What’s good for the goose is not always good for the gander—are conclusions from a clinical trial always universally exportable?

Minimally invasive approaches have revolutionized how surgery is performed and as technology and instrumentation continue to improve, the use of minimally invasive surgery (MIS) will be successfully applied to more complex surgical procedures. When considering a MIS approach, the first question a surgeon must ask is whether MIS provides at least equivalence in terms of short- and long-term outcomes compared to its open counterpart. As an example, the use of MIS approach for appendectomy approaches clinical equipoise compared to the open procedure, and only when applied to certain subset of patients do we see superiority of the MIS approach (1). On the other hand, the use of robotics for thyroidectomy [using the amusingly appropriate acronym, robotic assisted thyroid surgery (RATS)] remains, at best, controversial. Although still championed by a small number of surgeons, the robotic approach converts a straightforward, low complication, open surgery, to a complex and potentially morbid MIS procedure. The disadvantages (including longer operative time, and increased cost compared to conventional open thyroidectomy, as well as potential injuries to the brachial plexus, skin flap, esophagus, and trachea) must be weighed against the effort to compensate for minor cosmetic improvements (2). For the most part however, the literature suggests that MIS for a variety of surgical procedures does provide equivalence, if not improvement over open surgery, especially in terms of postoperative pain, length of stay and return to the patient’s baseline activities of daily living. Cholecystectomy is an early and prime example.