Grand Challenge: On the Way to Scarless Visceral Surgery

The ability to conduct operative procedures in the abdominal cavity with minimal or no scarring has been a dream long cherished by mankind. Therefore, it is not surprising that minimally invasive surgery spread across the world with remarkable speed after its introduction some 25 years ago. The patient has smaller incisions, faster recovery time, spends less time in hospital and the costs are also reduced. Surgeons rapidly learned the techniques, something demanded by patients (1). Using the standard laparoscopic technique, the procedure is performed in the abdomen with 3-4 trocars measuring 5-12 mm in diameter. Meta-analyses have in the meantime demonstrated that in the majority of visceral surgery procedures the standard laparoscopic technique has advantages for the patient compared with the open technique. Standard laparoscopic cholecystectomy has advantages over the open operation regarding duration of hospital stay and convalescence (2). Standard laparoscopic appendectomy provides considerable benefits over appendectomy, including a shorter length of hospital stay, less postoperative pain, earlier postoperative recovery, and a lower complication rate (3, 4). Standard laparoscopic antireflux surgery assures faster convalescence and return to productive activity compared with open surgery, with a reduced risk of complications and similar treatment outcome (5, 6). Standard laparoscopic bariatric surgery is a safer method of treatment than open surgery (7). Endoscopic repair of inguinal hernias has significant advantages in terms of pain-associated parameters in comparison to open techniques (8, 9). In a meta-analysis, elective standard laparoscopic sigmoid colectomy for diverticular disease showed lower overall morbidity, earlier return to bowel function, and shorter hospital stays than open surgery (10). Accordingly, the standard laparoscopic technique currently represents the gold standard in visceral surgery for several benign diseases. Although the risks are higher when using minimally invasive surgery for malignancies of intraabdominal organs, this technique is also being used in tumor surgery (11). Obviously, the laparoscopic approach can only be implemented in cases of early, small sized, cancers confined to the target organ (11). In the hands of experienced surgeons and with appropriate patient selection, use of the standard laparoscopic technique to treat colorectal cancer and gastric cancer can achieve long-term oncological results comparable with those of the open technique, with lower postoperative complication rates (12, 13, 14). Despite