Minimal access colonic surgery: is it truly minimally invasive?

Laparoscopic colonic surgery has an established role in the management of both benign and malignant conditions. Proposed benefits from laparoscopic surgery include decreased pain, decreased metabolic disturbance to the patient and faster recovery. It is now generally accepted that pro-inflammatory mediators, including cytokines, are to a great extent responsible for the metabolic changes associated with injury and surgery, and that these metabolic changes are related to postoperative recovery. Cytokine levels in the serum are decreased after major laparoscopic colorectal surgery compared with open surgery. However, the cytokine concentration in abdominal drain fluid is the same independent of the size of the incision and these concentrations are far higher than those found in the serum suggesting that the peritoneal would from the surgery itself is more important to metabolic events than the skin wound used to access the abdominal cavity to perform the operation. When looked at critically in programmes where patients are optimally managed perioperatively, there appears to be minimal metabolic benefit from performing a major colonic resection using minimal access surgery. Thus, it appears that the wound is critical when the operation involves only minor peritoneal disruption, such as in laparoscopic cholecystectomy, but when large peritoneal defects are created, such as in major colorectal surgery, then the skin wound becomes irrelevant to metabolism and hence recovery. Thus, minimal access does not necessarily equate to minimal invasion and the terms should not be used interchangeably in the context of laparoscopic colorectal surgery.