Minimally invasive surgery and enhanced recovery: Are we talking about apples and oranges?

Nanavati et al. have written a controversial paper on the juxtaposition of Enhanced Recovery After Surgery (ERAS) with laparoscopy for this issue of the Journal.[1] The places of both ERAS and minimally invasive surgery (MIS) are now well established and their fundamental benefits appear to be beyond debate, although it can be argued that applications are not necessarily universally advantageous. For example, a Cochrane review concluded that there was insufficient evidence for ERAS to be implemented as the standard of care for colorectal surgery,[2] and similar illustrations can be cited for advanced laparoscopic surgery. Such exceptions apart, the core theme of the paper by Nanavati et al. is that Indian surgeons place excessive emphasis, to the extent of vainglory, on MIS, and have failed to adopt ERAS adequately. As Shrikhande and Pai[3] perspicaciously pointed out in a leading article in this journal last year, ERAS is a philosophy — a way of thinking about and practising surgery — and its measurement is difficult; in contrast, laparoscopy, like any operation, is an event that lends itself easily to discrete analysis. Nonetheless, laparoscopic enthusiasts must take the submissions of Nanavati et al. seriously because of their explicit thrust that by neglecting to achieve an appropriate balance between our interests in the technique as well as the technology of surgical craft and perioperative care, we are doing disservice to our patients.

I have addressed three ostensibly troubling issues that have been identified by Nanavati et al., and I will discuss each separately. Although I am a self-confessed MIS enthusiast and, truth be told, I have spent a vastly greater proportion of my waking hours thinking about MIS than about ERAS, I have attempted genuinely to approach this task dispassionately.

WHY IS THE TECHNICAL DIMENSION OF MIS VALORISED BY SURGEONS?

The somewhat provocative insinuation of Nanavati et al. about bravado in the technical execution of complex operations by MIS cannot, and should not, be dismissed with a trite retort that ‘You, too, would do it if you could’. Instead, it is fruitful to pay some heed to the history of surgical ethics.[4] As surgeons, our distinction from physicians is derived from the craft of our practice, and display of the skills of craftsmanship is ingrained in surgical lore. Indeed, the very appellation ‘operating theatre’ is a salutary reminder that our surgical forebears operated in public arenas. Whilst I endorse the appeal of Nanavati et al. that holistic patient care should not be sacrificed in the quest for fame and fortune through technical brilliance (a prominent example is that of Christian Barnard, who was lecturing in another country when Louis Washnawsky, the recipient of the first heart transplant, died of postoperative complications), we must accept the paradigm shifts that have occurred in modern surgery. Patient care is increasingly multi-disciplinary and we, as surgeons, cannot be omniscient. ‘Letting go’ of the control of perioperative care might remain alien, even repugnant, to many surgeons; but, like it or not, increasing specialisation is upon us and it is important to focus on that which we do best. That said, surgery is more than just operations, and perceptions of the practice of MIS have to be addressed, even if we disagree, if only in order to sustain reputation and credibility.

WHAT IS THE CORRECT PLACE FOR MIS: ANOTHER TECHNIQUE OR SPECIALTY?

Nanavati et al. have raised the somewhat disturbing — but nonetheless worthy of deliberation — question of whether MIS is a distinct specialty within surgery. Stated bluntly, are those of us who style ourselves as ‘laparoscopic’ or ‘minimally invasive’ surgeons being disingenuous aspirants to a dubious claim? The American College of Surgeons recognises 14 specialties within surgery, without a consistent pattern of organ system or disease classification. The Royal College of Surgeons of England lists 9 separate specialties. MIS is not assigned specialty status by either college. Of relevance to gastrointestinal surgery, only colorectal surgery is a distinct specialty; both colleges implicitly include hepato-pancreatic-biliary (HPB) surgery, oesophago-gastric surgery, bariatric surgery and surgical oncology within the umbrella of general surgery. Nonetheless, each one of the preceding disciplines has vibrant associations and societies, and members who proclaim sub-specialist practice boldly. Thus, it would appear that the definition of a sub-specialty is derived from a body of surgeons who are convinced that their particular knowledge base, skills and practices are sufficiently distinct from others. The distinction may come from anatomic localisation [e.g., HPB or upper gastrointestinal tract (GI)] or from disease (e.g., obesity or cancer). By extension, why should specialist designations not be based on techniques and technology? Minimally invasive surgeons will argue robustly that their education, cognitive as well as motor skills and, pertinently, patient-selection and postoperative care practices are sufficiently distinct from practitioners of conventional, open surgery. The existence of large associations of endoscopic surgeons — SAGES, IAGES, ALSGBI and many others — makes it exceedingly difficult to argue otherwise; to do so would be to disenfranchise many surgeons and, indeed, to question the legitimacy of many other sub-specialist bodies that are based on similar grounds.

WHAT IS THE ROLE OF MENTORING IN MIS?

What is a mentor? The classical illustration is that of a wise guide — an elder statesman — who helps a neophyte through uncharted territory. In Homer's Odyssey, the goddess Athena assumes the guise of the venerable warrior, Mentor, to lead Telemachus in his quest to find his father. Mentorship, in various forms, can be invaluable in surgical training. Many of the current generation of senior laparoscopic surgeons are self-taught; the challenge for the next generation is to acquire expertise without the catastrophes faced by the pioneers. There is now good evidence that focused training in laparoscopic surgery, with varying degrees of site-specific specialisation, is immensely beneficial.[5] Fellowships in MIS surgery can play a critical role in training; like fellowship programmes in any specialty, quality of training can be variable and necessary quality-control mechanisms should be in place. But that is a poor reason to dismiss MIS fellowships.

What, then, is the junction of MIS and ERAS? There is undoubtedly a role for ERAS philosophy within MIS, as within all other specialties. Whilst Nanavati et al. may have a valid point that ERAS is under-emphasised and under-utilised in India, the conflation of ERAS and MIS is not, in my view, productive. There is accumulating evidence that laparoscopic surgery provides benefits above and beyond those of ERAS —[6,7] in other words, MIS is not merely a component of ERAS but is a distinct discipline, a sub-specialty that should embrace ERAS in order to continue to improve patient care.