Minimally Invasive Surgery

Minimally invasive surgery refers to advanced techniques performed through small incisions instead of open operations. These methods reduce trauma, blood loss, and recovery time, offering significant benefits for patients.

Laparoscopic and robotic-assisted surgeries are widely used in cardiology and vascular medicine. They provide precise results with less risk of infection, minimal scarring, and faster hospital discharge.

Patient selection is crucial in minimally invasive surgery. Not all individuals are suitable candidates, especially those with complex or advanced disease, requiring careful preoperative evaluation.

Compared to traditional methods, minimally invasive surgery may involve higher costs due to advanced technology. However, faster recovery and fewer complications often offset these expenses.

What does minimally invasive surgery mean?

One of the most common questions our patients ask is: What is minimally invasive? As the name suggests, this term means making the least possible intervention in the body. In traditional open surgeries, the surgeon needs to make a large incision, usually 15-20 centimeters, in order to comfortably reach the organ to be operated on. This means cutting the skin, subcutaneous tissues and muscles, which is the main cause of postoperative pain and prolonged recovery.

Minimally invasive surgery changes this picture completely. Instead of one large incision, several small “keyhole” incisions are used, usually 1-2 centimeters. Through one of these incisions, a thin instrument called an “endoscope” with a high-resolution camera and light source at the end is sent into the body. Through this camera, the surgical site is projected on large screens in the operating room, magnified tens of times and extremely clear. The surgeon watches the operation on this screen and performs the surgery with specially designed, long and thin surgical instruments inserted through other small incisions. So, in fact, the surgeon’s eye and hand can reach even the deepest points of the surgical site with extraordinary precision thanks to this technology.

What are the main differences between conventional surgery and minimally invasive surgery?

A clearer understanding of the differences between these two modern approaches reveals why the minimally invasive method is increasingly preferred. The most obvious differences between them are the following:

• Incision Size: Minimally invasive surgery involves several very small incisions, whereas open surgery involves a single, large incision.
• Tissue Damage: Thanks to the small incisions, muscles and surrounding tissues are gently pushed aside instead of being cut. This means less damage to the body.
• Quality of Vision: Thanks to high-resolution cameras and magnification, during minimally invasive surgery the surgical site is visualized in much greater detail and clarity than it would be with the naked eye.
• Speed of Recovery: The less the body is battered, the faster the recovery.

What are the advantages of the minimally invasive method for patients?

The answer to the question of what minimally invasive surgery is actually hidden in the advantages it brings. The benefits of this method directly improve the quality of life after surgery. To list the most important advantages:

• Less postoperative pain
• Much shorter hospital stay
• Faster return to everyday life and work
• Significantly less blood loss during surgery
• Significant reduction in the risk of wound site infection
• Much better cosmetic results (small and indistinct scars)

These advantages are based on a single principle. The less trauma we inflict on the body, the faster it recovers. Less pain allows the patient to stand up, walk and breathe deeply sooner after surgery. This early mobilization also reduces serious risks such as lung infections and blood clots. In short, the benefits trigger each other like a chain reaction, making the overall healing process both faster and much more comfortable.

Like any surgery, does the minimally invasive approach have risks?

As every medical intervention has potential risks, minimally invasive surgery has its own challenges and risks. Being transparent about these is essential for the patient and physician to make the best decision together. It should be noted that most of these risks are extremely rare and can be managed by an experienced surgical team.

In general, the following situations can be encountered:

• Risks of General Anesthesia: As with any surgery, reactions due to anesthesia may occur.
• Bleeding and Infection: Although these risks are much lower with the minimally invasive method, they are never zero.
• Organ Injury: There is a possibility that the instruments used during surgery may damage surrounding tissues or organs.
• Longer Operation Time: Sometimes the preparation of the equipment and delicate maneuvers may slightly increase the duration of surgery compared to open surgery.
• Possibility of Transition to Open Surgery: Although very rare, an unexpected situation (for example, bleeding that is difficult to control or poor visualization of the anatomy) may occur during surgery. In such cases, the safety of the patient is always the priority and the surgeon may decide to switch to traditional open surgery in a planned manner. This is not a failure, but rather a responsible decision to protect the patient’s health.

Each patient’s situation is unique. Previous abdominal surgeries, excess weight or certain anatomical differences may affect the applicability of the minimally invasive method. Therefore, the most appropriate method should be decided after a detailed evaluation with your surgeon.

Which technologies are used in minimally invasive surgery?

The success of minimally invasive surgery relies entirely on high-tech instruments and systems. Without these technologies, “keyhole” surgery would be a dream. As the eyes, hands and ears of the surgeon, these systems take human capabilities to an even higher level.

The key components of this technology are:

• Endoscopic Camera Systems: These are the “eyes” of the surgery. They are thin, tube-like instruments with a high-resolution camera and fiber optic light source at the end. Today, with 3D and 4K image quality systems, the surgical site can be seen with incredible detail and depth perception.
• Special Surgical Instruments: These instruments (scissors, grippers, energy devices, etc.), which we can think of as the surgeon’s “long and thin fingers”, are designed to pass through small incisions. They have models whose tips can bend and rotate at angles that the human wrist cannot.
• Insufflator Devices: These are devices that create a safe working area for the surgeon by inflating the abdominal cavity with carbon dioxide gas in a controlled manner, especially in abdominal surgeries.
• Robotic Surgery Systems (da Vinci etc.): This is the pinnacle of minimally invasive surgery. The surgeon manages the arms of the robot by sitting at a console. The robot transmits the surgeon’s hand movements to the surgical site, completely eliminating shaking and scaling (a 1 cm movement of the surgeon can turn into a precise 1 mm movement at the tip of the robot). thanks to its 3D image and superior maneuverability, it provides a great advantage especially in surgeries in hard-to-reach and sensitive areas (such as heart, prostate, uterus).

How is minimally invasive surgery used to treat heart disease?

When you think of heart surgery, the first thing that comes to mind is a major operation in which the breastbone (sternum) is cut across. This traditional method is still life-saving in many cases. But in suitable patient groups, minimally invasive heart surgery is a great alternative that dramatically changes the recovery process. The fact that the breastbone is not cut is the biggest and most transformative advantage of this method.

There are some important conditions that can be treated with a minimally invasive approach in cardiac surgery:

• Coronary bypass surgery
• Mitral valve repair or replacement
• Aortic valve replacement
• Tricuspid valve repair or replacement
• Removal of intracardiac tumors
• Closure of some congenital heart holes (such as ASD)
• Arrhythmia surgery (Maze procedure)

In these operations, a 5-7 cm incision (mini-thoracotomy) is usually made on the side of the chest, between the ribs. The camera and special instruments are inserted through this incision and the operation is performed. Because the sternum remains intact, patients experience much less postoperative pain, do not have to wait for the bone to fuse and can return to their daily lives weeks or even months earlier.

For whom is minimally invasive coronary bypass surgery an option?

Coronary bypass is one of the most common heart surgeries to remove blockages in the arteries supplying the heart. When performed with a minimally invasive method (MICS CABG), the patient’s recovery process takes on a whole new dimension. However, this method may not be suitable for every patient. Patient selection is critical for the success of the surgery.

The patient profile generally considered suitable for minimally invasive bypass has some characteristics:

• Patients with blockage in one or more blood vessels
• Those whose heart function is not severely impaired
• Those without serious lung disease or chest wall deformity
• Those who are not overweight (morbidly obese)
• Those who have not received radiotherapy (radiation therapy) in the chest area before

The minimally invasive approach may be an ideal option, especially for patients at risk of sternal bone wound healing due to diabetes, advanced age or chronic obstructive pulmonary disease (COPD). The results are much more successful in planned cases where surgery is not urgent. The final decision will be made by your cardiovascular surgeon after detailed examinations (angiography, echocardiography, lung function tests, etc.).

What is the recovery process after minimally invasive heart valve surgery?

The recovery process is perhaps the most striking advantage of the minimally invasive procedure. Because the breastbone is not cut, the experience for patients is much milder than with traditional surgery.

During the recovery process, patients usually expect the following:

• Hospitalization: It is usually between 3 and 5 days. In open surgery, this period can reach 7-10 days.
• Pain Control: Pain is much less and is usually easily controlled with simple painkillers.
• Movement: Patients can stand up and start walking the day after surgery. When they are discharged, they can easily take care of their personal care.
• Return to Normal Activity: Light brisk work such as office work can be resumed within 2-4 weeks. Driving a car can also be started in a similar period. In open surgery, these periods may take 2-3 months.
• Physical Restrictions: Since the sternum is not cut, there are no restrictions such as patients lying on their backs for months or avoiding putting loads on their arms. They are only advised to avoid heavy lifting for a few weeks to allow the incisions to heal.

Are catheterized minimally invasive procedures (TAVR, EVAR) different from surgery?

Yes, this is a very important distinction. Methods such as TAVR (Transcatheter Aortic Valve Replacement) and EVAR (Endovascular Aneurysm Repair) are also minimally invasive, but they are performed through a vein instead of a surgical incision. These methods usually use the inguinal artery.

• TAVR: In patients with severe aortic valve stenosis who are at high risk for open heart surgery, a new biological valve is inserted into the narrowed valve using a catheter inserted through the groin. The rib cage is never opened.
• EVAR: It is used to treat a dangerous bubble (aneurysm) in the aortic artery in the abdomen or chest. A special stent (stent-graft) is inserted through the groin, covering the inside of the aneurysm and allowing blood to flow through it. The abdomen or chest does not open at all.

These endovascular (intravenous) methods are a revolution, especially for elderly patients, those with comorbidities and those who cannot tolerate major surgery. Recovery times are much shorter than surgery and patients can usually be discharged within 1-2 days. A “heart team” consisting of cardiology and cardiovascular surgery specialists decides together which patients are suitable for surgery and which are suitable for endovascular intervention.

In conclusion, for whom is minimally invasive surgery the right choice?

As you can see, minimally invasive surgery is one of the most valuable offerings of today’s medicine. However, it is not a silver bullet and may not automatically be the best option for every patient. Many factors are taken into account when determining the best course of treatment.

Critical factors in choosing the right method are:

• Age and general health status of the patient
• Type, location and degree of progression of the disease to be treated
• Suitability of the patient’s anatomical structure to the method
• Other additional diseases, if any (lung, kidney problems, etc.)
• The experience and technological infrastructure of the surgeon and the hospital

Our aim is to evaluate these factors in detail for each patient and create the safest and most effective treatment plan. Sometimes traditional open surgery may be the best option, but for many patients, minimally invasive procedures offer an opportunity to improve quality of life to an extraordinary degree. It is best to make this decision in a trusting relationship with your doctor, who will explain the advantages and disadvantages of all options.

Frequently Asked Questions

Prof. Dr. Yavuz Beşoğul

Prof. Dr. Yavuz Beşoğul graduated from Erciyes University Faculty of Medicine in 1989 and completed his specialization in Cardiovascular Surgery in 1996. Between 1997 and 2012, he served at Eskişehir Osmangazi University Faculty of Medicine as Assistant Professor, Associate Professor, and Professor, respectively. Prof. Dr. Beşoğul, one of the pioneers of minimally invasive cardiovascular surgery in Türkiye, has specialized in closed-heart surgeries, underarm heart valve surgery, beating-heart bypass, and peripheral vascular surgery. He worked at Florence Nightingale Kızıltoprak Hospital between 2012–2014, Medicana Çamlıca Hospital between 2014–2017, and İstinye University (Medical Park) Hospital between 2017–2023. With over 100 publications and one book chapter, Prof. Dr. Beşoğul has contributed significantly to the medical literature and is known for his minimally invasive approaches that prioritize patient safety and rapid recovery.