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Immanuel K. Ho, M.D., FACG
Crozer-Chester Medical Center, Upland, Pennsylvania
What is laparoscopic surgery?
Laparoscopic surgery refers to a special technique by which the
surgeon performs the surgery through several small holes in the
abdomen with the aid of a camera. It is also known as “minimally
invasive surgery”. These incisions are much smaller than
would have been required using traditional surgical techniques.
Generally the operation that is performed is still the same operation,
even though the incisions are much smaller.
What advantages does laparoscopic surgery have over conventional
surgery?
Laparoscopic surgery usually results in reduced hospital stays,
fewer wound infections, less pain, and a faster recovery time.
From a surgeon’s perspective, laparoscopic surgery may allow
for easier dissection of abdominal scar tissue (adhesions), less
surgical trauma, and improved outcomes in certain groups like the
elderly and extremely overweight individuals.
What are the indications for laparoscopic surgery?
These days, many surgeries that were once performed “open” (longer
incisions of the abdominal wall allowing direct visualization of
abdominal contents) can be performed laparoscopically. The laparoscopic
surgeon can operate upon many organs, including but not limited
to the colon, small intestine, stomach, gallbladder, liver, and
pancreas. Any previous surgery can create scar tissue in the abdomen
making a laparoscopic procedure more technically difficult. The
surgeon would decide if a laparoscopic approach is the best choice
for you. Certain conditions or disease states lend themselves well
to laparoscopic intervention.
In the colon, the major indications for laparoscopic intervention
are diverticulosis (see the ACG patient web page on diverticulosis),
removal of large growths called polyps that are unable to be completely
resected by colonoscopy, and colon cancer. The operation is typically
performed by making four or five small abdominal incisions with
the largest one being used to remove the specimen from the body.
In general, these operations result in less blood loss during the
surgery, less need for blood transfusions, and quicker time to
eating a meal after surgery. Despite the accessibility of the colon
by a laparoscope there has been much debate over the past decade
regarding the safety of laparoscopic surgery for colorectal cancer.
The main concern involves the possibility of spreading tumor cells
to the surrounding tissue when the laparoscopic instrument contacts
the tumor. Recent research presented at various national and international
conferences by experienced laparoscopic surgeons indicates that
laparoscopic surgery for colorectal cancer appears to be safe in
expert hands.
The stomach is very accessible by the laparoscope. Repair of a
perforated (ruptured) or bleeding peptic ulcer as well as removal
of some stomach tumors can be performed laparoscopically. Another
procedure that has received a lot of media attention is laparoscopic
surgery for obesity or bariatric surgery, an operation designed
to enable weight reduction. (see below).
Gallbladder surgery is one of the most common operations performed
in the United States, and lends itself well to the laparoscopic
approach. The advent of laparoscopic gallbladder surgery has benefited
many patients tremendously. In addition to not having to endure
a cosmetically displeasing scar, patients can be quickly discharged
from the hospital and return to their normal lifestyle within several
days. This is in contrast to twenty to thirty years ago, when gallbladder
surgery by the traditional open incision method routinely resulted
in a 5 to 7 day hospital stay followed by several additional weeks
of recovery time.
For conditions of the small intestine, laparoscopic surgery may
be performed to repair hernias, perforations (ruptures of the wall),
and remove short segments of the intestine that contain tumors
or focal areas of active inflammatory bowel disease. A hernia is
a weakness in the muscle wall through which a portion of the small
intestine can be trapped, causing pain and reducing the blood supply
to the trapped tissue. Laparoscopic surgery of hernias provides
the surgeon the opportunity to repair the weak muscle wall so the
tissue cannot be trapped and allows earlier return to normal activities.
Infections as can occur at the site of a ruptured diverticulum,
or focal areas of inflammation as in Crohn’s disease can
be treated laparoscopically.
The liver is a vascular (many blood vessels) organ that can bleed
easily if cut, and until recently was not accessed laparoscopically.
Indications for laparoscopic intervention of the liver include
drainage of cysts, abscesses, and biopsies of growths. Ablation
(destruction by laser or chemical means) of some liver tumors can
be performed laparoscopically. In recent years, skilled laparoscopic
liver surgeons have performed segmental (partial) resections of
the liver as well.
Laparoscopic surgery involving the pancreas is usually a “staging
laparoscopy” when there is concern for a cancer or benign
(non-cancerous) tumor. During this procedure, the surgeon examines
the entire abdomen for signs of tumor spread beyond the pancreas.
Pancreatic tumors are often very tiny and may not be detected by
x-rays. If a pancreatic tumor has spread far from the site of origin,
surgical resection of the primary tumor cannot be done. In learning
this information during the staging process, the patient is saved
from undergoing a more extensive operation.
What is anti-reflux surgery?
One of the most important options for certain patients with chronic
and severe gastroesophageal reflux disease is anti-reflux surgery.
In normal individuals, reflux of acid from the stomach up into
the esophagus is prevented by a barrier created by a ring of muscle
in the lower esophagus called the lower esophageal sphincter (LES).
If the LES becomes weak, free reflux of acid can occur, resulting
in inflammation and ulcerations in the esophagus. Chronic reflux
may be associated with development of Barrett’s esophagus,
a condition that has a small but real risk of esophageal cancer.
Laparoscopic surgery can effectively reestablish this barrier in
carefully selected individuals, resulting in control of symptoms
long-term (in some studies, reported as high as 90%) and avoiding
the need for chronic acid suppression medications. This operation,
referred to as “fundoplication”, consists of wrapping
the upper part of the stomach around the lower end of the esophagus.
Prior to the development of proton pump inhibitors, the most common
indication for anti-reflux surgery was the inability to control
GERD on medical therapy. However, this is rarely the case now with
the use of proton pump inhibitors or high-dose H2 receptor antagonists.
On the other hand, these drugs are expensive and generally require
at least daily dosing for symptom control. Other indications for
anti-reflux surgery include difficult to manage strictures, rare
non-healing ulcers, severe bleeding from esophagitis and aspiration
symptoms. The presence of Barrett’s esophagus alone is not
an indication for anti-reflux surgery. Neither surgical nor medical
series have consistently shown the regression or resolution of
Barrett’s esophagus with effective acid suppression.
The menu for successful anti-reflux surgery is both simple and
complex. The primary criteria are the right surgeon and the right
patient. The surgeon should be experienced and skillful. The diagnosis
of GERD must be well established prior to referral for surgery.
All patients require a comprehensive evaluation of gastroesophageal
function prior to operation. The minimal evaluation should include
upper GI endoscopy, esophageal manometry, primarily to identify
a weak esophageal pump and exclude achalasia or scleroderma, and
24-hour pH monitoring, especially in patients without esophagitis,
selected patients may also require gastric emptying studies, if
there are symptoms of nausea, vomiting, or bloating.
In summary, laparoscopic intervention may be an option in a wide
variety of digestive disorders. At present, laparoscopic gallbladder
surgery is readily available in most community hospitals. Some
surgeries may require the skill of a surgeon who has completed
advanced laparoscopy training, therefore, an understanding of a
surgeons training and experience is recommended prior to the procedure.
If at any time during a laparoscopic procedure the surgeon feels
it important to view the entire abdomen they could remove the laparoscope
and revert (change) to an open procedure. Obviously, this would
only be done in the interest of patient safety and trying to assure
the best outcome. You should consult with your doctor whether some
type of laparoscopic surgery is most suitable for your needs.
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