Journal of Pediatric Urology (2010) 6, 95

Commentary to ‘‘‘Open’ minimally invasive surgeryin pediatric urology’’Ought we not (re)define minimally invasive surgery?

Luke Harper*

Paediatric Surgery, CHR F Guyon, Bellepierre, 97405 Saint-Denis, Reunion, France

Received 28 August 2009; accepted 1 September 2009Available online 12 October 2009

Dear Editor,

I read with interest the article entitled ‘Open’ minimallyinvasive surgery in pediatric urology. The authors reportand discuss their experience with, what they call, openminimally invasive surgery (MIS). Open MIS is defined asa surgical technique which uses small incisions and obviatesthe use of laparoscopic instruments.

It is true that the term ‘minimally invasive surgery’ was,by tradition, understood to refer to laparoscopic or endo-scopic surgery. This was probably already a lexical shortcutsince, though the incisions might individually be smaller,the surgery itself is often not less invasive. The problemwith new terms such as ‘open minimally invasive surgery’ isthat these appellations are purely arbitrary, they relatesolely to incision size, and in some cases the surgery itselfseems more invasive than classic surgery.

In this report, the authors refer to open MIS for renalsurgery performed through small incisions (ranging from1.3 to 2.5 cm in patients <1 year of age, and 2.4 to 5.4 cmin patients >10 years of age). What is the definition ofsmall? Is it defined just as smaller than we used to perform?Or smaller than other surgeons do? Most of us try to usesmall incisions, but when do they become minimally

DOI of original article: 10.1016/j.jpurol.2009.02.195.* Tel.: þ262 262 906494; fax: þ262 262 905498.

E-mail address: harper_luke@hotmail.com

1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Publishedoi:10.1016/j.jpurol.2009.09.007

invasive? The article also refers to a mini-Pfannenstielincision. What defines a mini-Pfannenstiel incisioncompared to a Pfannenstiel incision? The question is, if wewant to know what we are talking about, should we defineexactly when open surgery becomes minimally invasive,through standard incision sizes related to child weight, forexample?

Furthermore, the report mentions performing orchi-opexy through a circumcision incision after completedegloving of the penis. I am surprised that this can be calledminimally invasive compared to a circumcision and scrotalincision. Full penile degloving seems rather aggressive andnot without risk, nor potential postoperative discomfort,whilst the cosmesis of scrotal incisions is close to irrele-vant. I honestly question whether this kind of alternativetechnique should be coined minimally invasive compared toclassic techniques. Finally, the least invasive surgeryremains no surgery at all. Nowadays there are very fewindications for performing any kind of surgery for multi-cystic dysplastic kidneys or low-grade VUR for example, andnot all reports on ‘minimally invasive techniques’ clearlyaddress the question of indications.

Finally, I believe we should clearly (re)define what‘minimally invasive’ means, in order to give the term anydegree of scientific value.

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