Editorial
Incisions in the Quest to Perfection
HO Kok Sun*
Department of Colon and Rectal Surgery, Ho Kok Sun Colorectal Pte Ltd, Singapore
*Corresponding author: HO Kok Sun, Department of Colon and Rectal Surgery, Ho Kok Sun Colorectal Pte Ltd, Singapore
Published: 11 Oct, 2017
Cite this article as: HO Kok Sun. Incisions in the Quest to
Perfection. Clin Surg. 2017; 2: 1667.
Editorial
Since the advent of minimally invasive surgery, there has been greater emphasis on incision
length. It is widely perceived that the shorter/smaller the incision, the less pain it causes, and hence
the faster the recovery. It is common for the earlier papers on laparoscopic surgery to report on the
various lengths of the incision. It is probably a common thinking that smaller incisions equate to
better surgical skills. There were even discussions into comparing incision lengths of skin versus
incision length of fascia, as in that the skin can be stretched and would not be a true representation
of the surgeons’ skill. For laparoscopic surgery involving the removal of a relatively solid organ
(such as colon, kidney), it is important to remember that the length of the incision is dependent
upon the size of the lesion that is to be removed, instead of the operative skill of the surgeon. If one
were to look at it at another level, one could even argue that a larger incision reflects a better skilled
and more confidant surgeon, who is willing to treat a larger lesion with laparoscopic means.
The advent of robotic surgery has given surgeons better tools in their armamentarium. However,
there are still major constraints of the robot, namely, its restricted field of operation. There are
purists who insist that robotic colorectal surgery has to be performed entirely using the robot, thus
having to make a few additional laparoscopic incisions to dock the robot in different positions. The
pragmatist among us will use the robot judiciously, confining its use to deep pelvis where it gives
the biggest advantage, and do the rest of the dissection using the same ports with laparoscopic
instruments.
The quest for smaller incisions continue, where smaller is better, but none is perfect. Hence
NOSES, NOTES came about. What we should never forget is that incisions in surgery are
unavoidable – the only difference is only whether the incision can be seen. Each and every incision
carries a cost and a risk of complication: for skin (infection, cosmesis), fascia (hernia), stomach,
colon, rectum (anastomostic dehiscence), and vagina (dyspareunia, possible enterovaginal fistula).