MINIMAL ACCESS SURGERY OF THE GASTROINTESTINAL TRACT

In the last 5 years, surgery of the gastrointestinal tract has been revolutionized by the application of minimal access techniques. Following initial enthusiasm, which suggested that most abdominal surgery would ultimately be done via this approach, there is now need for appraisal and evaluation of the role of a number of these minimal access techniques when compared with open surgery. Undoubtedly, the most convincing and total application of minimal access techniques has been in the treatment of gallstone disease. Laparoscopic cholecystectomy is now standard therapy for cholelithiasis and endoscopic sphincterotomy with stone extraction is standard therapy for choledocholithiasis. Where the two conditions co‐exist, operative cholangiography allows for the recognition of stones in the bile duct at the time of laparoscopic cholecystectorny and provides the potential avenue for treatment. Most major centres also would recommend routine operative cholangiography during laparoscopic cholecystectomy for the detection of unsuspected stones and as an extra safety procedure in the early identification of potential bile duct injuries. The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies. Doubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro‐oesophageal reflux, inguinal hernias and jaundice due to non‐resectable cancer. For all three of these conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparoscopic techniques. The application of minimal access surgery for colorectal procedures, peptic ulcer therapy, liver and pancreatic surgery or surgery of the spleen and adrenal has been demonstrated; however, its ultimate place awaits the further development of instruments and a demonstration of efficacy over open approaches before it can be recommended for use in prospectively conducted comparison trials.