Pros and Cons of Keyhole Surgery
27 Jul 2013
What’s the most advanced surgery of recent years? I believe most surgeons would quickly respond, "laparoscopic surgery", often referred to as keyhole surgery. But never let the word "keyhole" lead you astray.
In 1991 Dr. Joacques Perissat at the University of Bordeau, in France, announced at the World Congress of Surgeons that he had removed a gallbladder (cholecystectomy) using optical instruments through small incisions. Now, a number of more complicated operations are performed by this method.
Laparoscopic surgery has been a great boon for patients. Without a large incision there’s less pain, speedier healing and shorter hospital stay. But as in any type of surgery there are unexpected pitfalls.
One problem is that the term "keyhole surgery" leaves the impression that tiny incisions mean a simple, uncomplicated way to perform operations. Unfortunately, this is not always the case and a small incision can cause catastrophic complications.
There’s a huge difference between opening the abdomen to have a direct look at a diseased organ and performing laparoscopy. Rather than hold a scalpel, surgeons watch a video camera while manipulating a variety of grasping, cutting and suturing devices. It’s an entirely different ball game with a steep learning curve. It’s wise to remember the old saying that "practice makes perfect" whether dealing with a plumber or surgeon.
To perform laparoscopy the abdomen is first filled with gas to lift the abdominal muscles away from underlying organs and blood vessels. Then, hollow tubes are inserted to act as portals for the laparoscopic instruments which act much like the periscope on a submarine. This is when underlying bowel or arteries can be injured, luckily a rare occurrence.
Most complications occur during removal of an organ such as the gallbladder. For instance, the common bile duct that carries bile from the liver to the bowel can be inadvertently injured. It’s a serious complication and if not repaired can result in jaundice and death. In one study of 613,706 cholecystectomy operations 0.39 percent of cases suffered this injury.
Many years ago, a distinguished English surgeon severed the bile duct of Sir Anthony Eden, Britain’s Foreign Secretary, who later became Prime Minster. I was a medical student at Harvard at the time Eden was flown to Boston to have the bile duct repaired by Richard Cattell, at that time the world authority on bile duct surgery.
Laparoscopy has many benefits. But wise generals know when to retreat and so do experienced surgeons. It may become apparent in the OR that previous operations have caused extensive adhesions, obscuring vision, and it is more prudent to end the laparoscopy and use an abdominal incision. The same reasoning applies if there’s a complication such as excessive bleeding.
Like any procedure, laparoscopy can be overused. Since 1989, when doctors first used this procedure the number of cholecystectomies has risen 20 to 40 percent.
Studies show that about 10 percent of North Americans have gallstones, often accidentally discovered during tests to diagnose other conditions. In general, gallstones not causing trouble are best left to the crematorium. Or as one of my professors once told me, "Remember, it’s impossible to make a patient feel any better who doesn’t have any symptoms."
Looking at the total picture, laparoscopic procedures beat the old abdominal incisions by a mile. For instance, many women with benign fibroid growths can now circumvent abdominal hysterectomy by having fibroids removed by laparoscopy. Others plagued by excessive bleeding are able to have the lining of the uterus reduced by this technique. Still others, suffering from Crohn’s Disease or diverticulitis, can be treated by laparoscopy. Even patients with large bowel malignancies can be treated this way.
It’s always prudent to go to surgery on a first class ticket. If you are lucky to know someone who works in the OR or who has performed many of these procedures, listen carefully to their advice. If that surgeon is 100 miles away that’s where you should go. Often I’ve heard patients say, "But I’d rather go to this hospital because family and friends can visit me". That’s a big error. The skill of the surgeon is the more important consideration.
