Laparoscopic Surgery

Laparoscopic or “keyhole” surgery

I have heard of this “keyhole surgery” and I think it is a sort of videogame, but not true surgery, isn’t it?

No, it is not a videogame. Laparoscopic or “keyhole” surgery is proper surgery, but performed with a different access. With laparoscopy we can perform exactly the same operations we are used to with open surgery, but without the need to perform a big incision on the abdomen (or the chest). Do you remember those big awful incisions on the abdomen you can still see – on the beach – on some people who had an abdominal operation? Well, they are going to disappear.


Wow! How can you do that?

If a patient needs an operation – say, he or she has appendicitis and his/her appendix must be removed – we usually start the operation with a 1.5-2 cm hole close to or into the belly button. There we insert a small cannula whose size is that of your thumb. A long camera is then passed through the cannula and into the abdomen, to inspect the whole abdominal cavity. The images are magnified and projected on a big screen. Then we insert two more ports, usually 5 mm each through which we advance into the abdomen two long instruments to detach and take out the appendix. The ports are then extracted and the small holes closed. Of course, more complex operations, such as the excision of a tumour, may need more ports.


What operations can be performed by keyhole surgery?

Virtually all the operations in the abdomen or in the chest can be performed by this relatively new technique. The very most of the operations have been standardized and are quite diffused worldwide. This is the case of cholecystectomy, appendicectomy, colorectal surgery, hernia surgery, antireflux surgery. Other procedures, such as surgery of the pancreas or the liver, are performed only in selected centres.

What if any complication arises, say, a bleeding or any other unexpected event?

We are able to deal with the very most of intraoperative complications by laparoscopy, but rarely we are not. In those cases the only option is to convert the operation to traditional surgery and open up the abdomen to control the complication and finish the operation. Conversion can also happen in any other case when the laparoscopic surgeon considers unsafe to continue by laparoscopy and needs to put his or her hands in. The rate of conversion varies in relation to experience of the surgeon, kind of operation and conditions of the patient.

What are the advantages of laparoscopic surgery?

Not having a long incision in the abdomen means less pain and quicker recovery. Patients who underwent laparoscopic surgery can be discharged earlier with respect to “traditional” surgery patients, sometimes on the same day of surgery. Their bodies recover quicker after the operation and they need less pain killers. Usually they are able to restart their normal life and come back to work much earlier. Furthermore, laparoscopic surgery is much more accurate than open surgery, as movements of the surgeon’s hands are more precise and more targeted and small anatomical structures are magnified on the screen. As you can see, it is not at all about aesthetics!!! But, of course, also the absence of an ugly scar makes laparoscopy particularly acceptable to patients!

A friend of mine told me that anyone could do keyhole surgery.

This is completely wrong. Keyhole surgery should be performed only by surgeons who have completed a training in surgery – ideally, they should be consultants – and then specialized in laparoscopic surgery. Training in laparoscopy is neither simple nor short. The surgeon who wants to specialize in laparoscopic surgery must get a complete knowledge of the laparoscopic approach and must be able to master all the many aspects of this technique. He or she must spend hours on the simulator, as a flight pilot!, to get the manual skills and to improve his/her eye-hand coordination. In fact, the most difficult skill to learn is to mentally transform a 2D image seen on a screen to a 3D mental image that can allow him/her to move his/her hands effectively into a 3D space. Most important, the laparoscopic trainee must be tutored and mentored by a very experienced laparoscopic surgeon, at least until he or she reaches complete proficiency in this technique. Usually, a complete laparoscopic training takes at least 4 or 5 years and virtually it never ends, as new instruments come up and new techniques are standardized and introduced in everyday practice. Laparoscopic surgery is one of the most rapidly growing fields in medicine.

What is the future of laparoscopic surgery?

It is difficult to say. Some years ago a big innovation was introduced in our theatres; the surgical robot is a machine that can allow the surgeon to perform very complex operations while standing  – or sitting – far from the patient, usually in the same room but possibly also overseas! The real advantage of the robot is that it is able to reproduce the complex movements of the human hands but without tremors and with greater precision. Some specific tasks – such as suturing – are much easier with the robot than with the usual laparoscopic surgery. Unfortunately, the surgical robot is still a very expensive machine that is yet to be widely diffused. The future will see completely autonomous pre-programmed micro-robots which will be introduced into the patient and will perform the operation by themselves with minimal human input.

History of laparoscopic surgery

Ancient period

Ezekiel: “For the king of Babylon stood at the parting of the way, at the head of the two ways, to use divination: he made his arrows bright, he consulted with images, he looked in the liver.” (Ez 21;21)

Celsus: (About the methods to expel bad humours): “…some perform this manoeuvre just below the belly button, some 4 inches at its left side, some perforate the navel itself, someone else burn the skin and enter the abdomen through a small incision …”

Abu al-Qasim: “… a ribbed exploration probe, mounted on a handle…”

Ippocrates: Rectal exploration with a speculum.

Modern period

1585: Julius Caesar Aranzius uses a light source for an endoscopic procedure: sun light is focused through a water bottle and projected into the nasal cavity

1706: The word “trocar” is invented, coming from the French “trochartor troise-quarts”, this was an introducer with a pyramidal tip, inserted in a metallic cannula

1806: Filippo Bozzini builds an aluminium cannula (lichtleiter) with a small mirror that reflects the light of a candle and can be used to explore the urinary tract

1853: Antoine Jean Desormeaux uses Bozzini’s lichtleiter to explore the abdomen of a patient

1868: Kussmaul performs the first oesophagoscopy with a rigid instrument on a sword-eater.

Contemporary period

1901: Russian gynaecologist Dimitri Ott inserts a small speculum into the posterior vaginal fornix of a pregnant woman to visualize her pelvic organs. As light source he uses a frontal mirror.

1901: German surgeon Georg Kelling uses a cystoscope to explore the abdominal cavity of a dog, after creating pneumoperitoneum with normal air.

1910: Jacobeus performs the first “coelioscopy” on a patient with ascites.

1911: Bertram Bernheim performs the first “organoscopy” in the USA with a rigid proctoscope

1918: Goetze invents a needle for automatic abdominal insufflation

1920: Swiss surgeon Zollikofer uses CO2 to inflate the abdomen

1929: German Heinz Kalk invents a 135° laparoscope and proposes a two-port approach for diagnosis of hepatobiliary diseases. In 1939 he publishes his experience with 2000 laparoscopic liver biopsy with no mortality

1938: Hungarian Janos Veress invents a particular insufflation needle to create therapeutic pneumothorax. Subsequently the same needle is used also for pneumoperitoneum

1960: German gynaecologist Kurt Semm invents an automatic insufflator for pneumoperitoneum

1972: Courtnay Clarke proposes a technique of laparoscopic suture

1977: Dekok performs the first video-assisted appendicectomy, where appendix is visualized and pulled out and the operation is completed with open surgery

1978: Chicago gynaecologist Hasson proposes a different method to obtain pneumoperitoneum, with an open access under vision with a blunt trocar, to avoid injuries of the abdominal viscera

1983: Kurt Semm performs the first laparoscopic appendicectomy. For this reason he is considered mad by his colleagues and obliged to have a head CT to rule out brain tumours.

1985: Erich Mühe performs the first laparoscopic cholecystectomy

1987: Philippe Mouret performs the first videolaparoscopic cholecystectomy. During a pelvic laparoscopy on a woman with recurrent biliary colics, he decides to move the scope towards the upper abdomen to try and identify the reason for her symptoms and manages to remove the gallbladder.

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