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Laparoscopic surgery--the good, the bad and the ugly.

This year marks the 20th anniversary of the modern era of laparoscopic surgery. It is remarkable that in this short space of time, most abdominal operations can now be performed laparoscopically--often with greater precision than with open surgery--while offering all the advantages of minimal access surgery. The 'bad' aspect of laparoscopic surgery, at least during its fledgling years, was that the proper acquisition of surgical skills was severely compromised. The learning curve was painful and the proverbial two-edged sword soon reared its ugly head.

This review intends bringing the nonspecialist up to date with the current status of established laparoscopic abdominal operations, highlighting some of the emerging and advanced procedures and providing a glimpse at what the future holds for this fascinating new approach to surgery.

Cholecystectomy

There is general acceptance that laparoscopic removal of the gallbladder is the preferred operation for gallstone disease. The fact that this is perceived to be a lesser operation than open surgery should, however, not be construed as a mandate to relax on indications. The main indication for cholecystectomy remains biliary colic and as a general rule asymptomatic gallstones do not warrant removal of the gallbladder. Bile duct injuries remain the major concern with this operation. Unfortunately, the majority of these injuries still go unrecognised at the time of surgery, and there is often a delay in diagnosis during the postoperative period. Since general practitioners are often the first to see these patients, they should take note of the insidious way in which bile peritonitis may present. Bile does not cause early signs of peritonism. Hence patients are frequently discharged from hospital with a seemingly uncomplicated postoperative course. Typically, patients present with vague abdominal pain and distension, fatigue, nausea, loss of appetite, an ileus, mildly deranged liver function tests and a raised white blood cell count. Prompt referral for further investigations is of paramount importance to avoid the devastating consequences of this complication. It should be emphasised that no cholecystectomy is an easy operation and that it is a more hazardous procedure in elderly males, those who have had previous attacks of acute cholecystitis and those with associated bile duct stones.

Antireflux operations

Riding on the crest of 'key hole surgery', laparoscopic antireflux surgery (LARS) for gastro-oesophageal reflux disease (GORD) has enjoyed a meteoric rise since its introduction in 1990, particularly in Western countries. In South Africa, which must have one of the highest operation rates for GORD, the prohibitive expense of proton pump inhibitors (PPIs) (which do not qualify for chronic illness benefits by medical aids) has driven many patients prematurely into the hands of surgeons, who are mostly called upon to evaluate these patients.

In expert hands a long-term cure is of the order of 75-80%, but troublesome side-effects such as dysphagia and 'gas-related' symptoms occur in about 10% of patients and may be difficult to treat. It should also be noted that improvement of extra-oesophageal symptoms (hoarseness, asthma and chronic cough) is unpredictable when they fail to respond to PPI therapy. Regression of Barrett's mucosa and the reduction in risk for malignancy are also not achieved with antireflux surgery. Patients should be informed about these facts when surgery is offered.

LARS should be regarded as an alternative to PPI therapy in GORD and should only be considered in patients with proven PPI dependency or where medical therapy fails in patients with regurgitation (high-volume reflux).

Heller's myotomy

Laparoscopic Heller's myotomy with a partial fundoplication has become a well-established operation for achalasia. The jury is still out on whether to dilate or to operate as there appears to be no short-term benefit of the one over the other. As a day-case procedure balloon dilatation, which can be done under conscious sedation, remains an attractive first-line treatment but there is some evidence that it is less effective in young patients and that myotomy provides better overall long-term results.

Sympathectomy and adrenalectomy

Although less commonly performed, sympathectomy and adrenalectomy are eminently suitable for the laparoscopic approach and are now the preferred treatment for hyperhydrosis and most adrenal tumours, respectively. However, large adrenal tumours, most of which are malignant, usually require open surgery.

Bariatric operations

Morbid obesity has become enemy number one among lifestyle-related diseases in Western countries, particularly in the USA, and South Africa carries a fair share of this burden. It is universally accepted that dietary measures and medical therapies are ineffective and that bariatric surgery is the only successful method of achieving sufficient weight loss to address the complications of morbid obesity.

The current recommendation for bariatric surgery is a BMI over 40 kg/[m.sup.2]. Three types of laparoscopic bariatric operation are performed today, namely gastric banding for a BMI of 40-50, Roux-en-Y gastric bypass for a BMI of 50-60 (Fig. 1), and a biliary-pancreatic bypass procedure for those with a BMI of more than 60. The cost of these procedures is substantial, particularly when subsequent plastic operations are added to the equation, but proponents argue that this outweighs the cumulative long-term expenses related to the disease. These complex operations, which carry considerable morbidity, should be performed only in specialist units with a multidisciplinary team of accredited endocrinologists, dieticians, psychologists and surgeons.

[FIGURE 1 OMITTED]

Appendicectomy and inguinal hernia repair

There is ongoing debate regarding the role of laparoscopic appendicectomy and hernia repair. While most randomised controlled trials have not demonstrated an appreciable benefit with the laparoscopic approach, subgroups of patients seem to benefit. The current recommendations for laparoscopic appendicectomy are obese patients and young women, while hernia repair should be reserved mainly for recurrent and bilateral hernias.

Colorectal surgery

The development of specialised staple devices has contributed significantly to the development of laparoscopic colorectal operations. Again, randomised trials have not yet shown clear benefits over open operations, particularly from a cost perspective. Currently the laparoscopic approach is most suitable for right and sigmoid colectomy, reversal of a Hartmann's colostomy, raising of a colostomy and repair of a rectal prolapse.

Other advanced laparoscopic operations

Exciting new and advanced operations are currently being developed in the upper gastrointestinal and hepatopancreatobiliary field. Examples are: oesophagectomy, distal pancreatectomy and left lateral segmentectomy of the liver, which are increasingly performed in high-volume specialised units with promising results.

The future

Only time will tell where the phenomenal advances in technology will take the scope of laparoscopic surgery in the future, but there is no question that the remarkable progress witnessed over the last 20 years will continue and that the art of surgery has been changed for ever. Robotic surgery has become a reality with a recent 'transatlantic' cholecystectomy being performed where the surgeon was stationed in France and the patient was being operated on in a hospital in the USA. But, the learning curve for most advanced procedures is long and the current expense of longer theatre time and equipment remains a limiting factor in their wider application outside high-volume specialised centres.

P C BORNMAN, MB ChB, MMed (UOFS), FRCS (Edin), FCS (SA), FRCS (Glasg)

Professor, Department of Surgery, Surgical Gastroenterology, Groote Schuur Hospital and University of Cape Town
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Copyright 2007 Gale, Cengage Learning. All rights reserved.

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Title Annotation:More about ... Update on surgery
Author:Bornman, P.C.
Publication:CME: Your SA Journal of CPD
Geographic Code:1USA
Date:Jul 1, 2007
Words:1174
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