Laparoscopic surgery – also called minimally invasive surgery (MIS), bandaid surgery or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5–1.5 cm) as opposed to the larger incisions needed in laparotomy.
Keyhole surgery makes use of images displayed on TV monitors to magnify the surgical elements.
Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy.
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include reduced pain due to smaller incisions and hemorrhaging and shorter recovery time.
The key element in laparoscopic surgery is the use of a laparoscope. There are two types:
(1) A telescopic rod lens system, that is usually connected to a video camera (single chip or three chip)
(2) A digital laparoscope where the charge-coupled device is placed at the end of the laparoscope, eliminating the rod lens system.
Also attached is a fiber optic cable system connected to a ‘cold’ light source (halogen or xenon or LED), to illuminate the operative field, inserted through a 5 mm or 10 mm cannula or trocar to view the operative field. The abdomen is usually insufflated, or essentially blown up like a balloon, with carbon dioxide gas. This elevates the abdominal wall above the internal organs like a dome to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures
Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5–10 mm diameter instruments (graspers, scissors, clip applier) can be introduced by the surgeon into the abdomen through trocars (hollow tubes with a seal to keep the CO2 from leaking). Over one million cholecystectomies are performed in the U.S. annually, with over 96% of those being performed laparoscopically.
There are two different formats for laparoscopic surgery. Multiple incisions are required for technology such as the da Vinci Surgical System, which uses a console located away from the patient, with the surgeon controlling a camera, vacuum pump, saline cleansing solution, cutting tools, etc. each located within its own incision site, but oriented toward the surgical objective. The surgeon’s hands manipulate two haptic grippers which track hand movements and rotations while relaying haptic sensations back to the surgeon.
In contrast, requiring only a single small incision, the “Bonati system” (invented by Dr. Alfred Bonati), uses a single 5-function control, so that a saline solution and the vacuum pump operate together when the laser cutter is activated. A camera and light provide feedback to the surgeon, who sees the enlarged surgical elements on a TV monitor. The Bonati system was designed for spinal surgery and has been promoted only for that purpose.
Rather than a minimum 20 cm incision as in traditional (open) cholecystectomy, four incisions of 0.5–1.0 cm will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gall bladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient’s navel. The length of postoperative stay in the hospital is minimal, and same-day discharges are possible in cases of early morning procedures.
In certain advanced laparoscopic procedures, where the size of the specimen being removed would be too large to pull out through a trocar site (as would be done with a gallbladder), an incision larger than 10mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well 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. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient’s abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons who choose this hand-assist technique feel it reduces operative time significantly versus the straight laparoscopic approach. It also gives them more options in dealing with unexpected adverse events (i.e. uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.
Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, 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 bariatric procedures for morbid obesity), gynecologic surgery and urology. Based on numerous prospective randomized 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 colon.
The restricted vision, the difficulty in 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.
The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic gallbladder removal.
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:
- Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.
- Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.
- Less pain, leading to less pain medication needed.
- Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.
- Reduced exposure of internal organs to possible external contaminants thereby reduced risk of acquiring infections.
- Although laparoscopy in adult age group is widely accepted, its advantages in pediatric age group is questioned. Benefits of laparoscopy appears to recede with younger age. Efficacy of laparoscopy is inferior to open surgery in certain conditions such as pyloromyotomy for Infantile hypertrophic pyloric stenosis. Although laparoscopic appendectomy has lesser wound problems than open surgery, the former is associated with more intra-abdominal abscesses