Laparoscopic surgery is also known as 'keyhole' or 'minimally invasive' surgery as the majority of the surgery is performed by passing instruments into the body through tiny incisions known as ports. The major advantages are smaller incisions and quicker post-operative recovery – more details on this later.
How is it performed?
Laparoscopic colorectal surgery (LCS), requires a full general anaesthetic; you have to be fully asleep, it cannot be done under local anaesthetic.
Once asleep a small 2cm incision is made below the umbillicus to gain access into the abdomen. The incision is deepened until a small hole is made in the tough fibrous tissue in the middle of the abdomen called the 'linea alba'. Directly below this is the lining of the abdominal cavity. Once the opening is created a plastic port (see below) is inserted into the abdominal cavity. The camera is then inserted through this port and the abdominal cavity inflated with CO2 gas in order to create the working space between the abdominal wall and the contents of the abdomen (see picture).
View inside abdomen after inflating with CO2
Once the abdominal cavity is inflated and a clear view is obtained the remaining ports are inserted under direct view (picture above shows insertion of 5mm port). These ports vary in size (5-12mm diameter) and number depending on the procedure to be performed. In LCS when part of the bowel is to be removed between 3 and 5 ports in addition to the camera port below the umbillicus are usually required. Sometimes more are required depending on the difficulty of the procedure; all the incisions however are very small.
There are many different types of instruments used in LCS and some are down to surgeon preference. Some surgeons like myself prefer to use either the harmonic scalpel or diathermy scissors in order to make incisions in the tissues inside the abdomen to facilitate dissection. The harmonic scalpel (see picture) works by vibrating at a very high frequency causing the tissue between the jaws to fuse together and then separate. This is a very safe instrument to use when used in the correct fashion and helps provide the 'bloodless field' when we operate.
Diathermy scissors pass high frequency high voltage electrical current to the tips of the scissors in order to coagulate the tissue before cutting it. There are also other types of instruments that will do a similar job. The choice of dissecting instrument is a matter of personal choice and preference. All types of instruments carry certain risks and benefits as described below.
What are the benefits of laparoscopic colorectal surgery (LCS)
In experienced hands having your surgery performed laparoscopically has the following potential benefits:
- less post-operative pain
- smaller scars
- better cosmetic result
- shorter hospital stay
- quicker return to normal bowel function
- quicker return to normal activities
- quicker return to work
Will I be suitable for LCS?
Please remember that LCS is not always suitable for your particular operation or for you. There are a number of factors to take into account when considering suitability for LCS. Some of these factors include:
- your weight (in particular abdominal obesity)
- type of operation to be performed, including any additional procedures
- previous abdominal or pelvic surgery
- co-existent chest or heart disease
- experience of the surgeon
None of these are absolute contraindications and you should have a detailed discussion with your surgeon when making a decision on whether or not to proceed with LCS.
Are there any disadvantages for LCS?
LCS even in the most experienced hands is technically very demanding and usually takes longer to perform than the same operation done in the more traditional open fashion. Sometimes the operation is quicker laparoscopically than open and this is a further discussion you should have with your surgeon.
When introduced into the United Kingdom a detailed randomised clinical trial (CLASSIC) was performed comparing open and LCS and the only significant disadvantage was a slight increase in chest infections in those patients undergoing LCS. This is not unsurprising as long operations with the abdomen full of gas puts pressure on the lungs increasing the chance of infections. This is one of the reason why chronic chest problems are a relative contraindication for LCS.
LCS got a 'bad name' for itself in the very early years as it was thought that local recurrence rates were higher in patients having LCS compared to open surgery. This is not the case and there have been many trials since that have shown no difference in local, regional or distant recurrence of cancer in LCS.
It is not always possible to finish an operation laparoscopically once started due to difficulties in visualising structures, abnormal anatomy, intra-operative complications etc. At this point the operation has to be 'converted' to an open operation. The important point here is to recognise early on when conversion is required as delaying conversion to an open operation increases complication rates. This is where experience of the surgeon is of utmost importance.
If your operation is being performed for cancer please be assured the results for cancer surgery are as good in LCS as they are in open colorectal surgery.
What are the risks of LCS?
The risks of LCS are the same as the risks in the equivalent open operation. Any operation carries a risk of intra-operative or post-operative complications, which may happen even with the most skilled and experienced surgeons performing the operation. The risks of surgery and potential complications are tailored to the individual patient as patient related factors such as age, weight, and medical problems play a significant role in the likelihood of them developing. Some of the potential risks of both LCS and open colorectal surgery include (not an exclusive list):
- risk of dying as a result of surgery
damage to intra-abdominal organs such as
- small & large bowel
- spleen and liver
- ureter (carries urine from kidney to bladder)
- stomach & duodenum
- pelvic organs such as uterus, tubes and ovaries
- chest, wound, urine and abdominal infections
- clots in the legs (DVT) and the lungs (PE)
- heart attack
- leaking of any joins made in the bowel
- bleeding from the operative site
The above list looks very frightening, but please remember these are only potential complications and the risk of any one happening may be very small depending on your circumstances. Your surgeon is obliged to tell you of these potential complications as doing so is part of informed consent.
Some of the risks above can be individualised based on mathematical models (such as the risk of dying) and others such as leak rates can be quoted from national figures. Some surgeons keep detailed results of their work especially with cancer and it is possible to get figures specific to an individual surgeons practice in some cases.
Specific to laparoscopic surgery there is also the risk of 'conversion' from the laparoscopic to the open procedure due to the difficulties mentioned above. There are also mathematical models to help work this out for individual patients and the risk factors include patient weight, use of radiotherapy, operation being performed, and experience of the surgeon.
For more information about specific operations please look at the individual leaflets describing them available on the website.
Consultant General, Colorectal & Laparoscopic Surgeon