Minimally Invasive Proctology: Myths and Realities : Indian Journal of Colo-Rectal Surgery

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Minimally Invasive Proctology

Myths and Realities

Agarwal, Niranjan

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Indian Journal of Colo-Rectal Surgery 4(3):p 59-60, Sep–Dec 2021. | DOI: 10.4103/2666-0784.314978
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Minimally invasive surgery is the one performed through smaller incisions and now prevalent in almost all branches of surgery. These are technology based surgeries hence more costly and takes a long time to learn the same. The cost can be well compensated by quicker recovery, lesser pain and early return to work. The surgical trauma in such procedures is a minimal and the subsequent immune response is also better than for open surgery. Needless to say that the cosmetic results are the main iceing on the cake. From the surgeons points of view, these surgeries enhances the surgeon's image to someone with modern approach and gadgets which helps him to generate more work and revenue. However all these can only be justified provided the end results of these surgeries matches those of the conventional ones.

Minimally Invasive Procotology (MIP) is use of modern gadgets such as Endoscopes, Ultrasound, Lasers, Plugs, Staplers etc., combined with certain innovative approaches by the surgeons to minimize the trauma of the therapeutic procedures.

MIP in hemorrhoids is use of Laser, DGHAL, Stapler Anopexy or newer materials for Sclerotherapy or Rubber Band Ligation. The word minimal invasive surgery sold so much few decades ago, that the manufacturing company in India named the stapler procedure as Minimally Invasive Procedure for Hemorrhoids or MIPH when it was world wide called as stapled hemorrhoidopexy or stapled anopexy.

MIP in anal fistula is accomplished by means of VAAFT, FiLac, Plug, Glue or a Fixicion device.

MIP for anal fissures is use of Laser for sphinctertotomy or Injection of botulinium toxid. The point if injection is a surgery needs further deliberations though.

MIP in Pilonidal Sinus is use of an Endoscope (EPSiT) or Laser (SiLAT) or combination of both (VALAPS).

There are lesser common diseases such as Anal warts, Polyps etc., that can be managed by use of these tools in the treatment of such diseases.

The market compulsions have made these procedures household names and many a time all that glitters may not be gold. False claims have created more myths about these surgeries which needs to be clarified by stating hard realities. Whenever one searches the google engine for minimal invasive proctology the screen gets flooded by claims of surgeries which are 100% effective, without cut or stitches or scar. The claim of no pain, no recurrence are prominently shown. Even newspaper publishes articles showcasing some or the other procedure based on commercials as the new and the best thing available and promoting a particular surgeon for same. The myths created around laser is such that the fibre appears to be a magic wand and one stop solutions for all. Claims of no cut, no wound, no scar, no pain, no anesthesia, no admission, no complications, no recurrences etc., are for all to see. But is this true or far from truth. The realities differ a lot and facts are twisted and presented to the innocent patients. The aura created especially around the laser is so great that the adaptivity of laser in last few years has increased many folds.

Let us discuss each Myths and its associated realities through this article

  1. Pain - The biggest claim of these surgeries being painless is distantly far from truth. The fact is that it has less pain and the vas score in the initial 24 hr with most of these surgeries is 4 to 5. The cause of pain in these procedures can vary from wrong entry point of Laser fibre
  2. thermal Injury caused by excessive energy, misplaced stapler site, deeper stiches involving sphincters to being idiopathic in MIPH in hemorrhoids. Rupture of thinner tracts due to energy application to creation of false tracts by forceful insertion of fibre in fistula surgery may cause pain too
  3. Incision - No cut hence no wound so no scar as claimed by most proponent is blatant lie as the truth remains that there is actual smaller cut hence smaller wound and a lesser scar. In some surgeries like that for pilonidal sinus when operated with laser, an iatrogenic wound is infact created at the other end to drain the cavity. These smaller wounds definitely heal faster than traditional surgery wound
  4. Anesthesia – claims of no anesthesia is another marketing gimmick as most of these surgeries are carried out either under local or regional anesthesia. How can one expect a cut or burn to be afflicted without any anesthesia?
  5. Admission – apart from the OPD procedures such as sclerotherapy or rubber Band Ligation which are done in an office setting, most of these need a day care admission to say the least. Hence a claim of no admission is again misguiding and the fact is early discharge but not without admission
  6. Return to work – one cannot go to work directly from the OT table as promised by many since the average day off from work in most of these cases is 2 to 3. This is definitely much less than the day off work after traditional surgeries
  7. Complications – no surgery can be without its share of complications. The incidence may vary from procedure to procedure. Complications can arise due to improper use of technologies, inappropriate training and experience. Most literature has shown that MIP has its own share of pain, bleeding, recurrences, edema, infection, etc., etc.
  8. Recurrences – the claims of 100% effective is hilarious to call it least. The evidence is quite clear that most MIP has more recurrence than conventional procedures and they have not yet matched the long term benefits of traditional surgeries
  9. One shot solution- a magic wand curing all ills with the laser fibre can only be deplored as many circumstances particularly complications of disease and recurrent nature need a specific approach and MIP may be inappropriate to use in such conditions
  10. New Gold Standard – nothing can be more deceitful than to try and establish without evidence that any new procedure is the gold standard by means of marketing tools. If that was so, why would the giants in the field of MIP surgeries replace them with hybrid procedure, rather than using them as stand alone. As already mentioned no procedure can be claimed as gold standard unless and until it matches both the long term and short term benefits of the existing procedure.

So to conclude, less does not mean complete absence and short term advantages cannot replace overall benefits for any procedures. The need is to inform your patients the availability of various modalities available with their pros and cons and let him/her make an informed choice depending upon their immediate and long term needs.

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