Though not yet widely available, subcutaneous endoscopic procedures and single-port surgery are the next steps along the continuum of progress in the field of minimal access surgery. Eventually, camera lenses and instruments will have multiple joints or will be entirely flexible to allow most procedures to be performed through a single umbilical port. Until then, progress will need to be incremental and driven forward by mavericks in the field. Though each of us undoubtedly applauds this progress, we should also be mindful of the fact that patients, especially children, are not experimental subjects. In addition, cutting-edge procedures should not be attempted unless we have a reasonable expectation that the risks are as low or lower than what would be expected for the standard of care.
Standard minimally invasive procedures in the abdomen can be modified to improve cosmesis: using the minimum number of ports necessary; creating a true intra-umbilical incision rather than the standard periumbilical incision; placing an instrument next to the umbilical camera port incision rather than placing a second port; placing all port site incisions as far lateral on the abdomen as possible and avoiding the upper abdomen and the midline whenever possible; placing instruments that do not require replacement during the operation, such as a liver retractor, through the abdominal wall without using a port; and using U-stitches to retract or suspend certain structures (gall bladder, falciform ligament, stomach) instead of placing an extra port merely for a retractor.
Subcutaneous endoscopic procedures are useful for neck lesions, including the thyroid and parathyroid, but are technically demanding. In addition to the standard axillary incisions, peri-areolar incisions are also well positioned and cosmetically acceptable. The subcutaneous working space should be created with gentle blunt dissection whenever possible and only the minimum pressure of CO2 insufflation needed to maintain the space should be used. Excessive pressure can create widespread subcutaneous emphysema. Finally, one should be aware that there is a risk of burning the skin if the tip of the laparoscope comes into contact with the dermis for more than a few seconds, just as can occur externally when the scope touches the skin or the surgical drapes.