ADVANTAGES AND DISADVANTAGES OF LAPAROSCOPIC SURGERY

Video laparoscopy is a new tool in the surgical armamentarium.

Laparoscopy represents a change of tactics aiming for the same goals of standard surgery i.e.

· Safe;

· Low morbidity;

· Maximum chance of cure in case of malignant disease.

In absence of frank contra-indications, ALMOST ALL types of surgery can be done laparoscopically.

The question is why laparoscopy?

ADVANTAGES OF LAPAROSCOPIC SURGERY

1. Smaller incisions compared to open surgery

2. Smaller incisions, therefore less wound related complications

3. Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.

4. Less wound infection

5. Less Pain

6. Shorter period of disablement

7. Quicker return to work

8. Cosmetically better

9. Less post-operative hernias

10. Economically effective

DIS-ADVANTAGES OF LAPAROSCOPIC SURGERY

1. Specific instruments needed

2. Dependency on instruments

3. Expensive equipment

4. Own set of complications

5. Extensive training is needed

6. Limited mobility

7. Poor depth perception

8. Less tactile sensation of the tissue

9. Damage to surrounding structures

Contra-indications of laparoscopy

These are medical contra-indications of pneumoperitoneum

• Splinting the diaphragm and decreasing venous return

• Raising intra-abdominal pressure

Relative contra-indications of Laparoscopy

• Pregnancy.

• Extensive abdominal adhesions OR multiple previous surgeries

• Experience of surgeon versus extent of pathology.

• Adequacy of available instruments for the task.

An untrained surgeon is & will be the most important CONTRA-INDICATION

Essential equipment’s are:

1. Anaesthetic (Mechanical ventilator & Cardiac & respiratory monitoring)

2. Laparoscopic Instruments Set

IF ONE OR BOTH IS ABSENT THIS IS A CONTRA-INDICATION

Thus, in absence of frank contra-indications, almost all types of surgery can be done laparoscopically. The question is why laparoscopy?

Inherent advantages of laparoscopy:

Operative:

– Better visualization in some areas;

– More fine dissection;

– Less blood loss;

– With improvement of learning curve possibly less operative time.

Post-operative:

– Less pain;

– Less immunosuppression;

– Rapid recovery;

– Less hospital stays and consequently shorter sick leaves;

– Less post-operative adhesions.

The driving forces for laparoscopic implementation:

• Patient acceptance;

• Industrial and technological drive:

– Money investment;

– Shorter sick leaves.

• Doctor’s acceptance.

Actual limitations:

1. Relative high cost:

   1. Hospitals;

   2. Private patients;

   3. Third parties.

2. Learning curves;

3. Medical profession fears:

   1. Long term follow-up;

   2. Infection complications.

Surgeries done laparoscopically:

Diagnostic Laparoscopy

Only contra-indication is failure to create pneumoperitoneum or medical contra-indication to pneumoperitoneum.

Relative limitations are:

• Lack of tactile discrimination;

• Bi-directional vision (angled scopes and tri-dimensional in progress);

• Assessment of retro-peritoneal injuries in traumatic cases (more or less like open laparotomy) but it needs a highly trained laparoscopic surgeon

Cholecystectomy

Definite advantage for laparoscopy.

When to stop?

1. Lack of progress for 20-30minutes;

2. Non clear anatomy;

3. Suspected pathology in CBD with no available technology or expertise for laparoscopic exploration of CBD;

4. Suspected iatrogenic injuries.

Appendicectomy

Laparoscopy is advantageous in:

• Obese;

• Females with suspected diagnosis;

• Athletes.

Inguinal hernia

Definite advantage in recurrent hernia

Relative rapid recovery is an advantage.

Mesh repairs are usually tension free (trans-peritoneal or extra-peritoneal) the mesh needs fixation.

Laparoscopy has a definite advantage in bilateral recurrent cases.

Advanced techniques

Hiatus hernia:

• Indications for surgery did not change but probably patients and internal medicine acceptance to laparoscopy is better.

• For surgeons, laparoscopy offers better exposure.

• Long instruments which reach the dome of the diaphragm allow more space for suturing.

Peptic ulcer:

• Indications again are not different: laparoscopy only decreases parietal complications which are not the main disadvantages of surgical treatment of peptic ulcer on elective bases.

• However, these complications are appreciable in cases of perforated peptic ulcer which are usually acute and over 50% do not need definitive ulcer surgery later on: laparoscopy with proper technology may be more useful in these conditions.

Splenectomy, nephrectomy:

• Possible with small sized organs. However, endo-GIA staplers may be needed during laparoscopic management. Harmonic scalpel & Ligasure help.

Laparoscopically assisted colectomy

• It is possible with several advantage but however there is a theoretical fear of port site metastases.

Laparoscopic exploration of CBD

May be very useful in operative surprise of dilated CBD or the possibility of slipped stones during laparoscopic cholecystectomy or past history of jaundice with no present evidence of it. Otherwise, pre-operative ERCP combined with laparoscopic cholecystectomy may be as effective.

Other advanced laparoscopic surgeries:

• Laparoscopic subfascial ligation of varicosities.

• Laparoscopic face lift.

• Laparoscopic neck surgery (thyroid)

• Laparoscopic sympathectomy (chest)

• Laparoscopic Oesophagectomy

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