What is the role of innovative minimally invasive surgery in today's medicine?

Medical advancements are often accompanied by surgical innovation. One such example is the introduction of laparoscopy into general and specialty surgery. Gynecologic surgery was at the forefront of this development with the widespread use of laparoscopy as a minimally invasive approach for adnexal surgery. In urogynecology laparoscopy was introduced as an alternative to open Burch colposuspension before it was superseded by the introduction of TVT sling. Aside from the obvious argument that a vaginal approach to female pelvic floor reconstructive surgery represents the least invasive surgical technique within our specialty, there continues to be widespread interest in the use of traditional “straight stick” and robotic-assisted laparoscopy. At the 37th Annual Scientific Meeting of the Society of Gynecologic Surgeons in San Antonio, TX, USA, Drs Catherine Matthews and Michael Heit debated the topic of Robotic or Straight Stick Laparoscopy for Minimally Invasive Pelvic Surgery. The debate centered on the technique of sacrocolpopexy for pelvic organ prolapse, which is widely considered to be one of the gold standards in our field. The two articles that follow capture the spirit of that debate. Drs Matthews and Heit clearly present the feasibility of performing each procedure. However, we all currently work in a world that places tremendous pressure on physicians to focus on quality, safety, and reducing costs per case. Both Drs Heit and Matthews acknowledge that escalating health care costs are unsustainable and undesirable. As stated by Dr. Heit, current evidence does not support the widespread adoption of the robotic approach for most surgical procedures, yet this has not slowed the enthusiasm for training, nor hospitals marketing of this new and yet unproven technique. There is no question that the current experience demonstrates that robotic technology is far more expensive with little offsetting value. With respect to sacral colpopexy, most published small series suggest far longer operative times, increased costs, as well as higher complication rates with both the robotic and laparoscopic approaches compared to the traditional open approach. Dr Matthew asserts that like other technologic breakthroughs, such as cellular telephones, the cost will naturally decrease and the procedures will become easier. However, cost reduction is typically dependent upon high volumes and having competing companies and technology. For now, there is only one player in the robotic field, Intuitive Surgical. In addition, there are concerns regarding patient safety and higher risks of complications with many endoscopic approaches compared to traditional open techniques, creating yet another barrier for new techniques within modern medicine. If cost effective robotic surgery is not likely, will the default be laparoscopic? As Dr. Matthews points out, the challenges faced by gynecologic surgeons in obtaining advanced laparoscopic skills is indeed formidable. It should not come as any surprise that we have lagged behind our general surgery colleagues in endoscopic Further contributions to this debate can be found at doi:10.1007/ s00192-011-1619-5 and doi:10.1007/s00192-011-1620-z.