What is laparoscopic surgery and why perform it?
‘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.