Overview Of Laparoscopy

About Laparoscopy & Cancer

Minimally invasive surgery (MIS) or Minimal Access Surgery or Laproscopic Surgery or Laparoscopic Surgery has come a long way from the time when it was first performed on a human subject in 1910 by Hans Christian Jacobaeus of Sweden. It was only in 1950 that first Diagnostic Laparoscopy was reported by Raoul Palmer. The technology has improved along with the techniques and skills of surgeons. With the improvement in anesthetics and better vision systems for laproscopy, the surgeons started using MIS for more complicated surgeries. In the 70’s the first series on Salpingectomy was reported from Brazil. MIS remained in the domain of gynecologists for next 20 years. It was only in 1990’s that Laparoscopic surgery was accepted by General Surgeons and was used more extensively for general surgical procedures such as cholecystectomy and appendectomy. Today MIS is the gold standard for cholecystectomy for all the benefits it provides.
The goal of laparoscopic or minimally invasive cancer surgery (with or without robotic assistance) is to reproduce the oncologic results of an open procedure, while decreasing the surgical complications and postoperative recovery time. MIS is taking its baby steps into cancer care. More evidence is emerging day by day about the safety and standardisation of laparoscopy in cancer surgery. The advantages and disadvantages of Minimal Access Cancer Surgery (MACS) remains the same as other general surgical procedures.

It is important to bear in mind that Minimal Access Cancer Surgery is a treatment modality, and not a treatment by itself. It does not change the surgery itself, but only changes the way it is performed. Therefore, the preference to use laparoscopic surgery can be evaluated in terms of its effectiveness, patient recovery and ease of surgical performance.

What is more important in treating cancer patients is that long-term survival must not be compromised in exchange for improvements of short-term morbidity. The margin of error for inadequate surgery is extremely narrow and the price to pay is the patient developing recurrent or metastatic cancer that is usually fatal. As such all surgeons offering this surgical approach must first be competent in the open-approach and need to audit the surgical adequacy, cancer recurrence rate and survival outcomes from time to time.

Advantages Of Macs

The idea of MACS is to perform the same procedures as in traditional open surgery, using small incisions (Laproscopic surgery) instead of large incisions. There are studies which have shown

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reduced postoperative pain needing less analgesics

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better magnified vision quality for the surgeon

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lower blood loss reducing need for blood transfusion and its complication

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reduced risk of infection as the organs are not exposed to outside.

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increased postoperative comfort with reduced wound care and reduced hospital stay

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smaller would leading to quicker return to normal physical activities and ultimately a quicker return to work.

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Improved cosmesis and reduced wound complications associated with large scars

Disadvantages Of Macs

MACS is clearly advantageous in terms of patient outcomes, however, the procedures are more difficult to master and perform for the surgeon when compared to traditional open surgeries.

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The image is two dimensional and so lacks depth perception

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Less touch (haptic) sensation compared to open surgery.

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Tips of the instrument moves in the opposite direction to the actual hand movement due to pivot action at the entry point.

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Range of movement is limited to 5 degrees unlike 7 degrees of movement of our wrist and hand.

How To Start MACS ?

Minimal Access Cancer Surgery (MACS) has a long learning curve. One has to be comfortable at open surgery before venturing into MACS. The selection of suitable patients for laparoscopy is an essential step to ensure satisfactory outcomes. Selection criteria should incorporate both patient and tumor characteristics. It should be based on surgeon’s experience, with easier cases attempted initially and more complicated cases at a later stage. By doing this one can minimize the problems of prolonged operative time, surgeon frustration and patient complications. Thin patients and early tumors with no previous surgery or radiotherapy or chemotherapy would be ideal to begin with.

Previous abdominal surgery also increases surgical difficulty. Surgical scarring can range from minor adhesions to a complete absence of intraperitoneal operating space. The entry technique needs to be modified according to the scar. A ventral or incisional hernia from previous surgery further complicates the decision making. Obesity make MACS difficult, though they are the major benefactors of this technique as the surgical morbidity is significantly lowered among them. Chemotherapy or radiotherapy given in-order-to downstage the disease could lead to fibrosis and thus difficulty in defining the planes of dissection.Each patient has to be carefully considered for MACS with the surgeons experience in mind.