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.


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).