Laparoscopic surgery is an operation performed through small incisions (usually 0.5–1.5 cm) with the aid of a camera. It can either be used to diagnose a condition or to perform surgery.
Now termed as Minimally Invasive Surgery, therapeutic laparoscopy began among general surgeons in 1980s with the introduction of laparoscopic cholecystectomy (surgical removal of the gallbladder). With the range of laparoscopic procedures expanding rapidly, laparoscopic surgery has crossed all the traditional boundaries of specialities and disciplines.
- While traditional (open) removal of the gall bladder (due to various reasons) had to be done through an eight to10 cm long incision, laparoscopic cholecystectomy needs just four small incisions of 0.5– 1.0 cm.
- The length of post-operative stay in the hospital is minimal, and same-day discharges are possible in cases of early morning procedures.
Conceptually, the laparoscopic approach is intended to minimise post-operative pain and hasten the recovery, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes, in the last two decades, laparoscopic surgery has been adopted by various surgical sub-specialties including gastrointestinal surgery (including surgical procedures for morbid obesity), gynaecologic surgery and urology. Based on numerous prospective randomised controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers, such as cancer of the colon.
In certain advanced laparoscopic procedures, where the size of the part being removed would be too large to pull out through an opening made by an instrument called the trocar – as would be done with a gallbladder – a larger incision is made. The most common of these procedures are removal of all or part of the colon (colectomy), oesophagus (oesophagectomy), stomach (gastrectomy), small intestine (resection) or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision at the end of the procedure for specimen removal, or, in the case of a colectomy, to prepare the remaining healthy bowel to be reconnected. Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy.
The restricted vision, the difficulty in the handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception and the limited working area, are factors which add to the technical complexity of this surgical approach. For
these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgeons who wish to focus on this area of surgery, gain additional training or fellowship after completing their basic surgical training.
1. Smaller incision, reduces pain and shortens recovery time, resulting in less post-operative scarring.
- Although procedure times are usually slightly longer, hospital stay is less and often with a same day discharge. This leads to a faster return to everyday living.
- Reduced exposure of internal organs to possible external contaminants, thereby reducing risk of acquiring infections.
- There is probably a lower incidence of post-operative adhesions following laparoscopic surgery.
Risks to Keep in Mind
- The most significant risks are from trocar injuries to either the blood vessels or the small or the large bowel. The risk of such injuries is increased in patients who have below average Body Mass Index or have a history of prior abdominal surgery. While these injuries are rare, significant complications can occur. It is very important that these injuries are recognised as early as possible.
- Many patients with existing pulmonary disorders may not tolerate gas in the abdominal cavity (pneumoperitoneum, as the doctors call it). This results in a need for open surgery after the initial attempt at laparoscopic approach.
- Not all of the carbon dioxide introduced into the abdominal cavity is removed through the incisions during surgery. Gas tends to rise, and when a pocket of CO2 rises in the abdomen, it pushes against the diaphragm – the muscle that separates the abdominal from the thoracic cavities and facilitates breathing. This produces a sensation of pain that may extend to the patient’s shoulders. For an appendectomy (removal of the appendix), the right shoulder can be particularly painful. In some cases this can also cause considerable pain when breathing. In all cases, however, the pain is transient, as the body tissues will absorb the CO2 and eliminate it through respiration.
- Coagulation disorders and dense adhesions (scar tissue) from previous abdominal surgery may pose added risk for laparoscopic surgery and are considered relative contra-indications for this approach.
- The instruments are longer and sometimes more complex than those used in open procedure. The loss of tactile feedback and two dimensional imaging create significant problems of hand-eye coordination, but with experience these difficulties can be overcome. In conclusion, the principles of good surgery still apply: case selection, exposure, retraction, haemostasis and technical expertise. Minimal access surgery has changed the practice but not the nature of disease: a conventional procedure that does not make sense, does not make sense even if performed by minimal access surgery. There is much that is new in minimal access surgery; time will tell how much of what is new is better.