Laparoscopic surgery:

Laparoscopic surgery also referred to as minimally invasive surgery describes the performance of surgical procedures with the assistance of a video camera and several thin instruments. During the surgical procedure, small incisions of up to half an inch are made and plastic tubes called ports are placed through these incisions. The camera and the instruments are then introduced through the ports which allow access to the inside of the patient.

Laparoscopic surgery, also called minimally invasive surgery (MIS), bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen (Abdomen is Latin for belly) are performed through small incisions (usually 0.5 - 1.5 cm) as compared to larger incisions needed in traditional surgical procedures. Medically, laparoscopic surgery refers only to operations within the abdomen or pelvic cavity. Laparoscopic surgery belongs to the 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 videocamera (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. Additional 5- 10 mm thin instruments can be introduced by the surgeon through trocars (hollow sheaths). Rather than a 20 cm incision as in traditional cholecystectomy, four incisions of 0.5-1.5 cm will be sufficient to perform a laparoscopic removal of a gallbladder.

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 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.

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, gynecologic surgery and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidites 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 (hand-eye coordination), 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.

The first transatlantic surgery (Lindbergh Operation) ever performed was a laparoscopic gallbladder removal.

Advantages

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:

• Less time in the operating room, which equals a shorter time under anesthesia.
• reduced blood loss, which equals less risk of needing a blood transfusion.
• smaller incision, which equal less pain and shorter recovery time.
• less pain, which equals less pain medication needed.
• shorter hospital stay, which equals a faster return to everyday living.
• reduced exposure of internal organs to possible external contaminants therebey reduced risk of acquiring infections.

Possible benefits

The expert advisers said that laparoscopic surgery may increase the chance of completely removing the cancer. They also said it offers an improved chance of the cancer not returning.
The healthy tissue that is removed with the cancer is examined after surgery to check that all of the cancer has been removed. Eight studies of laparoscopic surgery and open surgery showed that the rate of not removing all of the cancer was similar. Two studies showed that this occurred more often with open surgery, and one study showed that it occurred more often with laparoscopic surgery.
Out of just over 1400 men treated with laparoscopic surgery, the cancer was not fully removed in 1 in 5 patients. Out of just over 22,000 men treated with open surgery, nearly 1 on 4 had some cancer that was not removed.

Risks

Some of the risks are briefly described below:

• Some patients have sustained electrical burns unseen by surgeons who are working with electrodes that leak current into surrounding tissue. The resulting injuries can result in perforated organs and lead to peritonitis.
• Many patients with existing pulmonary disorders may not tolerate pneumoperitoneum (gas in the abdominal cavity), resulting in a need for conversion to open surgery after the initial attempt at laparoscopic approach.
• Not all of the gas introduced into the abdominal cavity is removed through the incisions during surgery. The gas moves around in the body, usually ending up in the shoulders. For an appendectomy, the right shoulder can be particularly painful. Bubbles of gas can also move to near the solar plexus when lying down, causing considerable pain when breathing.
• Coagulation disorders and dense adhesions (scar tissue) from previous abdominal surgery may pose added risk for laparoscopic surgery and are considered relative contra-indications for this approach.

Robotics and technology

This is a laparoscopic robotic surgery machine developed by Intuitive Surgical.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:

• Visual magnification - use of a large viewing screen improves visibility
• Stabilization - Electromechanical damping of vibrations, due to machinery or shaky human hands
• Simulators - use of specialized virtual reality training tools to improve physicians' proficiency in surgery (example).
• Reduced number of incisions
• Patients may have chemical burns due to Mastisol Liquid Adhesive that is used to keep the bandages in place.
• 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.

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