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Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or pinhole surgery is a modern surgical technique in which operations in the abdomen are performed through small incisions (usually 0.5-1.5cm) as compared to larger incisions needed in traditional surgical procedures. 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.
The key element in laparoscopic surgery is the use of a laparoscope: a telescopic rod lens system, that is usually connected to a video camera (single chip or three chip). Also attached is a fiber optic cable system connected to a 'cold' light source (halogen or xenon), to illuminate the operative field, inserted through a 5 mm or 10 mm cannula to view the operative field. The abdomen is usually insufflated with carbon dioxide gas to create a working and viewing space. The abdomen is essentially blown up like a balloon (insufflated), elevating the abdominal wall above the internal organs like a dome. The gas used is CO2, as it is common to the human body and can be removed by the respiratory system if it absorbs through tissue. It is also non-flammable, which is important due to the fact that electrosurgical devices are commonly used in laparoscopic procedures.
It is difficult to credit one individual with the pioneering of laparoscopic approach. In 1902 Georg Kelling of Dresden performed the first laparoscopic procedure in dogs and in 1910 Hans Christian Jacobaeus of Sweden reported the first laparoscopic operation in humans. In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. It was not until 1985 when, with the advent of a new and specialized computer chip television camera, the approach was broadened in scope to include surgical resection of organs such as gall bladder. The first successful laparoscopic removal of gall bladder in humans was reported in 1987 in France. The introduction of computer chip television camera was a seminal event in the field of laparoscopy. This innovation in technology provided the means to project a magnified view of the operative field onto a monitor, and at the same time freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures. Prior to its conception, laparoscopy was a surgical approach with very limited application and used mainly for purposes of diagnosis and performance of simple procedures in gynecologic applications.
The introduction in 1990 of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made surgeons more comfortable with making the leap to laparoscopic cholecystectomies (gall bladder removal). Dr. Eddie Joe Reddick was the surgical guru for this procedure in the U.S., and he played a huge role in training the first generation of laparoscopic general surgeons.
Laparoscopic cholecystectomy is the most common laparoscopic procedure performed. In this procedure, 5-10mm 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). Rather than a minimum 20cm incision as in traditional cholecystectomy, four incisions of 0.5-1.0cm 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 1cm incision at the patient's navel. The length of postoperative stay in the hospital is usually 2-3 days.
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 that choose this hand-assist technique feel it reduces operative time significantly vs. the straight laparoscopic approach, as well as providing 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. Surgical residents who wish to focus on this area of surgery, gain additional training during one or two years of fellowship after completing their basic surgical residency.
There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:
Some of the risks are briefly described below:
Robotics and technology
The process of minimally invasive surgery has been augmented by specialized tools for decades. However, in recent years, electronic tools have been developed to aid surgeons. Some of the features include:
Robotic surgery has been touted as a solution to underdeveloped nations, whereby a single central hospital can operate several remote machines at distant locations. The potential for robotic surgery has had strong military interest as well, with the intention of providing mobile medical care while keeping trained doctors safe from battle.
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Laparoscopic_surgery". A list of authors is available in Wikipedia.|