In minimally invasive surgery, the surgeon reaches the affected area through small incisions or a natural opening in the body. Open surgery uses a larger incision. In suitable patients, small incisions may help reduce pain and allow an earlier return to everyday life. The choice depends on more than the size of the scar: the location and extent of the disease and the person's overall health are assessed together.
Two people with the same diagnosis may be offered different approaches. Laparoscopic surgery may be suitable for one, while open surgery may be a safer way to remove the diseased tissue in the other. In cancer surgery, the priority is to remove the tumour to the extent needed; a small incision does not replace this goal.
How do minimally invasive approaches differ?
Laparoscopic surgery uses a camera and instruments inserted through small incisions in the abdomen. In a thoracoscopic approach, the camera is inserted into the chest. For example, some operations on the oesophagus require work in both the abdomen and the chest, so the two techniques may be combined.
The abdominal and chest stages of such an operation can be seen in the video of Laparoscopic and thoracoscopic Ivor Lewis oesophagectomy. This is surgical footage intended for adults. It shows a specific operation and does not mean that this approach is suitable for every patient.
In transanal surgery, the rectum is reached through the anus, the opening through which the bowel empties. Transanal minimally invasive surgery, known as TAMIS, is used for local removal of some polyps, growths on the bowel's inner lining, and selected early cancers. Not every rectal tumour can be treated this way. The depth of the tumour and the likelihood of spread to the lymph nodes may require more extensive surgery.
In robotic surgery, the surgeon controls the instruments from a console. The robot does not make decisions independently. This system may make it easier to work in confined spaces, but its availability does not mean better results for every operation. The suitability of the technique and the team's training in that particular operation are assessed separately.
When might open surgery be needed?
A large tumour that has spread to nearby organs, dense adhesions from previous operations, or a condition requiring emergency treatment may affect the choice. Adhesions are bands of tissue that cause tissues inside the abdomen to stick together. Having had open surgery before does not necessarily mean that the next operation must also be open, but it may make access and separation of the tissues more difficult.
Heart and lung conditions are also taken into account. During some minimally invasive operations, the position in which the body is held and the pressure created inside the abdomen place additional strain on the patient. The anaesthetist, the doctor who provides anaesthesia and monitors vital functions during surgery, assesses with the surgeon how well the patient can tolerate this strain.
Sometimes an operation begins through small incisions and is then converted to an open procedure. This may be due to bleeding, an inadequate view, or an unexpected difficulty with the position of the organs. The possibility of conversion should be discussed before surgery. A decision made to protect the patient's safety does not automatically mean that something was done incorrectly.
Recovery and cancer outcomes are separate questions
After many operations performed through small incisions, wound pain and the length of hospital stay may be reduced compared with an open approach. However, the work inside the abdomen may still be extensive: removing part of the bowel and joining the ends requires the internal tissues to heal. A small wound on the outside does not mean you are ready to lift heavy objects.
Bleeding, infection and injury to a nearby organ can also occur with minimally invasive approaches. If sections of bowel are joined, there is a separate risk of leakage from the join. In this complication, bowel contents may escape into surrounding tissues, requiring further treatment and sometimes another operation. The extent of the operation and the method of access should therefore be explained separately.
Cancer recurrence and long-term survival are outcomes studied separately. Studies comparing laparoscopic and open surgery in appropriately selected patients with colon cancer show that these outcomes can be similar. This cannot be extended to every organ, every stage of cancer or every minimally invasive technique. In particular, the term robotic surgery does not in itself mean that cancer will be treated more effectively.
It is important to leave a margin of healthy tissue around the removed tumour and remove the necessary lymph nodes. Lymph nodes are small structures in the body's immune system, and cancer cells can spread to them. Examining the removed tissue under a microscope helps assess the outcome of surgery and the need for further treatment.
What should be clear when discussing the decision?
When discussing the surgical approach, the expected benefits should be explained in relation to your own situation. Your daily work, mobility, previous operations and whether you will have help at home all affect the recovery plan. For example, someone with a desk job and someone who does heavy physical work may not be able to return to work on the same timescale.
You can ask the doctor whether an open approach is an alternative, what circumstances might lead to a change of technique, and whether a non-surgical option is available. Pain management, when to start eating and the timing of follow-up are also part of the plan. If a medical term is unclear, asking for an explanation in everyday language can make the decision easier.
During recovery at home, worsening abdominal or chest pain, fever, repeated vomiting or pus draining from the wound require urgent contact with a doctor. Breathlessness, loss of consciousness or heavy bleeding require emergency medical help. Small incisions are not a reason to wait when these symptoms occur.