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Hard Core MIS BY EDITOR, DECEMBER 8, 2003

I may not be able to define it, but I know it when I see it.

Seriously, NO trend in surgical medicine has been stronger than MIS. Twenty years ago balloon angioplasty – despite a nearly 80% failure rate – pulled patients away from the chest cracking cardiac surgeons. Spine Tech's great innovation was expanding the adoption of anterior spine fusion – an MIS procedure. I'll never forget the conversation between two surgeons who, between them, bracketed a big American city – one guy was east, the other guy was west. The western guy fused the spine with 5 inch back incisions and 2-3 units of blood. The eastern guy did it with a 1 inch anterior incision and about 10cc of blood. The western guy actually had a patient leave him and go to the eastern guy because he could get his spine fused “through the tummy”.  And he was asking the eastern guy how he could learn the anterior approach.

Where would GI surgery be without MIS gall bladder surgery?

Is Kyphoplasty MIS? Is Zimmer's two-incision system MIS? Is Medtronic's Sextant? Endius's Atavi?

After twenty years of talking to lots of device manufacturers and surgeons, here's our take on ortho MIS;

1. Percutaneous treatments are MIS, but only a part of it. They are limited. They lack the kind of visualization traditional surgeons are accustomed to. Access usually boils down to working through a tube and the instrumentation has to be invented from scratch and it takes a decade to get it right. In the case of balloon angioplasty, it took an entirely new practitioner to drive it; the interventional radiologist, who brought new visualization, access and instrumentation tools to the problem.
2. No old surgical indication can survive unless it becomes either minimally or least invasive. In spine fusion, there is no highway for the surgeon to follow (like there is with balloon angioplasty) and the surgeon has to wait 12 -18 months to tell if the fusion is successful. So, MIS for traditional spine fusion must meet much higher standards for visualization and access than traditional percutaneous approaches, we think. To gain surgeon confidence manufacturers must find ways to deliver less invasive surgical (LIS) techniques. LIS implies that the surgeon can still use their existing techniques, but it will be less invasive and entail much less tissue destruction.
3. No new surgical indication will succeed unless it is MIS. Kyphoplasty is a case in point. If it had required open surgery to set the vertebral compression fracture, Kyphon would be in the dust heap. But it works because it is percutaneous access with adequate visualization (fluoroscopic) and unique instrumentation. Because both the instrumentation and visualization is novel Kyphon is driven to emphasize surgeon education. Very expensive; time consuming; but it succeeded and now, Kyphon has dominating market leadership in this new indication. Now comes disc arthroplasty. It has to be MIS and probably percutaneous, in our judgment, to capture widespread surgeon support.
4. Flexibility will eventually rule. There are a kaleidoscope of techniques among ortho surgeons. They all know that they must adapt to the MIS wave. The issues are clear: visualization, access and instrumentation. But the trick, we believe, will be flexibility which, in turn, will allow each surgeon to retain most of his/her own techniques. LIS delivers the least destructive technique but still allows the guy in Connecticut to treat his patients in his way and the woman in Texas to treat patients her way. And the key to LIS is instrument flexibility. As one surgeon described it to me - MIS is essentially a search for the perfect retractor. Exactly.