MINIMAL ACCESS SURGERY OF THE GASTROINTESTINAL-TRACT

In the last 5 years, surgery of the gastrointestinal tract has been re volutionized by the application of minimal access techniques. Followin g initial enthusiasm, which suggested that most abdominal surgery woul d ultimately be done via this approach, there is now need for appraisa l and evaluation of the role of a number of these minimal access techn iques when compared with open surgery. Undoubtedly, the most convincin g and total application of minimal access techniques has been in the t reatment of gallstone disease. Laparoscopic cholecystectomy is now sta ndard therapy for cholelithiasis and endoscopic sphincterotomy with St one extraction is standard therapy for choledocholithiasis. Where the two conditions co-exist, operative cholangiography allows for the reco gnition of stones in the bile duct at the time of laparoscopic cholecy stectomy and provides the potential avenue for treatment. Most major c entres also would recommend routine operative cholangiography during l aparoscopic cholecystectomy for the detection of unsuspected stones an d as an extra safety procedure in the early identification of potentia l bile duct injuries. The efficacy of laparoscopic appendicectomy and laparoscopic or thoracoscopic treatment of achalasia of the oesophagus also is supported by data from well conducted prospective studies. Do ubt remains regarding the advantage of laparoscopic surgery over other approaches in the treatment of gastro-oesophageal reflux, inguinal he rnias and jaundice due to non-resectable cancer. For all three of thes e conditions, prospective trials are underway and the results of these trials should be assessed prior to widespread adoption of the laparos copic techniques. The application of minimal access surgery for colore ctal procedures, peptic ulcer therapy, liver and pancreatic surgery or surgery of the spleen and adrenal has been demonstrated; however, its ultimate place awaits the further development of instruments and a de monstration of efficacy over open approaches before it can be recommen ded for use in prospectively conducted comparison trials.