Doctors, patients and their bystanders can now relax. The conventional methods of open surgery by cutting and stitching body parts are soon going to be extinct. Thanks to the advancement of Science and Technology in the medical field.
As the name suggests ‘Laparo’ means abdomen, ‘Scopy’ means vision. The surgeon visualizes the inner parts of the patients body through the laparoscope which is a small cut (incision 5-10 mm) on the abdomen. The magnified (up to 20 times larger) vision of the interior parts through the telescope is quite different from the traditional open surgery. Due to the small incision inflicted on the patients, it is also known as Minimally Invasive Surgery (MIS), Band – aid surgery and rarely pin hole surgery.
Origin and History
The first laparoscopic surgery was performed in dogs in 1902 by George Kelling of Dresden Germany. The first laparoscopic surgery in humans was conducted by Hans Christian Jacobaeus of Sweden in 1910. The first laparoscopic Cholecystectomy (removal of gallbladder) in humans was done in 1987 in France. The introduction of high definition camera, medical monitor and good electro surgical units made the procedure easier. In India the procedure is in practice for the past 20 years and is getting popular due to its very high advantages over conventional surgery.
How it works
The laparoscope, a telescopic rod lens system, is put through the small incision made around the umbilicus of the patient. The system is connected to a video camera (single chip or three chip). A fiber optic cable system connected to a ‘cold light source (halogen or xenon)’ is used to illuminate the operative field. The patient’s abdomen is distended with carbon dioxide gas to create a working and viewing space for the surgeon. Carbon dioxide is used as it is familiar to the human body and gets removed by the respiratory system if it gets absorbed through tissue. The surgical equipments are introduced into the abdomen through two 3mm incisions (punctures) made near the earlier entry. The skilled surgeon, by looking at the monitor can perform surgery with precision and perfection.
Advantages of Laparoscopic Surgery
Since only two or three tiny incisions are made in the abdomen the patient feels less pain. It reduces blood loss, compared to traditional open surgery. There is less need for blood transfusion, hence less chance for acquiring infection like Hepatitis B, HIV, Malaria etc. There is significant reduction in scar and wound infection. Scant use of antibiotics and painkillers is possible unlike in open surgery. Hospital stay for patients is limited to one or two days. Shorter hospital stay means less burden for the patient and relatives. Unlike open surgery, fast recovery through laparoscopic method saves money and consumption of medicines. The patients can return to normal work and profession within a shorter period. As external snitching is completely avoided, Laparoscopic method provides excellent cosmetic outcome. The diseased organ is tackled inside the abdomen and intestines are not brought out to be in contact with outside environment as in open surgery. Hence chance of adhesion (sticking together of intestines) is minimized in laparoscopy to the least.
Laparoscopy enables doctors for better diagnosis. Since the organs are seen in magnified form, the surgeon performs with high precision. There is less chance of contact with blood and tissue fluids. Hence less chance for surgeon and staff to contract dreaded infections.
The surgeon can visualize the entire abdominal cavity of the patients, by just turning the telescope in all directions. Laparoscopic method helps in detecting alternate pathology than one which is entertained pre operatively; which is not possible in open surgery due to limited access and vision. As one can start feeding the patient early in laparoscopy, the gastrointestinal problems are also minimized and nutrition is well maintained. Finally patients is highly benefitted. Use of advanced energy sources like harmonic scalpel reduces tissue damage and hence the resultant recovery time and tiredness.
Prospective fields of Laparoscopy
Laparoscopic treatment and surgery are ideal in the case of removal of gallbladder (laparoscopic cholecystectomy) , appendix ovary, uterus etc. It is very good for, hernia repair, bowel surgery and surgery on kidney and for surgery for weight reduction. The term Arthroscopy refers to the keyhole procedure for treatment of bone and joint problems and thoracoscopy for the procedure in chest.
How can the diseased organs be taken out through small opening ?
Usually the organs or affected parts removed are not too big. An appendix, gall bladder, cyst wall etc. are of small size which can come out through the one 10mm Incision made earlier. For females, specimen like uterus comes out through the vagina without any need for abdominal incisions. If necessary, using instruments like morcellator the specimen can be sucked out in smaller pieces completely.
Is cancer treatment possible?
Laparoscopic treatment has many advantages in detecting and removing tumors. Eight major scientific studies have proved that laparoscopic surgery is better than open surgery for surgically treating cancer. Postoperative complications in lungs, veins, intestines etc are significantly reduced by the fact that patients are not confined to bed after laparoscopy. As wounds are less, patients need not wait for the wounds to heal and early initiation of chemotherapy is possible. Waiting for wound healing makes the microscopic reminant Cancer to grow before chemo tackles it. Cancers of uterus, intestine, kidney etc. are tackled laparoscopically all over the world. Laparoscopy avoid major negative laparotomies which increase the tiredness, sickness of patients when the tumour is not surgically removable.
Hernia is protrusion of contents of abdomen through defect in abdominal wall. The treatment is to repair these defects by supporting with a mesh. In conventional surgery one has to cut all layers of the abdominal wall to place this mesh; obviously causing major wound, pain and sometimes weakening of tissues. In laparoscopy the procedure is done through 1 cm incision much away from the defect and a much larger mesh can be placed right at the place of starting of hernia. Being more physiological, the outcome is superior with very very less chance of recurrence compared to open surgery. No need for 3-6 months rest as in open surgery. Even multiple hernias can be tackled through the single 1cm incision plus two 3 mm punctures rather than cutting long at each place.
Obesity & Diabetic Surgery
Laparoscopic method may be the only safe option in bariatric surgery. Bariatric surgery is considered when the body mass index (BMI) is more than 35. It is really difficult to perform open surgery in obese patients and they go in for respiratory and wound complications. Highly desirable results are obtained by a laparoscopic approach which gives a very good access to the stomach.
Laparoscopic bariatric surgery brings back obese patients to normalcy by getting rid of the extra fat which was causing various medical illness like diabetes, high blood pressure, high cholesterol, cardiac illness , breathing difficulty , joint pain, cancers , infertility etc. Key hole surgery gives excellent result in attaining long term resolution of Diabetes Type II.
Gynecology & infertility
All gynaec procedures can be performed very successfully by laparoscopy and gives much better results in infertility. Taking out baby (Cesarean) may be the only procedure which may necessitate a wound. Opening abdomen for the removing uterus or cyst of any size is unnecessary as the laparoscopic surgery accomplish better outcome.
Thyroid surgery (Endoscopic Thyroidectomy)
The surgical solution available in most of the places is open thyroidectomy which involves a large transverse cut across the lower part of the neck. This definitely leads to an unsighty scar which is not acceptable, especially for women. The endoscopic thyroidectomy – the keyhole or minimally invasive technique is a very good alternative to other methods. It gives excellent cosmetic outcome especially when done by an axillary approach. It gives equal or even a better surgical outcome as far as the actual thyroid nodule management is considered.
The earlier belief was that the endoscopic no neck scar option for thyroid swellings are applicable to lesions of less than 4 cm size. But we have observed that swellings of size of even 12 – 15 cm can be tackled very successfully through this method. The only pre-requisite will be a surgeon with good experience, in both laparoscopic surgeries and thyroid surgeries. Any kind of pathologies like benign or cancerous nodules, thyoiditis can be safely tackled by endoscopic thyroidectomy.
Key hole surgery is an excellent method for treating disease in the chest. Lung cancers, & recurrent pneumathorax (air leak) , chest wall tumors and infection can be tackled through 1 cm cut using telescopic system. In conventional surgery (Thoracotomy) the 30-40 cm incision with rib cutting-mainly for access and vision cause extreme discomfort to patient at every breath for at least six months. The procedures can be performed with high precision and perfection with out these troubles when performed by the thoracoscopic method.
Previous Surgery & Associated medical Illness
Previous open surgery or laparoscopy in not a contra indication for laparoscopy. Medical illness like diabetes, Hypertension, asthma, cardiac illness though increase risk for anaesthesia the laparoscope surgery can be performed comfortably without increasing the risk . Less need for confinement to bed in laparoscopy actually reduces the post op complications in these patients with comorbid illness. Laparoscopic surgeries can be performed under regional anaesthesia (spinal / epidural) when general anaesthesia cannot be given.
What are the risks in Laparoscopy?
Laparoscopic procedures do not carry any additional risks, as nothing which can harm the body is used . Surgery related risks are very minimum compared to open surgery. The safety of the patient and the precision in treatment have increased manifold with the availability of ultrasonic and radio frequency instruments. Keeping blood in reserve is mostly not needed unlike in open surgery. Pain and infection after surgery is extremely rare for the patients in laparoscopy. The diseased organ is removed completely and no chance of recurrence of the problem, only because procedure was done laparoscopically.
There is no need for physical rest for the patient and can resume normal diet in twelve hours. No special preparation is required prior to laparoscopy. Four to six hours of fasting which mandates anaesthesia requirements is sufficient.
A good hand, eye coordination is required for laparoscopy. Lack of trained surgeons in laparoscopy is a major problem in India like other parts of the world. After sustained training to surgeons with easy availability of sophisticated instruments; major hospitals are now getting fully equipped to handle laparoscopic surgery. Surgeons should not give a prolonged illness & discomfort by a wound when patient comes for an illness which can be cured by surgery in 24hrs. Every surgeon should learn Laparoscopy and practice it. Lap surgery has taken away the fear of surgery-the pain. It is very pleasing to see patients walking around even on the 1st day after undergoing major surgery laparoscopically . But open surgery patient is confined to bed and require many persons to help, even to move.
Through laparoscopic surgery costs higher than open surgery, it has its own advantages financially. For laparoscopic surgery, a patient need not stay in the hospital for more than two days. It will be week long stay in the hospital for open surgery. Prolonged stay in hospital incurs expenses for accommodation, food, medicine etc. The patient after laparoscopic surgery can join work much sooner than those undergoing open surgery. This will have an impact on the income of family. The expenses incurred for bystanders and their availability are minimized in the case of laparoscopy. These indirect expenses definitely over weighs the apparent direct cost for laparoscopy.
The wound related problem like infection, adhesion and hernia leads to further expenses in open surgery group even later.