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1 Prophylactic Surgery: Why, When, and How?
11
complications that may develop due to the disease with PS especially the anxiety that occurs
due to the risk of cancer relieves and the QoL
increases.
1.2 In Conclusion
Prophylactic surgery aims to eliminate the target
organ before the life-threatening disease develops, increase the expected survival, and prevent
the decrease in the quality of life. The term “prophylactic surgery,“which indicates preventing
the probable event before it occurs, has become
more popular and gained importance by the current advances in medical literature, surgical techniques, and biomedical equipment.
Experienced centers should follow up the
patients with genetic predispositions, and
advanced diagnostic tools and specialist doctors.
Early diagnosis will result in a higher chance
of cure, more comprehensive surgery, fewer complications, less mortality, lower cost, longer survival, and improved quality of life.
Increasing the detectability of mutant genes,
mainly in genetically inherited cancers, will
result in high surveillance, prevention, and surgical interventions for prophylactic purposes will
become more important.
Surgical resections will begin to be performed in a different size, with a minimally
invasive surgery technique. As the pathophysiology of the diseases is well understood, PS
will nd more application areas in our future
lives and surgical clinics with its wide variety
of dimensions.
Prophylactic surgery will take its place in the
future as a discipline with a corporate identity
that adopts a multidisciplinary approach.
The cost-effective dimension of PS will
appear as new problems that should be evaluated
in the future by insurance companies and health
service providers.
Legal, ethical, social, and psychological
dimensions of prophylactic initiatives will need
to be examined with wide and multicentric center
participation.
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Minimally Invasive Procedures and
Prophylactic Surgery
ViktorJustin andSelmanUranues
2
2.1 Introduction
The aim of preventive surgery is to preclude the
development of diseases and/or their long-term
effects, and consequently to reduce morbidity
and mortality. In this context, the old dogmas
“primum nihil nocere” (rst, do no harm) and
“the cure must not be worse than the disease”
are of highest importance. A procedure that
aims to prevent a disease can be considered as
being highly elective, and morbidity as well as
complication rates must be as low as possible
and acceptable. These procedures are often performed on active healthy persons in working age
and thus should aim to be effective in prophylaxis
with minimal strain on patient health and quality
of life. That also includes fast recovery resulting
in early reintegration into daily life and minimal
socio-economic cost.
V. Justin
Department of Surgery, Section for Surgical
Research, Medical University of Graz, Graz, Austria
Klinik Donaustadt, Vienna Healthcare Group,
Vienna, Austria
e-mail: viktor.justin@gesundheitsverbund.at
S. Uranues (*)
Department of Surgery, Section for Surgical
Research, Medical University of Graz, Graz,
Steiermark, Austria
e-mail: selman.uranues@medunigraz.at
2.2 Historical Remarks
While surgical interventions date back millennia,
modern surgery started with the onset of anaesthesia and the rst ether narcosis in 1846 [1].
Almost at the same time, Semmelweis published
his observations on puerperal fever leading to a
new understanding of post-operative infections
[2]. While Semmelweis was mainly ignored, further research by Pasteur, Koch and Lister led to
the general use of antisepsis and consequently to
the further improvement of surgical outcomes [3,
4]. The discovery of antimicrobial therapy was
another milestone for better surgical outcomes
enabling major surgeries for all kinds of indications [5]. Following decades of continuous
development, the advent of minimally invasive
procedures marked the next revolution in surgery.
While the rst laparoscopy for diagnostic indications was described in the early 1900s [6], its therapeutic use was only slowly implemented after
several years of (at times erce) discussions in
the 1980s, with laparoscopic appendectomy and
cholecystectomy being the rst indications [7, 8].
Since then minimally invasive surgery (MIS) has
gained wide use with the constant development
of new technologies including reduced port surgery, which aims at a reduction in the number and
size of the ports. The use of robotic techniques
has led to an additional expansion of the armamentarium of the minimally invasive surgeons.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_2
15
16
V. Justin and S. Uranues
2.3 Learning Curve inMinimally
Invasive Surgery
Mastering a surgical skill requires time and
intensive training, which can be described by
a learning curve, a concept initially postulated
in aviation. In surgery, talent is supplementary
and does not replace training and experience
[9]. While there is no strict denition, learning
curves are usually drawn by comparing patient
outcomes and/or measures of efciency (complications, duration of operations, rate of conversion, adequate oncological resection, etc.) to
surgeon experience or case load [10]. While often
wrongly used, a steep learning curve implies fast
mastering of a procedure, while complex operations need higher caseloads resulting in a longer and gradually inclining curve. An acceptable
standard is reached when a surgeon is able to
perform the procedure independently and competently. From here on, further experience only
slightly improves outcomes leading to a plateau
that has to be maintained by a certain annual
case load. Interestingly, a so-called secondary
learning curve has been observed, describing a
temporary decline in performance after a certain
level has been reached. This may be explained
by more complex cases, or overestimation of
own competence and skill. Finally, a certain
deterioration in performance may be observed
with advancing age.
In a comparative study of individuals without surgical expertise, laparoscopic surgery was
perceived to be more difcult to learn than open
surgery [11]. To reach a stable skill level in MIS,
about 30–80 cases as necessary for colorectal
surgery, 80 cases for thoracoscopic anatomic
lung segmentectomy and 150 cases in esophagectomy [10, 12, 13]. However, these numbers
may vary substantially depending on pre-existing
skills, annual case load and previous expertise.
This can be illustrated by results for the implementation of minimally invasive pancreatic surgery, where centres with high expertise in open
surgery reported good results after a very short
learning curve of ten cases, while centres with
a low annual number of resections per surgeon
had worse outcomes [14–16]. Apart from pos-
sible short- and long-term morbidity, surgical
complications may also have a signicant impact
on psychosocial well-being even long after the
operation [17].
Consequently, preventive minimally invasive
surgery should not serve as a learning procedure and should only be undertaken by skilled
surgeons who have mastered the learning curve
for the respective indication and are performing
these procedures on a regular basis.
2.4 Surgical Stress Response
By its very nature, surgery is invasive and as
such triggers a surgical stress response that
impacts a variety of organ systems (Fig. 2.1).
Cortisol levels increase due to raised adrenal
stimulation via adrenocorticotropic hormones
(ACTH), resulting in immunomodulation and
increased insulin resistance, and thus elevated
glucose levels [18, 19]. The resulting post-operative hyperglycaemia has been shown to be a
signicant risk factor for surgical site infections
and consequent morbidity [20]. Immunological
changes leading to immunosuppression, such
as a reduction of natural killer cell toxicity, and
t-cell responses have been observed [21, 22].
Post-operative metabolism tends to increase catabolic characteristics with proteolysis especially
affecting muscle tissue [23]. Apart from surgical
trauma, other factors such as patient comorbidities as well as the type of anaesthesia, including
perioperative analgesia and uid support, may
inuence stress response [18]. Concepts such as
fast-track surgery and enhanced recovery after
surgery (ERAS) have been proposed to reduce
morbidity [24–26]. While these should be incorporated into clinical practice generally and in
preventive indications specically, they will not
be further discussed here.
MIS has been shown to reduce operative
trauma signicantly. Post-operative cortisol
levels are lower after minimally invasive surgery indicating a lower neuro-hormonal stress
response [27–29]. A randomized trial in patients
undergoing lobectomy for peripheral bronchogenic carcinoma observed a signicantly lower
2 Minimally Invasive Procedures and Prophylactic Surgery
17
Fig. 2.1 Surgical stress
response. (Adapted from
[18] with permission
from Elsevier)
Anesthesia
Regional
Perioperative
medication
vs. General
Surgical
trauma
Influenced i.a. by
approach modality:
vs. open
MIS
Surgical
stress
response
Neuroendocrine
Metabolic
lmmunological
Hematological
Preexisting
conditions
Diabetes, arterial
hypertension etc.
grade of leucodepletion and a reduced degree of
immunosuppression (as measured by T-helper
cell depression and NK cell numbers) after videoassisted thoracic surgery (VATS) compared to
open surgery [21]. Similar results in favour of
minimal invasive surgery have been reported in
several indications including oesophageal resections [30], cholecystectomy [28], colorectal [31–
33] and hepatic surgery [34].
2.5 Perioperative andShort-Term
Outcomes
MIS usually yields longer operative times [35].
However this difference is often no longer than
several minutes and seems to decrease with experience [14]. Estimated blood loss has been shown
to be signicantly lower both in laparoscopy and
thoracoscopy [35–40] Conversion rates to open
surgery vary according to indications and patient
selection criteria but generally lie around 10%
and below in dedicated centres for visceral, thoracic, gynaecological and urologic MIS [41–43].
In laparoscopic pancreatic surgery however conversion rates up to 34% are still reported [14].
The risk of severe post-operative complications
(Clavien-Dindo IIIb or higher) does not differ
signicantly between open and minimally invasive surgery [44].
Post-operative pain has been reported to
be lower after MIS [28, 45] as well as the rate
of surgical site infections (SSI) [36, 45, 46]. A
meta- analysis found that SSI can be reduced by
70–80% in obese patients when laparoscopy is
employed [47]. The duration of hospital stays is
shorter after MIS and leads to a quicker return to
daily life [14, 35, 45, 48, 49].
2.6 Long-Term Outcomes
Long-term procedure–related complications
depend on the respective primary operation. In
abdominal surgery, formations of adhesions and
subsequent bowel obstruction, as well as development of incisional hernia, are of major concern
[50]. A review of more than 440,000 abdominal
18
ab
V. Justin and S. Uranues
operations showed a higher incidence of small
bowel obstruction (SBO) after open cholecystectomy (7.1% vs. 0.2%), abdominal hysterectomy
(15.6% vs. 0.0%) and adnexal operations (23.9%
vs.0.0%) when compared to their laparoscopic
“counterpart” [51]. Incisional hernia occurs in
about 9.9% of cases after elective laparotomy
(11% midline vs. 4.7% transverse incision;
p = 0.006) and statistically is thus signicantly
more often than in laparoscopy (0.7%; p=0.001)
[52]. Apart from individual risk factors for incisional hernia such as obesity and smoking, a history of SSI additionally increases the incidence
of hernias.
While complications remain the most decisive factor for impaired post-operative quality of
life, certain studies also indicate a higher postoperative QOL in minimally invasively operated
individuals [53–56].
In order to round up this chapter with a practical example, applicable data from a meta- analysis
from Tan etal. [57] will be utilized. A 38-year- old
man, whose father died of colon cancer at age 40,
has been tested positive for hereditary nonpolyposis colorectal cancer (HNPCC). He has been
informed extensively and—nearing the age of his
father’s diagnosis—desires prophylactic colectomy. He is physically active and healthy, with
a history of hypertension on his medical record.
Your institution is a dedicated high- volume laparoscopic colorectal centre. You schedule him for
laparoscopic proctocolectomy with ileo-rectal
J-pouch anastomosis with protective ileostomy
closed after 6weeks.
The operation went as planned (Fig.2.2) and
took 3.2 h, about 30 min longer than the open
approach. Estimated intraoperative blood loss
was 336 mL (as opposed to 412 mL in open
surgery) and no blood products were needed.
Bowel function recovered after 2days, an average 2days earlier than after open surgery. He is
one of 85% who do not develop an anastomotic
leak and leaves the hospital after 6days (a mean
of 2.6days earlier than he would have with open
surgery). The small skin incision at the specimen extraction site heals without complications
(Fig.2.3). When you see him again after 6months,
he reports 3–5 bowel movements per day without strong urgency. As you adhere to compliance
policy at your institution, all he can give you is a
Fig. 2.2 Specimen after laparoscopic proctocolectomy: intraoperative (a) and back-table (b) view
2 Minimally Invasive Procedures and Prophylactic Surgery
Fig. 2.3 Two-year follow-up after laparoscopic procedure shown in Fig.2.2
big “thank you” and a rm handshake. And while
this case may be idealized: Is not that what you
would want for all your patients?
2.7 Conclusions
Given adequate resources and a high level of
skill, minimally invasive surgery is the desirable
approach in prophylactic indications. Operative
trauma, post-operative pain and the risk of longterm complications (SBO, hernia) are reduced,
while fewer surgical site infections and shorter
length of hospital stay can be observed.
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