Navigating challenges and maximizing potential: Handling complications and constraints in minimally invasive surgery

3.1 Reduced trauma and faster recovery

MIS represents a transformative approach to surgical interventions, offering patients a substantial reduction in trauma compared to conventional open surgeries. Traditional open procedures typically involve large incisions that necessitate cutting through layers of tissue, resulting in more extensive damage to the surrounding structures. This heightened trauma is not only associated with increased pain for the patient but also a greater risk of complications, including infection and a longer healing process. The inherent advantage of MIS lies in its utilization of small incisions, significantly minimizing the disruption to tissues [19]. This reduction in surgical trauma is particularly noteworthy in abdominal and pelvic surgeries, where delicate structures can be approached with precision through small ports, mitigating the need for large, invasive incisions. The impact of reduced trauma in MIS extends far beyond the surgical suite and into the patient’s recovery period. A key component of this advantage is the significant decrease in postoperative pain experienced by patients undergoing minimally invasive procedures. Smaller incisions result in less tissue disruption, nerve stimulation, and overall discomfort, contributing to a more comfortable recovery experience. Furthermore, the diminished trauma associated with MIS translates into a lower risk of infection, as smaller wounds are inherently less susceptible to microbial infiltration. This, in turn, minimizes the need for extended antibiotic regimens and facilitates a swifter and more uncomplicated recovery trajectory [20]. In addition to alleviating pain and reducing infection risks, the reduced trauma characteristic of MIS plays a pivotal role in shortening hospital stays and accelerating the overall recovery process. Patients undergoing MIS typically experience a quicker return to their daily activities compared to those who undergo open surgeries. The diminished impact on the body allows for a more rapid restoration of functionality and promotes early mobilization, further contributing to the expedited recovery. This advantage is particularly impactful in cases where the patient’s overall health and well-being are closely tied to their ability to resume normal activities promptly. In summary, the intrinsic link between reduced surgical trauma and faster recovery in MIS underscores the profound positive impact this approach has on patient outcomes and postoperative experiences [21].

3.2 Lower infection rates and improved safety

The reduction in infection rates is a critical aspect of the improved safety profile associated with MIS. The primary factor contributing to lower infection rates in MIS is the strategic minimization of incision size. In traditional open surgeries, larger incisions create expansive pathways for external contaminants, increasing the likelihood of postoperative infections. In contrast, MIS involves smaller, precisely placed incisions, significantly limiting the exposure of internal organs to potential pathogens. This strategic approach not only minimizes the risk of infections but also underscores the meticulous care taken to enhance patient safety during surgical interventions. The correlation between smaller incisions and reduced infection risk has profound implications for patient outcomes [22]. By minimizing the opportunity for microbial infiltration, MIS enhances the safety of surgical procedures, particularly in areas prone to contamination, such as the abdominal or pelvic regions. Lower infection rates contribute to a more favorable postoperative recovery experience for patients, as they are less likely to experience the complications associated with infections, such as delayed healing or the need for prolonged antibiotic therapies. Moreover, the improved safety profile of MIS aligns with broader healthcare objectives of reducing hospital-acquired infections and optimizing patient care quality. Beyond the direct benefits to patients, the lowered infection rates associated with MIS can also contribute to healthcare cost-effectiveness. The diminished risk of postoperative infections may result in a decreased need for prolonged antibiotic treatments and additional medical interventions aimed at managing and resolving infections [23]. This, in turn, can lead to cost savings for healthcare systems, highlighting the economic advantages of emphasizing MIS as a preferred surgical approach. Consequently, the intrinsic link between reduced infection rates and improved safety in MIS not only enhances individual patient outcomes but also aligns with broader healthcare goals of optimizing resource utilization and maintaining cost-effective, high-quality care [24].

3.3 Improved cosmesis

MIS introduces a notable aesthetic advantage through the promotion of improved cosmesis. Central to this benefit is the strategic use of small incisions, a characteristic feature of MIS procedures. Unlike the larger and more conspicuous scars often associated with open surgeries, the tiny incisions used in MIS are discreet and result in minimal scarring. This feature is particularly significant in surgical interventions where the operative site is visible, such as certain abdominal or facial surgeries [5,25]. The cosmetic advantages of MIS extend beyond mere appearances; they contribute to the preservation of the patient’s body image and self-esteem, addressing not only the functional aspects of surgery but also the emotional and psychological well-being of individuals. The aesthetic benefits of improved cosmesis play a crucial role in enhancing the overall patient experience and satisfaction. For many patients, the visibility of scars is a concern that can impact their self-perception and confidence. The inconspicuous nature of scars resulting from MIS addresses these concerns, fostering a positive psychological impact on patients [26]. The minimized scarring not only aligns with societal expectations of beauty but also supports patients in their recovery journey by reducing potential emotional distress related to the appearance of surgical scars. This positive impact on the patient’s mental and emotional well-being contributes to a more holistic approach to healthcare that extends beyond the physical aspects of surgery. Furthermore, the emphasis on improved cosmesis aligns with contemporary healthcare trends that prioritize patient-centered care. As patients become more informed and discerning about their healthcare choices, factors such as cosmetic outcomes play a role in decision-making [27]. Surgeons who incorporate MIS techniques recognize the significance of addressing not only the medical aspects of surgery but also the patient’s aesthetic concerns. This patient-centric approach enhances overall satisfaction and may positively influence patient-reported outcomes, reflecting a nuanced understanding of the comprehensive impact of surgical interventions on the individual’s quality of life. In conclusion, the aesthetic advantages of improved cosmesis in MIS underscore its role in fostering a positive patient experience and aligning with the evolving expectations of modern healthcare consumers [28].

3.4 Enhanced precision and visualization

Enhanced precision and visualization are fundamental advantages that MIS brings to the forefront of modern surgical practices, owing much to the integration of advanced imaging technologies. Laparoscopes, endoscopes, and robotic-assisted systems have become indispensable tools in the hands of surgeons, providing them with unprecedented real-time, high-resolution visuals of the operative field. These technologies act as the surgeon’s eyes inside the body, offering detailed views of internal structures with magnified clarity. The use of 3D visualization further elevates the precision, allowing surgeons to perceive depth and spatial relationships in a manner not possible with traditional open surgeries [29,30]. This level of visual acuity becomes paramount in procedures where meticulous accuracy is crucial, such as in neurosurgery or microsurgery, where the scale of the operative field demands a level of precision beyond what the naked eye can achieve. The ability to navigate with enhanced precision is a game-changer in the realm of MIS. Surgeons can visualize and manipulate tissues with exceptional accuracy, facilitating the performance of intricate procedures that demand a high degree of precision. In neurosurgery, for example, the precise visualization of intricate brain structures is imperative for success. MIS technologies allow for precise navigation in challenging anatomical locations, reducing the risk of damage to critical structures and enhancing the overall safety of the procedure [31]. This precision is not only a technical advantage but also a transformative element that contributes to improved patient outcomes, shorter recovery times, and minimized postoperative complications. Moreover, the integration of enhanced visualization in MIS extends beyond the immediate benefits for the surgeon. It serves as an educational tool, allowing surgical teams to observe procedures in unprecedented detail. This contributes to a collective learning experience, fostering a culture of continuous improvement and skill development within the surgical community. As technological advancements continue, the potential for even more sophisticated imaging modalities, such as augmented reality (AR), promises to further revolutionize the precision and visualization capabilities of MIS. In summary, the integration of advanced imaging technologies in MIS empowers surgeons with unparalleled precision, ultimately redefining the possibilities and standards in modern surgical care [32].

3.5 Reduced blood loss

The reduction in intraoperative blood loss stands out as a prominent advantage of MIS, setting it apart from traditional open surgical approaches. The strategic use of smaller incisions in MIS, coupled with the utilization of specialized instruments designed for precision, plays a pivotal role in minimizing blood loss during the procedure. Unlike open surgeries, where larger incisions can lead to more extensive bleeding and necessitate more aggressive hemostasis, the meticulous nature of MIS allows surgeons to target specific areas with precision, thereby significantly reducing the overall blood loss. This advantage holds particular significance in surgeries involving vital organs or structures where minimizing blood loss is crucial for patient safety and successful outcomes [33]. The implications of reduced intraoperative blood loss extend beyond the immediate surgical setting to positively impact patient outcomes. Lower blood loss diminishes the need for blood transfusions, a common requirement in surgeries with significant hemorrhage. This not only reduces the risk of complications associated with transfusions but also contributes to a more stable intraoperative environment. Maintaining hemodynamic stability is crucial for patients undergoing surgery, and the reduced blood loss associated with MIS supports this goal. Additionally, a more stable intraoperative environment provides surgeons with enhanced visibility and control, facilitating a smoother and safer execution of the procedure [17,34]. Furthermore, the reduced blood loss in MIS aligns with broader healthcare objectives related to resource utilization and patient recovery. The decreased reliance on blood transfusions translates to potential cost savings for healthcare systems and reduces the demand on blood banks. Patients benefit from a decreased risk of complications related to blood transfusions, such as infections or allergic reactions. The overall impact is a more streamlined and efficient surgical process that prioritizes patient safety, minimizes the need for additional interventions, and supports a faster postoperative recovery. In essence, the advantage of reduced blood loss in MIS underscores its pivotal role in promoting both patient safety and the efficiency of surgical care [35].

3.6 Versatility across surgical specialties

MIS stands out for its remarkable versatility, making it a valuable approach across an extensive array of surgical specialties. General surgery has seen a paradigm shift with the adoption of MIS techniques, with procedures such as laparoscopic appendectomies, cholecystectomies, and hernia repairs becoming standard practice. In gynecology, MIS has revolutionized procedures like hysterectomies and myomectomies, offering patients less invasive alternatives with reduced postoperative pain and faster recovery times [30,36]. Urology has also witnessed the transformative impact of MIS, with procedures such as laparoscopic prostatectomies and nephrectomies gaining prominence for their precision and patient benefits. Orthopedics has embraced MIS in procedures ranging from arthroscopic joint surgeries to minimally invasive spine surgeries. This approach allows for smaller incisions, reduced soft tissue damage, and quicker rehabilitation. In cardiothoracic surgery, MIS has found application in coronary artery bypass grafting, valve repairs, and lung surgeries [30,37]. The adaptability of MIS to these diverse specialties is rooted in its ability to provide enhanced precision, reduced trauma, and faster recovery, regardless of the anatomical region or specific surgical procedure. This versatility underscores the broad applicability of MIS, making it a transformative and widely utilized technique in contemporary surgical practices. The cross-specialty applicability of MIS not only reflects its technical adaptability but also its positive impact on patient outcomes. Patients undergoing MIS often experience less postoperative pain, reduced hospital stays, and faster recovery, irrespective of the surgical specialty. This versatility aligns with the evolving landscape of patient-centered care, emphasizing minimally invasive approaches that prioritize not only the successful treatment of medical conditions but also the overall well-being and satisfaction of patients. As technology continues to advance and surgical techniques evolve, the versatility of MIS positions it as a cornerstone in the ongoing transformation of surgical practices across various medical disciplines [38,39].

3.7 Earlier ambulation and reduced postoperative pain

MIS not only revolutionizes surgical procedures but also significantly improves the postoperative experience for patients, particularly in terms of reduced pain and earlier ambulation. The key to diminished postoperative pain in MIS lies in the smaller incisions and minimized tissue trauma associated with this approach. Unlike open surgeries, which often involve larger incisions and more extensive tissue disruption, the precision of MIS allows for a more targeted intervention. This translates into less damage to surrounding structures, nerves, and muscles, ultimately resulting in a reduction in postoperative pain [40]. This advantage is particularly notable in procedures involving the abdominal or pelvic regions, where postoperative pain can be a significant concern. The correlation between reduced postoperative pain and earlier ambulation is a pivotal aspect of the enhanced recovery associated with MIS. The diminished pain allows patients to mobilize sooner after surgery, which is crucial for preventing complications related to prolonged bed rest. Early ambulation is essential for maintaining circulatory health, reducing the risk of deep vein thrombosis, and preventing respiratory issues like atelectasis. By promoting mobility, MIS contributes to a smoother recovery trajectory, allowing patients to regain functionality sooner and resume their daily activities with less discomfort [41]. This aligns with the patient-centered care approach, emphasizing not only the success of the surgical procedure but also the quality of life and overall well-being of the patient throughout the recovery process. The combined benefits of reduced postoperative pain and earlier ambulation underscore the transformative impact of MIS on patient recovery. Patients experience a more comfortable and efficient recuperation facilitating a faster return to normal activities. As healthcare continues to prioritize patient-centered outcomes, the emphasis on reducing postoperative pain, and promoting early ambulation aligns with the broader goals of enhancing the overall patient experience and optimizing recovery outcomes. In essence, the advantages of MIS extend beyond the operating room, ushering in a new era of surgical care that prioritizes both the technical precision of the procedure and the holistic well-being of the patient [42,43].

3.8 Cost-effectiveness

Cost-effectiveness is a key consideration in the assessment of MIS, and while the initial investments in equipment and training may appear higher, the long-term economic benefits become apparent when evaluating various factors. One of the primary contributors to the cost-effectiveness of MIS is the reduction in hospital stays. Compared to traditional open surgeries, MIS procedures often result in shorter hospitalization periods due to faster recovery times [44]. This not only translates to reduced costs for patients, as they spend less time in the hospital, but it also optimizes the utilization of healthcare facilities by freeing up resources for other patients in need of care. The efficient turnover of hospital beds contributes to the overall effectiveness and resource optimization within healthcare systems. Lower infection rates associated with MIS further enhance its cost-effectiveness. The minimized risk of postoperative infections reduces the need for extended hospital stays, additional medical interventions, and prolonged antibiotic treatments [44,45]. Fewer complications contribute to streamlined patient care, potentially leading to a reduction in healthcare expenditures related to managing and treating postoperative infections. The economic impact extends beyond the immediate postoperative period, positively influencing the overall cost-effectiveness of MIS and aligning with the broader goals of healthcare systems to provide efficient and economically sustainable care [45,46]. Additionally, the reduced need for postoperative interventions and complications adds another layer to the economic benefits of MIS. The enhanced precision, reduced blood loss, and minimized trauma associated with MIS contribute to fewer complications, resulting in a smoother recovery process. Fewer complications mean a decreased requirement for follow-up procedures, rehospitalizations, or additional medical treatments, ultimately contributing to cost savings for both patients and healthcare systems. In essence, while the initial investment in MIS may seem higher, the long-term cost-effectiveness is underscored by the efficient use of resources, reduced hospital stays, and minimized postoperative complications, highlighting the economic advantages of embracing this advanced surgical approach [47,48].

3.9 Remote surgery possibilities

The integration of robotic-assisted MIS introduces a revolutionary concept – the potential for remote surgery. With this technology, surgeons can control robotic systems from a distance, allowing them to perform intricate procedures on patients located in different geographical areas. This opens up new possibilities for providing specialized care to individuals in underserved or remote locations where access to advanced surgical expertise may be limited [49]. The ability to conduct remote surgery has transformative implications for healthcare delivery, breaking down geographical barriers and democratizing access to cutting-edge surgical interventions. The concept of remote surgery is particularly impactful in scenarios where patients in remote or underserved regions lack proximity to specialized medical facilities. Through robotic-assisted MIS, expert surgeons can extend their reach to virtually any location with the necessary technological infrastructure. This not only enhances access to advanced surgical procedures but also addresses healthcare disparities by ensuring that individuals in remote areas receive the same level of specialized care as those in more urban or central locations [50]. Remote surgery has the potential to bring about a paradigm shift in healthcare delivery, promoting equity and inclusivity in the distribution of advanced surgical services. While the idea of remote surgery holds great promise, it also raises considerations regarding technological infrastructure, connectivity, and regulatory frameworks. Ensuring secure and reliable communication channels, safeguarding patient data, and adhering to ethical and legal standards are critical aspects that must be addressed to fully realize the potential of remote surgery. As technology continues to advance and these considerations are addressed, the integration of remote surgery capabilities in MIS has the potential to revolutionize how surgical expertise is delivered, making it more accessible and inclusive on a global scale [51,52].

3.10 Evolving technological innovations

MIS is at the forefront of a rapidly evolving landscape marked by ongoing technological innovations. The integration of AI and machine learning represents a transformative leap in the field of MIS. These technologies are being harnessed to enhance decision-making processes during surgery, providing real-time insights and predictive analytics [53]. By analyzing vast datasets and learning from diverse surgical scenarios, AI can offer surgeons valuable assistance, helping optimize procedures, improve surgical precision, and contribute to better patient outcomes. The synergy between AI and MIS exemplifies the potential for technology to augment the capabilities of surgeons and redefine the standards of care. Advanced imaging technologies are also undergoing continuous refinement within the realm of MIS [54]. Innovations in imaging, including 3D visualization and AR, are revolutionizing the way surgeons perceive and interact with the operative field. These technologies provide unprecedented depth and clarity, enabling surgeons to navigate with enhanced precision. The ongoing development of innovative instruments, coupled with advancements in imaging, holds the promise of overcoming existing challenges associated with MIS. Surgeons can expect to leverage increasingly sophisticated tools that facilitate intricate procedures with greater ease and efficiency [55]. This evolution not only pushes the boundaries of what is achievable through minimally invasive approaches but also contributes to a more patient-centric, efficient, and technologically empowered surgical landscape. The trajectory of MIS is shaped by a commitment to overcoming challenges and embracing opportunities presented by emerging technologies. As the field advances, surgeons can anticipate the integration of cutting-edge tools, robotic systems, and intelligent decision support systems that amplify their capabilities. The continuous evolution of MIS through technological innovations underscores its dynamic nature and its potential to further revolutionize surgical practices, ultimately benefiting patients by enhancing safety, precision, and the overall quality of care [56].

4.1 Laparoscopic surgery

4.2 Robotic-assisted surgery

4.3 Endoscopic surgery

4.4 Hysteroscopic surgery

4.5 Thoracoscopic surgery

4.6 Transoral surgery

5.1 General complications

5.2 Specific complications based on type of MIS

5.3 Management of complications

6.1 Learning curve and training

The learning curve is a notable limitation in the adoption of MIS. Surgeons transitioning from traditional open techniques to MIS, including laparoscopy or robotic-assisted surgery, often encounter a period of adaptation and learning. The techniques involved in MIS demand a high level of hand–eye coordination and precision, skills that may not be as prominently featured in traditional open surgeries [122]. The shift to navigating long, slender instruments through small incisions or manipulating robotic systems requires a significant adjustment in technique, making it essential for surgeons to undergo specialized training to become proficient in these minimally invasive approaches. During the initial phases of the learning curve, surgeons may experience longer operative times compared to their counterparts using open techniques. The need for a meticulous approach and the mastery of new technologies contribute to this temporary extension of surgical durations. Additionally, there may be an associated increase in the risk of complications as surgeons become accustomed to the nuances of MIS [123]. These complications can include inadvertent injuries, suboptimal placement of instruments, or challenges in suturing and knot tying. The recognition of this learning curve limitation underscores the importance of structured training programs and mentorship to facilitate a smoother transition and enhance the overall safety and efficacy of MIS procedures. Specialized training programs play a crucial role in mitigating the challenges associated with the learning curve in MIS. Simulation training, where surgeons can practice in a controlled environment, provides a valuable opportunity to refine skills and gain confidence before performing procedures on actual patients [124]. Additionally, mentorship programs, where experienced MIS surgeons guide and share their expertise, contribute to the transfer of knowledge and skill refinement. Continuous advancements in training methods aim to expedite the learning curve and ensure that surgeons can embrace MIS techniques with proficiency, ultimately maximizing the benefits of minimally invasive approaches for improved patient care [125].

6.2 Limited range of motion and maneuverability

The limited range of motion and maneuverability of instruments in MIS can present challenges, particularly in procedures that demand intricate and complex movements. In laparoscopic procedures, the instruments used are rigid and operate in a straight-line manner, which may restrict the surgeon’s ability to navigate and manipulate tissues with the same freedom as open surgeries. This constraint is particularly evident in surgeries requiring delicate and precise maneuvers, such as suturing in confined spaces or performing intricate dissections [125,126]. The restricted range of motion can be a limiting factor in achieving optimal outcomes, and surgeons need to adapt their techniques to work within these constraints while maintaining precision. Robotic-assisted surgery, with its advanced robotic arms and improved dexterity, represents a significant advancement over traditional laparoscopy. However, even in robotic procedures, there are limitations to the range of motion of robotic arms. The robotic system is designed to replicate the movements of the surgeon’s hands, but it may not entirely mimic the full spectrum of human motion. Surgeons must navigate within the defined range of motion of the robotic arms, which can be a consideration in surgeries that demand intricate and multidimensional movements [127]. While robotic systems provide enhanced maneuverability compared to laparoscopy, there remains a need for surgeons to carefully plan and execute their procedures, taking into account the specific capabilities and limitations of the robotic platform. The adaptation of techniques and strategies to work within the confines of limited range of motion is a key aspect of the surgeon’s skill set in MIS. Surgeons often undergo specialized training to optimize their proficiency in using laparoscopic or robotic instruments effectively. This includes developing strategies to achieve the desired outcomes despite the constraints, such as using specific trocar placements, altering instrument angles, or employing innovative approaches to accomplish complex tasks. As technology continues to evolve, there is ongoing research and development aimed at enhancing the maneuverability of instruments in MIS, seeking to address these limitations and further improve the feasibility and success of minimally invasive procedures [128].

6.3 Lack of tactile feedback

The absence of tactile feedback is a distinctive limitation of MIS, setting it apart from traditional open surgery where surgeons can directly feel tissues and structures with their hands. In MIS, the surgeon relies solely on visual information obtained from imaging devices, such as laparoscopes or robotic systems. While these visual cues provide detailed views of the operative field, the inability to physically feel tissues can be a significant disadvantage. Tactile feedback is valuable in open surgery for assessing the texture, consistency, and tension of tissues, which aids in identifying anatomical structures, detecting abnormalities, and making real-time adjustments based on the surgeon’s tactile perceptions [129]. The lack of tactile feedback in MIS can pose challenges in accurately interpreting the surgical field. Subtle variations in tissue characteristics that might be indicative of pathology may be challenging to discern through visual cues alone. For instance, identifying the boundaries of a tumor or distinguishing between normal and abnormal tissues may require a heightened reliance on imaging, potentially increasing the risk of overlooking subtle abnormalities. This limitation is particularly notable in procedures where precise tissue manipulation is crucial, such as delicate dissections or suturing [130]. Surgeons must compensate for the absence of tactile feedback by developing a keen understanding of visual cues and honing their skills in interpreting two-dimensional (2D) representations of 3D anatomical structures. The reliance on visual information over tactile sensations also contributes to a steeper learning curve in MIS. Surgeons transitioning from open to minimally invasive techniques need to adapt to a different sensory paradigm. Developing proficiency in interpreting visual cues and translating them into precise actions requires time and practice. While advancements in imaging technologies aim to enhance the visual information provided during MIS, efforts are ongoing to explore innovative solutions that may introduce some form of tactile feedback to further bridge the gap between open and minimally invasive surgical approaches [131].

6.4 Patient selection

Patient selection is a critical consideration in the application of MIS, as certain patient factors can influence the feasibility and success of these procedures. One notable factor is obesity, where the increased thickness of adipose tissue can present challenges in the visualization and manipulation of structures. In laparoscopic procedures, the limited range of instruments may be less effective in obese patients due to the additional layer of fat, potentially compromising the surgeon’s ability to navigate and operate with precision [132]. Adequate exposure and visualization are essential in MIS, and in obese patients, these may be compromised, necessitating careful evaluation of the risks and benefits before opting for a minimally invasive approach. Anatomical variations among patients can also impact the suitability of MIS. Individuals may exhibit differences in the location, size, or configuration of internal structures, influencing the accessibility of these structures during minimally invasive procedures. Surgeons must carefully consider these variations and assess whether the specific anatomical characteristics of a patient might pose challenges in terms of instrument access, maneuverability, or the ability to achieve optimal visualization. In cases where anatomical variations may impede the feasibility of MIS, alternative approaches or open surgical techniques may need to be considered to ensure the safety and effectiveness of the procedure [133]. The consideration of patient selection in MIS extends beyond anatomical factors to encompass overall health status and comorbidities. Certain medical conditions or pre-existing health concerns may impact a patient’s ability to tolerate the pneumoperitoneum required for laparoscopic procedures or influence their overall recovery following surgery. A comprehensive assessment of patient factors, including obesity, anatomical variations, and general health status, is essential in determining the appropriateness of MIS. This individualized approach ensures that the chosen surgical technique aligns with the patient’s characteristics and maximizes the likelihood of a successful outcome while minimizing potential complications [134].

6.5 Complexity of procedures

The complexity of procedures is a significant consideration when deciding on the suitability of MIS. While MIS has proven effective for a broad spectrum of surgeries, certain complex procedures may be better addressed through open techniques. The confined space and limited visibility inherent in MIS can pose challenges, particularly in surgeries involving extensive tissue resection, complex reconstructions, or those requiring multiple interventions. For instance, surgeries involving intricate anatomical structures or delicate manipulations may demand a level of precision and tactile feedback that is more readily achieved through open approaches [135]. In certain cases, the feasibility and success of MIS may be compromised by the complexity of the procedure. The restricted range of motion of instruments and the 2D visualization provided by laparoscopes or robotic systems may present limitations in addressing the intricacies of complex surgeries. Surgeons must carefully weigh the benefits and drawbacks of MIS for each specific clinical scenario. While MIS is celebrated for its reduced trauma, faster recovery times, and improved cosmesis, these advantages must be balanced against the technical challenges posed by the complexity of certain procedures. The decision to opt for MIS or open surgery involves a nuanced evaluation of the unique requirements of each case, aiming to optimize patient outcomes while ensuring the safety and effectiveness of the chosen surgical approach. Surgeons play a crucial role in assessing the complexity of procedures and making informed decisions about the most appropriate surgical approach [136]. The evolution of MIS techniques and technologies continues to expand the range of procedures that can be successfully performed using minimally invasive methods. However, ongoing research and advancements are necessary to address the challenges associated with complex surgeries, aiming to further enhance the capabilities of MIS and broaden its applicability across a diverse array of clinical scenarios [137].

6.6 Cost and resources

The cost and resource considerations associated with MIS are pivotal factors influencing its adoption and accessibility. The initial setup and investment in MIS equipment, particularly robotic systems, can represent a substantial financial commitment. Although the costs associated with MIS have decreased over time, driven by advancements in technology and increased adoption, these procedures may still be more expensive than traditional open surgeries. The acquisition of state-of-the-art equipment, such as laparoscopic instruments or robotic-assisted systems, contributes to the upfront expenses, and the financial implications extend beyond the initial investment to include ongoing maintenance, upgrades, and training costs [138]. Maintenance and training costs are ongoing considerations in the utilization of MIS. Ensuring that equipment remains in optimal condition requires regular maintenance, calibration, and occasional upgrades. Training healthcare professionals in MIS techniques, especially for new technologies like robotic-assisted surgery, is essential for achieving proficiency and optimizing patient outcomes. These ongoing costs contribute to the overall financial considerations associated with MIS [44]. In settings with limited resources, both in terms of financial constraints and trained personnel, the accessibility and affordability of MIS may become a limiting factor, potentially impacting the widespread adoption of these advanced surgical techniques. The cost-effectiveness of MIS also depends on factors such as reduced hospital stays, lower infection rates, and faster recovery times. While the initial investment may be higher, the overall economic benefits, including reduced healthcare utilization and improved patient outcomes, can offset these costs. However, healthcare institutions and policymakers must carefully weigh the financial considerations against the clinical advantages to make informed decisions about the integration and sustainability of MIS within their healthcare systems. Efforts to enhance cost-effectiveness, such as optimizing resource utilization and investing in training programs, are crucial for ensuring the continued accessibility and affordability of MIS in diverse healthcare settings [139].

6.7 Complications and conversions

MIS is generally recognized for its association with fewer complications compared to open surgeries. However, it is important to acknowledge that complications can still arise in MIS procedures. Unforeseen challenges, such as unexpected anatomical variations, bleeding complications, or difficulties in instrument manipulation, may occur during the course of an MIS [99]. While surgeons are adept at navigating through these challenges in many cases, there are instances where the complexity or severity of complications necessitate a transition from a minimally invasive approach to an open procedure. Complications that may prompt conversion to an open procedure include situations where the limited visibility and constrained range of motion in MIS become significant barriers to effectively manage challenges. For example, in cases of unexpected bleeding, the restricted access and reduced tactile feedback in MIS may make it challenging for the surgeon to achieve hemostasis or adequately visualize the source of bleeding. In such circumstances, converting to an open approach allows the surgeon greater control, direct visualization, and the ability to address complications with more traditional surgical techniques. The decision to convert from MIS to open surgery is a dynamic and complex one, requiring the surgeon’s expertise and judgment [140]. While MIS is often preferred for its reduced trauma and faster recovery times, the option to convert provides a safety net for managing unexpected complications effectively. It underscores the importance of surgeon experience, adaptability, and the ability to make real-time decisions based on the patient’s specific clinical scenario. Postoperative debriefings and analyses of cases that require conversion contribute to ongoing improvements in surgical protocols and decision-making, enhancing the overall safety and success of minimally invasive procedures [141].

6.8 Not universally applicable

Despite its numerous advantages, MIS is not universally applicable to all surgical scenarios. There are specific pathologies and anatomical considerations that may limit the feasibility and effectiveness of minimally invasive approaches. For instance, complex fractures or tumors located in challenging anatomical regions may necessitate open procedures for optimal visualization and intervention [142]. The confined spaces and limited maneuverability in certain anatomical locations may impede the surgeon’s ability to perform intricate and precise procedures through minimally invasive means. The decision to opt for open surgery over MIS is often guided by the specific requirements of each case. While MIS is celebrated for its reduced trauma, faster recovery times, and improved cosmesis, the diversity of surgical cases mandates a personalized approach. Surgeons must carefully evaluate the nature of the pathology, the location of the lesion or injury, and the overall anatomical considerations to determine the most appropriate surgical approach. In situations where the benefits of MIS may be compromised by the complexity or location of the pathology, open procedures offer the advantage of providing direct access, enhanced visibility, and greater control over the surgical field [143]. The limitations in the universality of MIS underscore the importance of individualizing treatment plans based on patient characteristics and the specific nature of the pathology. The goal is to optimize patient outcomes by selecting the most suitable surgical approach for each unique case. Advances in surgical techniques, technology, and ongoing research aim to expand the applicability of MIS, but surgeons must exercise discretion in choosing the most appropriate approach based on the intricacies of each clinical scenario [144].

6.9 Pneumoperitoneum-related effects

The creation of pneumoperitoneum, which involves inflating the abdominal cavity with carbon dioxide, is a fundamental step in laparoscopic surgeries. While this technique provides the necessary workspace for minimally invasive procedures, it is not without its potential limitations. One significant consideration is the impact of pneumoperitoneum on intra-abdominal pressure. The insufflation of carbon dioxide leads to an increase in intra-abdominal pressure, which can have physiological implications [145]. Elevated intra-abdominal pressure may affect hemodynamics, venous return, and organ perfusion, posing potential challenges, especially in patients with pre-existing cardiovascular conditions. Cardiovascular and respiratory effects related to pneumoperitoneum can be a concern, particularly in patient populations with underlying cardiopulmonary conditions. The increased intra-abdominal pressure may influence cardiovascular parameters, such as blood pressure and heart rate. In patients with compromised cardiac function, these changes may be less tolerable, requiring careful monitoring and management during the surgical procedure. Additionally, the respiratory system may be affected, leading to changes in lung mechanics and potential alterations in oxygenation and carbon dioxide levels [146]. Surgeons and anesthesiologists must take into account the patient’s baseline health status and tailor the insufflation parameters to minimize adverse effects, ensuring the safety and stability of the patient throughout the laparoscopic procedure. Patient selection and thorough preoperative assessments are crucial in mitigating the potential risks associated with pneumoperitoneum-related effects. Surgeons need to consider the overall health status of the patient, especially the condition of the cardiovascular and respiratory systems, when determining the appropriateness of laparoscopic surgery. In cases where the risks associated with pneumoperitoneum may outweigh the benefits of a minimally invasive approach, alternative surgical techniques or careful management strategies may be considered to optimize patient safety and outcomes [147]. Ongoing research and advancements in surgical practices aim to refine the use of pneumoperitoneum and enhance its safety profile, ensuring that the benefits of minimally invasive procedures can be realized across a broad spectrum of patients [148].

6.10 Limited access in challenging anatomy

MIS encounters limitations in scenarios where anatomical access becomes challenging. Certain anatomical locations present inherent difficulties for MIS due to their confined spaces or complex structures. Accessing structures in densely vascular areas or regions with intricate anatomical features can be particularly demanding. For example, procedures involving the pelvis, where vital structures such as blood vessels, nerves, and pelvic organs are closely situated, may pose challenges in achieving optimal access and visualization [149]. The limited range of motion and reduced maneuverability of instruments in MIS can become pronounced in such anatomical contexts, potentially compromising the surgeon’s ability to navigate and manipulate tissues with precision. In cases of challenging anatomy, the limitations in access during MIS may impact the surgeon’s capacity to perform complex procedures. Regions with intricate anatomical structures, such as the head and neck or certain areas within the abdominal cavity, require meticulous and precise maneuvers. The confined spaces in these anatomical locations may limit the range of motion of laparoscopic instruments or robotic arms, making it challenging to achieve the necessary degree of dexterity [150]. Surgeons must carefully assess the specific anatomical challenges posed by each case and weigh the benefits of MIS against the potential limitations. In instances where access proves to be a limiting factor, open surgical approaches may provide the necessary direct access and visibility for optimal intervention. Advancements in surgical technologies and techniques aim to address the challenges associated with limited access in challenging anatomy. The development of more flexible and articulating instruments, as well as innovations in imaging technologies, contributes to overcoming some of the constraints imposed by anatomical complexities. However, the decision to pursue MIS in challenging anatomical locations remains a nuanced one, requiring a thorough understanding of the specific anatomical nuances and potential trade-offs between the benefits of minimally invasive approaches and the need for optimal access and maneuverability [151].

6.11 Prolonged recovery times

Although MIS is frequently associated with quicker recovery, some cases contradict this trend. Complications such as undetected internal bleeding, infections, or delayed wound healing can prolong recovery. These issues may arise because the smaller incisions in MIS make it harder to detect and address such complications early. Studies have shown that for certain complex procedures, traditional open surgeries may offer more predictable recovery trajectories [100].

6.12 Longer operative times

MIS, particularly robotic-assisted surgeries, often requires extended operative times due to the complexity of the setup, equipment handling, and surgeon familiarity. The learning curve for MIS is steep, and during the initial phase, this can lead to increased operative durations and potentially higher complication rates [101].

6.13 Risks of complications

While the incidence of bleeding, infection, and organ damage is generally lower in MIS than in open surgeries, these risks are not negligible. For example, the lack of tactile feedback during MIS can increase the likelihood of inadvertent damage to adjacent structures. Additionally, managing complications in MIS can be more challenging due to the confined visual field and limited access [102].

6.14 Cost and accessibility

The financial burden associated with MIS remains a significant barrier, particularly in underfunded or rural healthcare settings. Robotic-assisted systems, while offering enhanced precision, are prohibitively expensive for many institutions. The costs extend beyond the initial purchase to include maintenance, upgrades, and specialized training for surgeons and staff. This has created disparities in access, with many patients in remote areas unable to benefit from MIS due to the lack of infrastructure and expertise [103].

MIS offers several advantages, such as less trauma, quicker recovery, and better cosmetic results. However, it is also important to consider the downsides and challenges of these techniques. In some cases, MIS can lead to longer recovery times compared to traditional open surgeries. For instance, while laparoscopic procedures usually reduce pain after surgery, some patients might face delayed recovery due to complications like internal bleeding or infections, which are harder to detect because the surgery is less invasive. In such cases, the benefit of smaller incisions may be outweighed by the difficulty in closely monitoring the surgical site afterward [100]. Another major challenge is the high cost of MIS, particularly when robotic-assisted systems are used. These systems require significant investment in equipment, ongoing maintenance, and specialized training for surgeons and staff. The high upfront and operational costs make it hard for many healthcare centers, especially those in rural or underfunded areas, to adopt these technologies. For example, robotic-assisted surgery is often too expensive for hospitals in rural areas, worsening the healthcare access gap between urban and rural populations [101]. Additionally, there are risks of injury to nearby organs during MIS because surgeons do not get the tactile feedback they do in open surgeries. Instead of feeling the tissues, MIS relies on visual feedback from cameras, which may not always be precise enough. This can increase the risk of accidentally damaging nearby structures, such as blood vessels or nerves, especially during complex procedures like gallbladder or prostate surgery. These issues can lead to complications such as bleeding, infections, or damage to organs, which may require a shift to traditional open surgery for better control [80,81,82,83,84,85].

Furthermore, hospitals in remote areas face additional challenges in adopting MIS due to a lack of advanced technology and the high level of expertise needed. Many hospitals in rural or underdeveloped regions cannot afford the specialized equipment or training required for MIS. Maintaining this equipment and keeping highly trained surgeons is also difficult, especially since robotic systems need regular maintenance and skilled operators, which may not be feasible in low-resource settings. This creates a significant barrier to widespread adoption of MIS in these areas [111]. To overcome these issues, several solutions are being explored. Efforts are being made to create more affordable MIS technologies, so the benefits of these advanced surgeries can be more accessible. In addition, remote training programs and simulation-based education are helping to increase the number of skilled surgeons, even in under-resourced areas. Some healthcare systems are also looking into mobile surgical units equipped with MIS technology that can be used in remote locations, helping to make these advanced surgeries more widely available [112].

8.1 Advanced imaging and visualization

The integration of advanced imaging technologies is poised to revolutionize the field of MIS. High-resolution imaging modalities, such as AR and VR, have the potential to enhance the surgeon’s visualization capabilities. These technologies can provide 3D views of the operative field, allowing for more precise navigation and manipulation of anatomical structures. AR and VR may also facilitate better preoperative planning, enabling surgeons to simulate procedures and anticipate challenges [153].

8.2 Robotics and AI

The role of robotics in MIS is expected to expand significantly. Robotic-assisted surgery has already demonstrated enhanced precision and dexterity, and future developments are likely to focus on improving robotic systems’ autonomy and adaptability. Integrating AI into robotic platforms can enable real-time decision support, allowing robots to analyze data, anticipate potential issues, and even learn from the surgeon’s actions. AI-driven assistance could enhance the safety and efficiency of MIS procedures [154].

8.3 Telemedicine and remote surgery

The convergence of MIS with telemedicine technologies opens the door to remote surgery. Surgeons may be able to perform procedures on patients located in different geographical areas, especially in regions with limited access to specialized healthcare. Remote surgery holds the potential to democratize healthcare, providing expert surgical care to underserved populations. However, ensuring the security and reliability of telemedicine platforms is a critical consideration for widespread adoption [155].

8.4 Nanotechnology and microbots

Advancements in nanotechnology are paving the way for the development of microbots – tiny robotic devices that can navigate within the body for diagnostic and therapeutic purposes. In MIS, microbots could be designed to deliver targeted treatments, perform precise interventions, or provide real-time diagnostics at the cellular or molecular level. This opens new possibilities for minimally invasive procedures with minimal impact on surrounding tissues [156].

8.5 Smart instruments and instrumentation

The instruments used in MIS are likely to become smarter and more adaptable. Integration of sensors into surgical instruments can provide real-time feedback on factors like tissue characteristics, temperature, and blood flow. Smart instruments may enable surgeons to make more informed decisions during procedures, enhancing the overall safety and efficacy of MIS [157].

8.6 Enhanced ergonomics

Surgeon ergonomics is a critical factor in the success of MIS procedures. Future developments may focus on creating more ergonomic platforms and instruments, reducing the physical strain on surgeons during long and complex surgeries. This includes the design of robotic consoles and interfaces that promote comfort and minimize fatigue, ultimately contributing to better outcomes [158].

8.7 Innovations in energy sources

Advances in energy sources used in MIS are anticipated to improve the efficiency and safety of procedures. The development of more precise energy devices, such as advanced electrosurgical and ultrasonic instruments, can contribute to reduce thermal damage to surrounding tissues and enhance the overall precision of energy-based interventions [159].

8.8 Integration of augmented intelligence

The synergy between human expertise and AI, termed augmented intelligence, is poised to play a significant role in MIS. AI algorithms can analyze vast datasets, providing insights into patient-specific factors, predicting outcomes, and assisting in personalized treatment plans. This integration has the potential to improve preoperative planning, optimize intraoperative decision-making, and enhance postoperative care [160].

8.9 Patient-centric innovations

Future directions in MIS will likely prioritize patient-centric innovations. This includes the development of less invasive techniques, reduced recovery times, and further improvements in cosmetic outcomes. Tailoring procedures to individual patient characteristics, such as anatomy and genetics, may become more common, leading to personalized and optimized treatment approaches [161].

8.10 Education and training

The future of MIS will require a robust focus on education and training. Simulated environments, VR training modules, and immersive learning experiences will become integral components of surgical education. Surgeons will need continuous training to stay abreast of evolving technologies and techniques, ensuring proficiency in the dynamic landscape of MIS [162].