WHAT’S NEW IN LAPAROSCOPY AND MINIMAL ACCESS SURGERY

Dr Arun Prasad MS,FRCS, Senior Consultant Surgeon, Apollo Hospital, New Delhi

The list of procedures that can be done laparoscopically, thoracoscopically (VATS) or endoscopically is ever expanding. The following is a list of advanced procedures that are being done now using minimal access techniques leading to shorter hospitalization, faster recovery with minimization of pain and discomfort.

Abdomen nEsophagectomy nAchalasia Cardia nHiatus Hernia nIntestinal resection nMesenteric nodes nAppendicectomy nHernia Repair nGall Bladder nSplenectomy nSympathectomy nSpinal surgery nRectal prolapse nPiles n

Urology nNephrectomy nAdrenalectomy nStone disease nProstate nVaricocele n n Axilla &Breast nAxilloscopy nSubcutaneous Mastectomy

nChest nMediastinoscopy nThymus nPericardial window nHilar/ Mediastinal Node nPleural lesions nLung biopsy nLung resections nEmpyema nEffusions nSympathectomy (ETS)

Neck nThyroid nParathyroid nThymus n Spine nAbscess drainage nDiscectomy nBiopsy nScoliosis n

Gynaecology nOvaries nUterus nInfertility nEctopic n Vascular nAortic stents nVaricose veins Robotics

 

As the demands of the surgeons to the industry increases, the latter is trying to respond by giving tools that are more and more minimally invasive.

HOW IS THIS DIFFERENT FROM CONVENTIONAL LAPAROSCOPY ?

‘Traditional’ laparoscopy required cuts of 11 mm diameter to be able to insert certain instruments like the clip applicator which is used to occlude blood vessels and ducts. Once the more advanced laparoscopic surgeons started stitching these structures by a procedure known as intracorporeal suturing, the need for the 11 mm hole diminished to 5 mm and subsequently instruments that had similar strength with just 3mm diameter arrived.

WHAT ARE THE ADVANTAGES ?

1. The picture on the left shows in pairs, 11mm on the left, 5 mm in the centre and 3 mm instruments on the right. Theoretically it gives the patient 1/3^rd size of cut and hence reduction in the pain and trauma. Also as there is no stitch removal later, the patient is saved the discomfort of stitch removal. Out of station patients need not come back to the surgeon and can be checked by their local doctor.
2. It is cosmetically more acceptable as now even that one stitch of laparoscopic surgery is obsolete. The small cuts are now closed by either medical super glue or sterile paper tapes.
3. Using stitches inside the body makes the internal operation identical to the traditional open surgery with all the added advantages of the minimally invasive instruments. In the traditional laparoscopic method metal clips used for sealing the cut ends are left inside forever but here, absorbable vicryl stitch is used which is identical to the one used in open surgery.
4. Wound infection, swelling etc. incidence is greatly reduced.
5. Rarely hernia have been known to form from 11 mm cuts but are unheard of with 5mm and 3mm cuts.
   
   If you would like to watch a very brief video clip of a laparoscopic operation done by 3mm instruments, click here.

CAN ALL OPERATIONS BE DONE BY 3MM INSTRUMENTS ?

The answer is no. At times thick walled gall bladders cannot be properly grasped by these fine instruments necessitating the change over to 5 mm instruments. Rarely as is true with traditional laparoscopic surgery, unforeseen circumstances (1-2% cases), may require conversion to open surgery. No surgeon can ever give an undertaking contrary to this.

SINGLE INCISION LAPAROSCOPIC SURGERY ( SILS, SPA, LEAP ETC )

The other advancement is Single Incision Laparoscopic Surgery. Click here for details on SILS.This is going to be the technique of 21^st century. While gall bladder and appendix operations can be done with the same equipment ( hence cost remains the same ), advanced laparoscopic surgery like weight loss bariatric surgery would need special instruments.

SILS is also known as Single port access (SPA) surgery, laparo endoscopic single-site surgery (LESS) or one port umbilical surgery (OPUS) or single port incisionless conventional equipment-utilizing surgery (SPICES) or natural orifice transumbilical surgery (NOTUS), or Embryonic Natural Orifice transumbilical surgery (E-NOTES) is an advanced minimally invasive surgical procedure in which the surgeon operates almost exclusively through a single entry point, typically the patient’s navel. Since the entire surgery is performed through the navel, it does not leave any visible scar like a traditional multi-port laparoscopic approach. Surgeons employing this technique contend that patients should benefit from less post-operative pain, less blood loss, faster recovery time, fewer complications, and better cosmetic results.

There is less pain, chances of infection is reduced to 25% as there is one cut compared to four earlier, less need of medications, and possibly early return to routine activities. It is a cosmetic delight to the younger age scar conscious population. One of my patient is a school girl who I think was the happiest of all the patients we have had. We would like to call it "Cosmetic Laparoscopy" as suggested by one of our patients. The procedure can be readily learned and performed by laparoscopic surgeons without the need for expensive or experimental equipment. Using a single portal of entry to the abdominal cavity, the umbilicus, cosmesis, and scar reduction is achieved.

Click here to see is a brief video of the procedure.

HOW EXPENSIVE IS ALL THIS CHANGE ? WHO BEARS THE EXTRA COST ?

Change to micro laparoscopy usually means an extra investment of about 3 lakhs (Rs) for the surgeon/ institution. Also, as these instruments are more delicate, their life is short leading to constant recurrent expense.

Equipment for SILS include special ports, instruments that bend and flexible telescope. These cost extra but at a hospital where many operations are done, the extra cost can be absorbed by the volume of work.

At our center , NO extra charge is added to the bill of the patient. The same package applies to all patients.

This is the method of the new millennium.

Dr Arun Prasad is one of the few surgeons worldwide who have taken a lead to provide this service to the patients. Sooner or later all laparoscopic surgeons will adopt this technique.

The following are links to some of the sites that tell us the latest views of international experts in the field of minimal access treatment.

ADVANCES IN LAPAROSCOPIC SURGERY - AMERICAN SITE

GALL STONE SURGERY OVER THE YEARS

HERNIA TREATMENT - UK SITE

GALL BLADDER DISEASE - UK SITE

GALL BLADDER DISEASE - US SITE

HEMORRHOID AND PILES - UK SITE

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Contact us for more information on any of the above procedures.