Over the last 15 years, minimally invasive surgery has taken a leading role in the field of Surgery. In the beginning however, there were many obstacles to overcome. Minimally invasive surgery in the early 1990’s faced several problems like, surgeons who were trained only in the techniques of open surgery and hospitals that did not want to bear the financial strain of acquiring new equipment in order to keep up with the new technology. In addition, there is the risk of the laparoscopic procedure converting to open, which in turn doubles the cost.

However, patient issues with open surgery include increased physical trauma, poor cosmetic results, increased postoperative pain, lengthy hospital stays, lengthy recovery time, all imposing financial burden associated with two to three months of recovery. In addition, hospitals have problems with open surgery as well. These include, but are not limited to, poor bed and nursing utilisation (open surgical patients are difficult to take care of as compared to laparoscopic patients), discharge planning, and decreasing insurance reimbursement.

One of most difficult challenges to overcome was educating surgeons to a new technique. Surgeons are taught to develop a tactile sensation for the tissue they are handling, much of which is lost during minimally invasive surgery. Patient advantages such as faster recovery, less pain, better cosmesis, and earlier return to work forced the medical field to proceed with minimally invasive technology.

As this specialty evolved, the operating room certainly became the main target for education and innovation. Specifically, different equipment is required, surgeons have to be trained as mentioned above, ancillary staff, nursing, and technical personnel all have to adapt to new and more complicated procedures. This included, everyone becoming aware of safe patient-positioning, proper padding and cushioning, and increased education to use and troubleshoot new equipment.

From an oncological point of view, laparoscopic surgery has significant immunologic effects as compared to the open colorectal surgery. For example, there is a significant decrease in the physiological stress to the patient. As a result, articles began to appear in the New York Times, Web MD and Cancer News showing the profound patient advantages. Several hospitals began analysing the learning curve and the eventual cost savings for the hospital ? and in turn ? to the patient and the employer. (See references listed below.) Medicare reimbursement continued to show an economic advantage for minimally invasive surgery and its benefits.

In light of this evidence, the preoperative preparation of the patient, education for the surgeon and the nursing staff, and the OR design and layout continues to evolve. Some of which include mobile equipment, operating room cabinets that make it easier to visualise contents, space necessary for highly technical machines and constant education and re-education for all perioperative staff involved. Specific safety concerns needed to be addressed such as energy sources, acute changes in the patient’s physiology, and knowledge to develop and use new instrumentation specific to these highly technical procedures. Other changes included charting needs such as equipment documentation of serial numbers should there be a fault that occurred.

Surgical teams need to be motivated to learn, practice and rehearse the procedure, as well as, plan ahead for case specific needs. They need to understand what could go wrong and having a backup plan should the need to convert to an open procedure arise.

The next step is how to implement this technology into a safe Operating Room Environment. Education and rehearsal is the key. Once an idea has been transferred into reality, how do we proceed as healthcare providers into making this idea a safe operating room procedure? First we need to rehearse. Assemble the operating room team and go through the procedure step by step from the pre-op paperwork (possible IRB consent) to positioning on the OR table, through the procedure and post operative care. Second is patient selection. Anytime a new procedure or technique is tried, selecting the proper patient, especially for the first few cases is also very important. Third, perioperative support personnel should also be present for the first few cases in the rare instance of equipment failure. When trying out new techniques or equipment unforeseen events can occur. It is best to have as many personnel available to trouble shoot the “unforeseen event” to avoid a patient catastrophe. Lastly and equally important is outcome data. Following the patient though their perioperative period and out patient follow-up is key to tract our outcomes. Evidence-based medicine is the new standard of care.

Even with all these challenges it is increasingly noted that this technology could be adopted in any healthcare environment from a small 40-bed hospital to a big university hospital with several thousand beds. This is attributed to the tremendous benefits and economic impact on the patients.

Because of the evolution and the demand for minimally invasive surgery it has now taken a forefront in the surgical world. In light of this fact and that laparoscopic simulation is now available for the surgeon and nursing staff to practice these procedures, any operating suite can safely and efficiently master this technique, thus providing tremendous benefits to their patients.