What is laparoscopic surgery and why perform it?

Laparoscopic Surgery‘Laparoscopy’ is  often called keyhole or belly button surgery. The first laparoscopy was performed in Sweden in 1910 and was already  being used to perform simple operations within the abdominal and pelvic cavities  in the early 1930s.  The first operations  performed were for diagnosis of ectopic pregnancy (pregnancy in the tube) and  to perform tubal sterilization. The next  major landmark in the development of laparoscopic or keyhole surgery occurred with Raoul Palmer of France, who used carbon dioxide gas to inflate the abdomen  in 1947; with subsequent development of fibre optic light sources in the  1960s.  By the 1970s progressively more  complicated operations were being performed by keyhole surgery.

What is a laparoscope?

A laparoscope is  something similar to a telescope, and generally has a form of a 5-10mm diameter  rod lens telescope, which is attached on the outside end to a small high  definition video camera.  The surgeon and  the surgical team on a high definition television monitor in the operating room  view the video image.  One of the chief  advantages of this kind of surgery is that it gives magnification greater than  that seen with the naked eye, which means that the operation can be done more  precisely and with less blood loss.

After the laparoscope  is placed through a small incision, usually in the base of the belly button two  or three other small (approximately 5mm) incisions are made in the abdomen,  usually just towards the middle from the hip bones and one in the middle at the  hairline.  Electrodes, lasers, graspers,  scissors and other instruments may be placed through these wound incisions in  order to carry out an operation or diagnostic procedure.

The combination of  small and very dexterous instruments with the magnification achievable via  laparoscopy equals surgical precision that is almost impossible to achieve at  laparotomy (conventional open surgery).   This level of precision and magnification becomes extremely important  when the surgeon is treating endometriosis, adhesions, ovarian cysts and  performing more complex operations such a laparoscopic hysterectomy.

Because the incisions  are smaller and the operation is carried out more precisely, laparoscopy has  proven advantages in recovery time, time spent in hospital, reduced use of  medications and fast return to work which create economic advantages for both  the hospital, healthcare system and patients.   Smaller incisions are also much more “cosmetic”.

This fast recovery  means that most patients undergoing laparoscopy, sometimes quite complex  procedures, are discharged the same day.   Even a total laparoscopic hysterectomy (removing the uterus and cervix  via a completely laparoscopic approach) involves only a one to two night  hospital stay.

Which procedures can be performed laparoscopically?

Almost any  intra-abdominal or pelvic procedure can be performed laparoscopically, with an  appropriate level of expertise.  The only  limiting factors are really surgical access i.e. the ability to physically see  and manipulate the structures within the abdomen in order to achieve an  appropriate operative outcome, and expertise.

Why are so few major gynaecological procedures and  hysterectomies performed laparoscopically?

Many kinds of  laparoscopic surgery, apart from a simple diagnostic laparoscopy, require  extensive training and expertise and ongoing exposure.  Many gynaecologists only perform one or two  operations a week and this is usually not enough to develop and maintain the  level of skill required.  Like any  complex motor skills, whether it is driving a car, painting a picture or  playing a musical instrument there is a certain learning curve where a certain  intensity of experience is required to achieve proficiency.  To maintain that level of proficiency  requires ongoing exposure, practice and ongoing education about new  procedures.

As a result,  unfortunately many gynaecological operations for quite simple benign conditions  are still performed abdominally through a large cut in the abdomen although  most experts agree that the vast majority could be performed laparoscopically  with complete efficiency and safety.

However laparoscopic  surgery is slowly taking hold.  I  remember, as a medical student in the late 1980s and early 1990s watching the  first few laparoscopic gall bladder operations being performed.  At the time these operations were thought to  be unnecessarily complex, costly and difficult to master, however master them we did and within a few years many surgeons were able to perform these  operations in half an hour.  Certainly  nobody would now dream of having their gall bladder removed via a large cut in  the abdomen unless special and complex circumstances existed.