Who should decide the best minimally invasive approach? Should we listen to our patients?

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To the Editors,We read with special interest the article entitled PatientPreferences for New Techniques: Should We Invest inNew Approaches? by Rao et al. [1] published online 19May 2010. This definitely well-designed article with aninteresting methodology tried to question people aboutminimally invasive surgery considering their differenteducational backgrounds. Nevertheless, we cannot helpdisagreeing with some important points stated by Rao et al.[1].An important issue stated in this paper is the assumptionthatsingle-portsurgeryinvolvesthesameprinciplesasthosecurrently recognized widely as foundational to ‘‘regularlaparoscopic surgery.’’ As we stated in previous communi-cations, single-port procedures are not regular laparoscopicsurgery and therefore should be performed only by experi-enced laparoscopic surgeons with specific training in theanimal lab before they are applied to human cases. Loss oftriangulation (even with articulating instruments), collisionof instruments, and important ergonomic concerns showthat, although similar, this type of procedure (laparoendo-scopic single-site surgery) implies different training anddemands much more effort than regular laparoscopy [2].Therefore, needlescopic surgery should be considered notonly the most similar alternative to regular laparoscopicsurgery, but also the technique offering better cosmeticresults thanlaparoscopy.However,thisoptionwasforgottenby the authors and not presented to the individuals inter-viewed [3] (Fig. 1).In addition, after working with all the devices availableon the market and even considering single-incision surgeryas proposed by Podolsky and Curcillo [4], we find it dif-ficult understand that these procedures can be performedthrough a 12-mm incision because the minimal diameter ofcurrent ports is in the range of a 25-mm incision [4, 5].Another point is that as incision size is increased, the ratesof incisional hernia and infection should rise proportionally[6–8].We congratulate the journal and Rao et al. [1] for statingthat we should always ask the main individual interestedin our minimally invasive surgical techniques: the patient[9–11]. As a matter of further contribution, we suggest thatthis type of survey should be reproduced adding needle-scopic surgery, a currently established and well-studiedalternative that should be offered as a surgical approachoption to the interviewers, including pictures of postoper-ative cases to illustrate the difference among the surgicalaccess scars [3]. It could definitely help patients to thinkbetter about their decision [12].Despite the apparent widespread enthusiasm for mini-mally invasive procedures worldwide in recent years, theirvalue extends beyond the demonstrated or potential clinicalbenefits [13]. In addition, economic considerations ofpatients, surgeons, and hospitals are prominent factors inthis debate and should influence the adoption of these