Commentary on “Transumbilical Single-Incision Laparoscopic Fundoplication: A New Technique for Liver Retraction Using Cyanoacrylate”

I have been invited to provide comment on “Transumbilical Single-Incision Laparoscopic Fundoplication: A New Technique for Liver Retraction Using Cyanoacrylate.” ¹ I am more than happy to do so, and would like to take this opportunity to both salute and commend the authors. This is not necessarily in regard to the use of the single-incision laparoscopic surgery technique or cyanoacrylate glue, but for their efforts to make changes in procedures in order to benefit their patients.

Many, if not the majority of, surgeons learn a technique for the surgical treatment of a disease during their training and may continue the use of that exact same technique over a 20- or 40-year span, with little or no change, unless driven by economic forces. Usually, we surgeons perceive that however we are performing a particular procedure is working as good as is possible for us and our patients, and we are reluctant to change. We are all “riding a winning horse” and feel no need to change horses. (We are all also, remarkably, above average in our own opinion.)

The authors, however, have demonstrated the admirable characteristic of looking at the procedures they are performing and trying to decide where they can make changes that will improve the outcomes and bring benefit to their patients. This is true in both their utilization of a single-incision technique for performing common surgeries and the use of cyanoacrylate glue for the retraction of the liver.

The use of single-incision techniques is more “revolutionary.” It requires the use of different viewing angles, new instrumentation, altered “angles of attack” to the laparoscopic target, and new skill sets. It represents a more radical alteration in the techniques that came before. The use of cyanoacrylate glue to carry out the mundane task of liver retraction is far more “evolutionary.” Regardless, the authors are still to be commended for their efforts at change to improve operations for their patients.

In my home, with The Methodist Hospital's Department of Surgery, we believe so strongly that surgeons need to be pushed to keep up with advances in surgical technique that we have worked with our hospital to create The Methodist Institute for Technology, Innovation, and Education (MITIE^SM). MITIE (https://www.mitietexas.com) is dedicated to helping practicing surgeons avoid becoming “mired” in the knowledge and techniques they acquired during their residency and fellowship training. We strongly believe that surgeons need a place to retrain or “retool” in order to keep pace with the rapid developments occurring in the techniques of delivery of surgical care. Whether surgeons just need to keep current or want to be on the “bleeding edge” (pardon the expression) of the delivery of surgical care, we think they should be offered a trustworthy, knowledgeable, reliable place to do so. It is from this background that I am compelled, then, to salute and commend the authors.

I am not certain that single-incision procedures will ever achieve widespread adoption because of technical issues and surgeon skill sets. I am not certain that the use of cyanoacrylate glue will “stick” (pardon again) because of technical and cost concerns. What I am certain about is the need for surgeons, like the authors, to continually reevaluate each and every aspect of the surgical techniques we perform every day, looking for ways to improve outcomes, cut costs, and simplify procedures, all to the benefits of our patients. For their efforts along these lines I salute and commend the authors.