Over the past two decades, there has been a dramatic increase in the interest and application of the minimally invasive approach to the management of cancer.

The increase in utilization of the minimally invasive approach can be attributed to patient demand as well as data demonstrating improved perioperative outcomes associated with the minimally invasive approach compared with open surgery. 

With the advent of better surgical techniques and surgical technological advances, the attractiveness for a minimally invasive procedure has only enhanced. Patients are now more in favour of minimally invasive procedures and also demand such procedures, if feasible for their treatment.

Besides the obvious cosmetic benefits, minimally invasive procedures have been proved to be beneficial across multiple areas of patient care. The minimally invasive approach has been associated with smaller incisions, less incisional pain, reduced need for opioids, shorter length of stay, as well as possibly lower overall morbidity and improved quality of life. Therefore, all considered, minimally invasive approach has been proven beyond doubt to be beneficial in enhancing peri-operative care and is thus an important cog in the wheel of the Enhanced Recovery After Surgery or ERAS protocols being followed world over today.

The potential benefits of minimally invasive surgery, especially as they relate to patients with cancer, are several-fold. Surgery has long been thought of as a “stressor” with associated changes in immunity and possibly derivative effects on cancer progression. It has been widely postulated that surgery or intervention of any kind can prove to be a stressor to the patient and can theoretically adversely affect the patient with regards to his/her oncological outcome. Many hypotheses exist regarding the immunologic response to surgery and whether a less “stressful” minimally invasive approach might result in better oncologic outcomes. Therefore, in this regard minimally invasive procedures can prove to be a better option in patients with regard to their oncological care by decreasing the stress to the patient.

Similarly, opioid use has been postulated by some to have a potential effect on angiogenesis and cellular-mediated immunity. As such, a minimally invasive approach that is “opioid sparing” due to less associated incisional pain could also benefit patients with cancer.

While these topics remain debated, there are also prospective data to suggest that the minimally invasive approach has at least comparable oncologic outcomes as open surgery.

Specifically, prospective trials dealing with cancers of the rectum and colon have compared minimally invasive with conventional surgeries with regard to their immediate oncological outcomes. In most of these trials, it has been proved that the minimally invasive approach is at least non-inferior to the conventional approach with regard to the immediate outcomes such as nodal yield, completeness of resections as well as short term survival and recurrence outcomes. There also was no difference between the two groups with respect to morbidity and mortality.

Taken together, the comparable oncologic outcomes combined with the improved perioperative patient-centered outcomes (eg, pain, length-of-stay, quality of life) make the minimally invasive approach to cancer surgery very appealing.

However, other studies have demonstrated that caution needs to be exercised. Studies involving cancers of the rectum and cervix has showed data that minimally invasive approach may be inferior to the conventional approaches with regard to short term oncological outcomes.

Therefore, at the present day and age, minimally invasive approaches in oncology is a very attractive option in view of post-operative morbidity. As such, while enthusiasm for the minimally approach may be high, additional data and studies are needed to ensure comparable oncologic outcomes for some cancers/anatomic locations. Upcoming prospective data may provide an answer to presently unsolved questions.


About Author:

Dr Faheem Abdulla, MBBS, MS, DNB, (MCh Surgical Oncology) is a Surgical Oncology Resident at Regional Cancer Centre, Thiruvananthapuram, Kerala