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camera / display that allowed the surgical team to share the same view. Courses were held around the world to train surgeons in this new technique. There was suddenly no further interest in mini-laparotomy for cholecystectomy. As laparoscopic cholecystectomy became more widespread, there were many reports of bile duct injuries which raised significant concerns in the surgical and medico-legal com- munities. These seemed to be a result of the “ learning curve ” and are seldom discussed today as a particular con- sequence of using minimally invasive surgery techniques. Within a few years, nearly every abdominal operation had been performed using minimally invasive surgery tech- niques. The techniques for abdominal minimally invasive surgery were rapidly adapted to minimally invasive surgery resections in the chest as well, such that thoracoscopic lung resections are the standard approach. The minimally inva- sive surgery approach is standard for operations such as ap- pendectomy, Nissen fundoplication, colon resection, splenectomy, and others. There is further evolution going on in laparoscopic liver resection, laparoscopic gastrectomy, and other procedures. As minimally invasive surgery techniques were adopted for the treatment of patients with malignancies, there were early reports of previously rare lesions such as port-site re- currences that raised many red flags in the surgical com- munity. There were many questions raised about oncologic safety and long-term outcomes, and some of these remain unanswered, the majority have stood the test of time and study. The revolution in surgery created by the minimally invasive approach is nothing short of remarkable. It has re- sulted in improved patient outcomes, a wide range of changes in healthcare, and has fueled the rapid growth of many industries. It is not surprising that many people are searching for the “ next revolution ” in surgery. Laparoscopic surgery for malignant lesions of the pancreas Despite the reverence (and fear) held by many surgeons regarding the pancreas, within a few years of the intro- duction of laparoscopic cholecystectomy, laparoscopic surgery of the pancreas had been attempted. The first laparoscopic PD was reported in 1994 [6]. Despite this early report of laparoscopic PD, the next series of devel- opments in laparoscopic surgery of the pancreas related to distal pancreatectomy (DP). This is a less demanding technical procedure compared to PD, and laparoscopic DP has become a widely used approach for patients with benign or small malignant lesions of the distal pancreas [7]. Laparoscopic DP is the most widely used minimally invasive surgery approach to lesions of the pancreas. Many surgeons find that laparoscopic DP provides im- proved exposure and visualization compared with the open procedure, and patients have enhanced postopera- tive recovery with less morbidity [7]. The first large series of laparoscopic DP was reported in 1996 [8]. This was followed by a large number of comparative studies and meta-analyses [7, 9, 10]. Lap- aroscopic DP can be performed with or without splenic preservation. As of this writing, there have been no ran- domized controlled trials of laparoscopic DP vs. open DP [8, 9]. There was a meta-analysis of 12 non-randomized studies of laparoscopic DP reported in 2016 [9]. In aggregate, these studies included 1576 par- ticipants with 394 undergoing laparoscopic DP and 1182 undergoing open DP. The reviewers felt that the studies were of overall poor quality. There were no studies that examined quality of life outcomes. Overall, patients in the laparoscopic DP group had shorter hospital stays [9]. While laparoscopic DP is widely performed, there is no high-quality data to support this practice. Randomized prospective trials are needed to appropriately evaluate this application of minimally invasive surgery. Some studies report a shorter hospital stay after lap- aroscopic DP compared with open DP [7]. Some also re- port decreased need for pain medication. In general, laparoscopic DP is associated with less intraoperative blood loss and longer operating times than the open DP. Mortality and morbidity rates of the two procedures are similar, as are the rates of pancreatic fistula formation. There is little data on long term oncologic outcomes. In summary, laparoscopic DP can be performed safely and effectively and has become the procedure of choice for lesions of the distal pancreas except in patients with large lesions or lesions in the central portion of the pan- creas [7]. Given that laparoscopic DP is already the de facto standard, prospective trials may never be con- ducted, similar to what happened in the beginnings of laparoscopic cholecystectomy. Although laparoscopic PD was first reported in 1994, large numbers of patients were not reported until much later. C o mpleting three anastomoses using minimally invasive surgery techniques is a technical challenge, which has limited the widespread adoption of this procedure. There have been quite a few series of laparoscopic PD reported, but there are no randomized trials to date. This operation can be performed safely. Some authors have reported a hybrid approach with mini-laparotomy or hand port [11]. In general, reviews have focused on indications, operative outcomes (e.g. blood loss, operative time, hospital stay) and short-term oncologic outcomes (e.g. lymph node resection) [7, 11]. Short-term outcomes in a small series from Japan were reviewed in 2009 [12]. These authors compared 15 pa- tients who underwent laparoscopic PD from 2007 through 2008 with 15 patients who underwent open PD in the same time interval. The authors reported similar mean operative time and blood loss in both groups. The status of the surgical margins and numbers of lymph Lefor BMC Biomedical Engineering (2019) 1:2 Page 3 of 15 b s t a c lat m w l D r p g t r e th i m v camera / display that allowed the surgical team to share the same view. Courses were held around the world to train surgeons in this new technique. There was suddenly no further interest in mini-laparotomy for cholecystectomy. As laparoscopic cholecystectomy became more widespread, there were many reports of bile duct injuries which raised significant concerns in the surgical and medico-legal com- munities. These seemed to be a result of the “ learning curve ” and are seldom discussed today as a particular con- sequence of using minimally invasive surgery techniques. Within a few years, nearly every abdominal operation had been performed using minimally invasive surgery tech- niques. The techniques for abdominal minimally invasive surgery were rapidly adapted to minimally invasive surgery resections in the chest as well, such that thoracoscopic lung resections are the standard approach. The minimally inva- sive surgery approach is standard for operations such as ap- pendectomy, Nissen fundoplication, colon resection, splenectomy, and others. There is further evolution going on in laparoscopic liver resection, laparoscopic gastrectomy, and other procedures. As minimally invasive surgery techniques were adopted for the treatment of patients with malignancies, there were early reports of previously rare lesions such as port-site re- currences that raised many red flags in the surgical com- munity. There were many questions raised about oncologic safety and long-term outcomes, and some of these remain unanswered, the majority have stood the test of time and study. The revolution in surgery created by the minimally invasive approach is nothing short of remarkable. It has re- sulted in improved patient outcomes, a wide range of changes in healthcare, and has fueled the rapid growth of many industries. It is not surprising that many people are searching for the “ next revolution ” in surgery. Laparoscopic surgery for malignant lesions of the pancreas Despite the reverence (and fear) held by many surgeons regarding the pancreas, within a few years of the intro- duction of laparoscopic cholecystectomy, laparoscopic surgery of the pancreas had been attempted. The first laparoscopic PD was reported in 1994 [6]. Despite this early report of laparoscopic PD, the next series of devel- opments in laparoscopic surgery of the pancreas related to distal pancreatectomy (DP). This is a less demanding technical procedure compared to PD, and laparoscopic DP has become a widely used approach for patients with benign or small malignant lesions of the distal pancreas [7]. Laparoscopic DP is the most widely used minimally invasive surgery approach to lesions of the pancreas. Many surgeons find that laparoscopic DP provides im- proved exposure and visualization compared with the open procedure, and patients have enhanced postopera- tive recovery with less morbidity [7]. The first large series of laparoscopic DP was reported in 1996 [8]. This was followed by a large number of comparative studies and meta-analyses [7, 9, 10]. Lap- aroscopic DP can be performed with or without splenic preservation. As of this writing, there have been no ran- domized controlled trials of laparoscopic DP vs. open DP [8, 9]. There was a meta-analysis of 12 non-randomized studies of laparoscopic DP reported in 2016 [9]. In aggregate, these studies included 1576 par- ticipants with 394 undergoing laparoscopic DP and 1182 undergoing open DP. The reviewers felt that the studies were of overall poor quality. There were no studies that examined quality of life outcomes. Overall, patients in the laparoscopic DP group had shorter hospital stays [9]. While laparoscopic DP is widely performed, there is no high-quality data to support this practice. Randomized prospective trials are needed to appropriately evaluate this application of minimally invasive surgery. Some studies report a shorter hospital stay after lap- aroscopic DP compared with open DP [7]. Some also re- port decreased need for pain medication. In general, laparoscopic DP is associated with less intraoperative blood loss and longer operating times than the open DP. Mortality and morbidity rates of the two procedures are similar, as are the rates of pancreatic fistula formation. There is little data on long term oncologic outcomes. In summary, laparoscopic DP can be performed safely and effectively and has become the procedure of choice for lesions of the distal pancreas except in patients with large lesions or lesions in the central portion of the pan- creas [7]. Given that laparoscopic DP is already the de facto standard, prospective trials may never be con- ducted, similar to what happened in the beginnings of laparoscopic cholecystectomy. Although laparoscopic PD was first reported in 1994, large numbers of patients were not reported until much later. C o mpleting three anastomoses using minimally invasive surgery techniques is a technical challenge, which has limited the widespread adoption of this procedure. There have been quite a few series of laparoscopic PD reported, but there are no randomized trials to date. This operation can be performed safely. Some authors have reported a hybrid approach with mini-laparotomy or hand port [11]. In general, reviews have focused on indications, operative outcomes (e.g. blood loss, operative time, hospital stay) and short-term oncologic outcomes (e.g. lymph node resection) [7, 11]. Short-term outcomes in a small series from Japan were reviewed in 2009 [12]. These authors compared 15 pa- tients who underwent laparoscopic PD from 2007 through 2008 with 15 patients who underwent open PD in the same time interval. The authors reported similar mean operative time and blood loss in both groups. The status of the surgical margins and numbers of lymph Lefor BMC Biomedical Engineering (2019) 1:2 Page 3 of 15 JULY 2021 | The Surgical Technologist | 305