Minimal access surgery.

Minimal access coronary surgery offers the patient two potential advantages, to be spared the damaging effects of cardiopulmonary bypass, and a large and painful incision. Furthermore, it offers those who have to foot the bill the promise of a cheaper operation and a shorter hospital stay. Put like that, one might feel compelled to join the bandwagon for fear of being left behind as it gathers speed. But you would not be alone in hesitation. Bruce Lytle of the Cleveland Clinic, a surgeon who combines enormous experience with modesty and wisdom, began his recent editorial on minimal access surgery with a quote from Bruce Springsteen, "The door's open but the ride it ain't free."' Ullyot titled his commentary on the avoidance of bypass for coronary surgery, "Look Ma, No Hands!"2 These engaging snatches of colloquial American in the leading journals of cardiothoracic surgery, both advising caution, give us pause for thought. What are we being asked to consider? The avoidance of cardiopulmonary bypass and a change in the incision are different questions. These two issues are packaged in the appealing phrase "minimal access" but they must be unpacked to examine the contents. The coronary operation can be done: through a median sternotomy but without cardiopulmonary bypass3-6; with a limited incision but with femoro-femoral cardiopulmonary bypass7; or with avoidance of both.8-'4