioning from traditional open surgery to minimally invasive surgery (MIS). MIS, which includes video-assisted thoracoscopy, laparoscopy, and Da Vinci robotic surgery, has revolutionized the field by reducing invasiveness, shortening hospital stays, and improving patient outcomes. However, both MIS and traditional open surgery share a common limitation: they fail to maintain the integrity of organs while resecting lesions. This approach, which involves resecting not only the lesions but also partial or complete organs, leads to organ loss and necessitates anatomical reconstruction of the remaining organs. Such procedures often result in complications and a decline in the quality of life (QoL) for patients.

In response to these challenges, a new surgical approach known as Super Minimally Invasive Surgery (SMIS) was introduced by Linghu in 2016. SMIS aims to cure diseases while preserving the integrity of human organ anatomy, ensuring that the normal structure and function of organs are maintained. This article provides a comprehensive overview of SMIS, its definition, comparison with MIS, applications, nomenclature, advantages, and future perspectives.

Definition of Super Minimally Invasive Surgery

SMIS is defined as “curing the disease while preserving the integrity of human organ anatomy.” The primary goal of SMIS is to treat diseases without damaging organ structure and function, thereby ensuring normal survival time and post-operative QoL. Unlike traditional open surgery and MIS, which often involve the resection of organs, SMIS focuses on removing lesions while keeping the organs intact.

Surgical treatments such as endoscopic mucosal resection, endoscopic submucosal dissection (ESD), and endoscopic submucosal tunnel dissection are considered SMIS because they can be used to resect early gastrointestinal cancer without injuring the integrity of the gastrointestinal duct. However, not all endoscopic operations are classified as SMIS. Similarly, some laparoscopy and thoracoscopy procedures that do not affect the anatomical structure of organs should also be regarded as SMIS. For example, video-assisted thoracoscopic enucleation, which only resects lesions without damaging the organ, falls under the category of SMIS.

Comparison Between SMIS and MIS

To better understand the differences between SMIS and MIS, it is essential to compare their applications in treating the same type of disease. For instance, in the treatment of early gastric cancer, traditional open surgery and MIS often result in partial loss of the stomach, necessitating reconstruction of the stomach and small intestine. This can lead to complications such as anastomositis and gastric retention. In contrast, SMIS successfully cures the lesion by endoscopic drainage, leaving the anatomical structure of the stomach intact.

Another example is the treatment of suppurative appendicitis. MIS is typically used for an appendectomy, which involves the removal of the appendix. In contrast, SMIS cures the lesion by endoscopic drainage, preserving the appendix and its function. These examples highlight the key difference between SMIS and MIS: SMIS aims to preserve organ integrity, while MIS often involves organ resection.

Laparoscopy- and thoracoscopy-assisted endoscopic surgery have been reported as methods to overcome the relatively significant invasive nature of MIS and make endoscopic resection less challenging. For example, when treating early cancer with lymph node metastasis, cancer can be resected under endoscopy, while lymph nodes can be resected by laparoscopy. This cooperative application of endoscopy and laparoscopy should be regarded as SMIS.

While MIS is well-developed and regarded as the main surgical operation, it cannot completely replace traditional open surgery. Similarly, SMIS is emerging as a new treatment method; however, it might not completely replace MIS in the near future. Nonetheless, SMIS provides a new direction for the future of medicine.

Applications of Super Minimally Invasive Surgery

SMIS has a wide range of applications, particularly in the treatment of gastrointestinal diseases. These applications can be broadly categorized into obstruction relief and lesion resection.

Obstruction Relief

Obstruction relief treatments mainly include foreign body removal, stenosis relief, pus drainage, necrosis drainage, and bile duct obstruction removal. These procedures aim to alleviate blockages and restore normal organ function without damaging the anatomical structure of the organs.

Lesion Resection

Lesion resection treatments mainly include the resection of early gastrointestinal cancer, submucosal tumors, polyps, and neuroendocrine tumors. The digestive endoscopic tunnel technique (DETT), first proposed by Linghu in 2009, played a landmark role in the development of SMIS. DETT involves dividing the gastrointestinal tract wall into two layers by establishing a tunnel between the mucosal and muscularis propria. This technique makes endoscopic treatment of diseases that were previously treated by surgery possible, breaking the boundary between gastrointestinal internal medicine and surgery.

For most benign lesions, SMIS is believed to achieve a therapeutic effect similar to that of surgical treatment. For malignant lesions, SMIS is mainly applied to those in the early stage. For lesions in the advanced stage, traditional open surgery and MIS are still regarded as the optimum resection methods. The applications of SMIS are affected not only by the development of techniques and equipment but also by the characteristics and the stage of the disease. However, with the increasing early diagnosis of diseases due to advancements in medicine, more and more diseases are indicated for SMIS.

Nomenclature of Super Minimally Invasive Surgery

When SMIS is performed to treat a disease, the type, location, and stage of the lesion, as well as the treatment method, should be demonstrated. The SMIS should be described as “location + disease + SMIS (type).” For example, when ESD is used to treat early esophageal cancer, the standard demonstration should be “esophageal early cancer (T1aN0M0) SMIS (ESD).” This nomenclature ensures clarity and consistency in describing SMIS procedures.

Advantages of Super Minimally Invasive Surgery

SMIS offers several advantages over traditional open surgery and MIS. The most significant advantage is that it does not affect the QoL and life expectancy of patients. By preserving the anatomical structure of organs, SMIS ensures that patients can maintain their normal bodily functions without experiencing additional discomfort or complications.

SMIS also has the advantages of being less invasive, having a shorter operation time, requiring a shorter hospital stay, and being less expensive than MIS and traditional open surgery. For example, when SMIS is applied to resect early rectal cancer close to the anus, the anatomical structures of the rectum and anus are maintained. The defecation method after the operation is similar to that before surgery, and the QoL and life expectancy are not affected.

Compared with open surgery, MIS was reported to improve QoL outcomes when treating early gastric cancer. However, when making a comparison between SMIS and MIS, MIS showed a worse QoL due to the loss of organs. These findings highlight the superior benefits of SMIS in preserving organ integrity and improving patient outcomes.

Perspectives on Super Minimally Invasive Surgery

Both traditional open surgery and MIS fail to maintain the integrity of organs while resecting lesions. The treatment method, namely, “resect not only lesions but also partial or complete selected organ,” has not been changed. In contrast, SMIS is intended to cure the disease while preserving the integrity of human organ anatomy. SMIS provides a new treatment mode for medicine and specifies the development direction for medicine.

With more and more diseases diagnosed in their early stage, SMIS will be widely used and is expected to be the leading method of surgery in the future. Surgery that fails to maintain the integrity of organs will be eliminated. SMIS is still at the preliminary stage of development; however, it shows promise for application in obstruction relief and lesion resection. Experts in the World Endoscopy Organization (WEO) also believe that SMIS will play an important role in the development of medicine. An ad hoc committee named “super minimally invasive interventions” belonging to WEO has been established to further promote and develop this innovative approach.

The treatment of digestive diseases simply belongs to a branch application of SMIS. SMIS can also be applied to diseases of other systems, such as urinary system diseases, respiratory diseases, and mediastinal surgery. Similar to MIS, SMIS is a type of treatment method and theory suitable for different diseases, offering a promising future for the field of surgery.

In conclusion, SMIS represents a significant advancement in surgical treatment, offering a less invasive, more effective, and organ-preserving approach to disease management. As medical technology continues to evolve, SMIS is poised to become the leading surgical method, providing patients with better outcomes and improved quality of life.

doi.org/10.1097/CM9.0000000000001534

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