Dr. Aditya Kulkarni is a Consultant Laparoscopic and Robotic Gastrointestinal, Hepato-biliary-pancreatic and Cancer Surgeon at the renowned Ruby Hall Clinic,
What is Laparoscopic Surgery?
Laparoscopic surgery is also called minimally invasive surgery (MIS), or “keyhole” surgery. It is a specialized surgical technique in which operations in the abdomen are performed through small incisions or “ports” usually 0.5–1.5 cm. Keyhole surgery uses images displayed on TV monitors for magnification of the surgical elements. Laparoscopic surgery can also be used for operations within the abdominal or pelvic cavities. Keyhole surgeries performed on the thoracic or chest cavity are called thoracoscopic surgery.
What is the difference between open and keyhole surgery?
|Open surgery||Minimally Invasive (laparoscopic/robotic) surgery|
|Large (8 – 10 inch) incision or “cut”||3 to 4 small (1/4 or 1/2 inch) incisions|
|More pain due to large incision||Pain is much less|
|Excessive bleeding with blood transfusion||Less bleeding, no blood transfusion needed most times|
|Longer post-operative recovery||Faster post-operative recovery|
|Long hospital stays||Shorter hospital stay|
|Higher chances of wound infections||Lesser chances of wound infections|
How is the keyhole surgery performed?
The laparoscope is long, thin, and shaped like a telescope, which illuminates and magnifies the structures inside the abdomen. It is attached to a light source such as halogen or xenon. These are inserted through a 5mm or 10mm cannula or trocar to view the operative field. After prepping, the abdomen is filled with carbon dioxide gas. This elevates the abdominal wall above the internal organs like a dome creating a working and viewing space. A vast majority of the abdominal operations can be done by laparoscopy with excellent results, minimum pain, and quick recovery.
Laparoscopic Surgeries performed:
Laparoscopic Heller’s myotomy is a minimally invasive procedure that opens the tight lower esophageal sphincter (the valve between the esophagus and the stomach) by performing a myotomy (cutting the thick muscle of the lower part of the esophagus and the upper part of the stomach) to relieve the dysphagia (difficulty swallowing). Further, a Dor fundoplication (a partial wrapping of the stomach around the esophagus to make a low-pressure valve) is performed to prevent reflux from the stomach into the esophagus following the myotomy. This procedure results in a great symptomatic relief.
The term “heartburn” is a symptom of gastroesophageal reflux disease (GERD). In this condition, stomach acids reflux or “back up” from the stomach into the esophagus. Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck. The feeling may radiate through the chest and into the throat and neck. The commonly performed operation for GERD is called a Nissen fundoplication. A fundoplication involves fixing the hiatal hernia, if present, and wrapping the top part of the stomach around the end of the esophagus to reinforce the lower esophageal sphincter, and this recreate the “one-way valve” that is meant to prevent acid reflux. This can be done by minimally invasive techniques using several small incisions, called laparoscopic surgery. The advantage of the laparoscopic approach is that it usually provides reduced postoperative pain, shorter hospital stay, faster return to work and improved cosmetic result.
Oesophagectomy is a high-risk surgical procedure which is associated with significant morbidity and mortality. Open oesophagectomy results in considerable trauma of access, generates a substantial systemic inflammatory response, and is associated with significant postoperative pain and reduced postoperative mobilization. Thoracoscopic oesophagectomy is performed by 3 small (half-inch) incisions on the chest as compared to one large (8-10 inch) opening. Pain is much less, and recovery is faster with this approach.
Sleeve gastrectomy: It is performed laparoscopically using five or six small incisions in the abdomen and performing the procedure using a video camera (laparoscope) and long instruments that are placed through these small incisions. Approximately 2/3rd of the left side of the stomach is removed laparoscopically using endoscopic staplers. The stomach thus takes the shape of a sleeve with capacity between 60 – 100 cc. The part of the stomach that contains ghrelin, the hormone for hunger is removed; it drastically reduces your appetite.
Laparoscopic repair of congenital and diaphragmatic defects is associated with smaller incision, less pain and faster recovery as compared to open approach.
Laparoscopic cholecystectomy removes the gallbladder and gallstones through several small cuts in the abdomen. The surgeon inflates your abdomen with air or carbon dioxide to see clearly. The surgeon inserts a lighted scope attached to a video camera (laparoscope) into one incision near the belly button. The surgeon then uses a video monitor as a guide while inserting surgical instruments into the other incisions to remove your gallbladder. Recovery is much faster and less painful after laparoscopic surgery than after open surgery. The hospital stay after laparoscopic surgery is shorter than after open surgery. People generally go home the same day or the next day, compared with 2 to 4 days or longer for open surgery.
Laparoscopic removal of common bile duct stones is an option for patients whose stones were not able to be removed by endoscopy. The gallbladder is removed at the same time. This offers a “one-step” solution to the problem. Recovery with laparoscopic common bile duct exploration is much faster than open technique.
A laparoscopic distal pancreatectomy is a minimally invasive surgical procedure that is performed to remove benign or malignant (cancerous) tumors in the body or the tail of the pancreas. The surgeon most often will need to remove the spleen because it is located near the pancreas and shares some of the blood vessels.
Pancreatic necrosectomy is the surgical procedure used in the management of acute necrotising pancreatitis, a condition characterised by the inflammation of the pancreas. Pancreatic necrosectomy is traditionally performed via an open surgery with an abdominal incision. However, surgeons with specialized training can perform this procedure laparoscopically. With the use of laparoscopic ports and camera, the necrotic cavity is accessed. Purulent materials are gently suctioned to minimise the contamination of the abdominal cavity. The pus is also collected as specimen and sent for culture studies to determine the proper antibiotic therapy to be used later. The goal of necrosectomy is to remove all the areas of infection and necrosis. Using forceps, the necrotic pancreatic tissues and debris are removed. Following the procedure, drains are inserted from the pancreatic area to minimise the exposure of the abdominal contents to the pancreatic juice.
Splenectomy is a surgical procedure to remove spleen. The spleen is an organ that sits under the rib cage on the upper left side of the abdomen. It helps fight infection and filters unneeded material, such as old or damaged blood cells, from blood. The most common reason for splenectomy is to treat a ruptured spleen, which is often caused by an abdominal injury. Splenectomy may be used to treat other conditions, including an enlarged spleen that is causing discomfort (splenomegaly), some blood disorders, certain cancers, infection, and noncancerous cysts or tumours.
During laparoscopic splenectomy, four small incisions are made in the abdomen. A tube with a tiny video camera into the abdomen through one of the incisions. The surgeon watches the video images on a monitor and removes the spleen with special surgical tools that are put in the other three incisions.
After laparoscopic splenectomy, patient mostly goes home the next day or day after. After open surgery, patient may be able to go home after four to six days. To reduce the risk of infection, vaccines against pneumonia, influenza, Haemophilus influenzae type b (Hib) and meningococci are recommended. In some cases, preventive antibiotics are needed, especially for children under 5 and those with other conditions that increase the risk of serious infections.
Choledochal cyst is a congenital anomaly of the duct (tube) that transports bile from the liver to the gall bladder and small intestine. It can cause liver problems or inflammation of the pancreas (pancreatitis) because it blocks the main duct from the pancreas gland to the intestine. Patient with choledochal cysts have a higher rate of cancer of the bile duct in adulthood. Laparoscopic choledochal cysts excision is done through small incisions using miniaturized surgical tools and cameras or telescopes. Laparoscopy usually results in less pain, less scarring and a quicker recovery time.
Standard approach to removal of an inflamed appendix is laparoscopy, which gives greater advantages in terms of less pain, shorter stay and early recovery.
Many of the common colon procedures can be performed through small incisions. Depending on the type of procedure, patients may leave the hospital in a few days and return to normal activities more quickly than patients recovering from open surgery. Surgeons operate through 4 or 5 small openings (each about a quarter inch) while watching an enlarged image of the patient’s internal organs on a television monitor. In some cases, one of the small openings may be lengthened to 2 or 3 inches to complete the procedure. It has the advantages of less postoperative pain, shorter hospital stays, faster return to solid-food diet, quicker return of bowel function and normal activity, along with improved cosmetic results.
GPatients with a rectal prolapse have a protrusion (prolapse) of the rectum through the anus. The rectum folds on itself and protrudes through the anal canal. They may also have such symptoms as a change in bowel habits, rectal bleeding, mucus drainage, anorectal pain or faecal incontinence. A rectal prolapse is thought to occur because of a loss or weakness of the normal support structures for the rectum.
Laparoscopic rectopexy is one of the surgeries that is used to repair a rectal prolapse. In this surgery, the rectum is restored to its normal position in the pelvis, so that it no longer protrudes through the anus. Usually, stitches are used to secure the rectum, often along with mesh.
A laparoscope (a tiny telescope with a television camera attached) is inserted through a cannula (a small hollow tube). The laparoscope and TV camera allow the surgeon to view the hernia from the inside. Other small incisions will be required for other small cannulas for placement of other instruments to remove any scar tissue and to insert a surgical mesh into the abdomen. This mesh, or screen, is fixed under the hernia defect to the strong tissues of the abdominal wall. It is held in place with special surgical tacks and in many instances, sutures. Usually, three or four 1/4 inch to 1/2-inch incisions are necessary. The sutures, which go through the entire thickness of the abdominal wall, are placed through smaller incisions around the circumference of the mesh. This operation is usually performed under general anaesthesia. It has the advantages of less post-operative pain, shortened hospital stay, faster return to regular diet, quicker return to normal activity, less wound infections
Laparoscopic inguinal hernia repair uses an instrument called a laparoscope. Between two and four small incisions are made through the abdominal wall through which are passed the laparoscope (a thin telescope with a light on the end) and surgical instruments into the abdomen. The incisions are small, so the whole technique is often called keyhole surgery. (Conventional surgery is called open surgery.) It is also often referred to as minimally invasive or minimal access surgery. The hernia is then viewed from inside the abdomen, from the other side of the abdominal wall. The abdominal cavity is inflated with carbon dioxide gas to give the surgeon space to work inside the patient and the actual operating is done remotely with long instruments. The hernia defect or hole is covered with mesh from within the abdomen and staples commonly fired through it into the muscle tissue to fix it as a patch