Through the keyhole: laparoscopic surgery

Authors: Ajay Belgaumkar, Dominic Coull, RI Swift, PR Hurley 

Publication date:  29 Sep 2007


Ajay Belgaumkar , Dominic Coull, and colleagues explain how surgical trainees can develop skills

Training in laparoscopic techniques is vital for aspiring surgeons. The advantages of laparoscopic surgery include a reduction in tissue trauma, leading to less postoperative pain, faster recovery, and improved cosmetic result (box 1). Minimal access surgery has been applied to most surgical specialties, including cardiothoracic, orthopaedic and ear, nose and throat surgery. There is an expanding evidence base for advantages over open surgery, and increasing demand from patients.

Box 1: Advantages and disadvantages of minimal access surgery

Advantages

  • Smaller scars lead to less pain and better cosmetic result

  • Less surgical trauma leads to an attenuated inflammatory response

  • Better view of operative field in some procedures

Disadvantages

  • Expensive equipment

  • Longer procedures

  • Longer learning curve

  • Different type of tactile feedback through the instruments, taking longer to acquire

  • Alternative set of complications

Through the retrospectoscope

Examination of the peritoneal cavity through a small incision in the posterior fornix of the vagina was first performed by a German gynaecologist in 1901. Fibreoptic technology, closed circuit television, and thermocoagulation equipment led to widespread introduction of laparoscopic techniques, including fallopian tube ligation for sterilisation, among gynaecologists through the 1970s.

General surgeons incorporated diagnostic laparoscopy into their practice during the early 1980s, with laparoscopic liver biopsy and cancer staging. The first laparoscopic cholecystectomies were performed by European gynaecologists in the late 1980s. The technique was rapidly adopted by general surgeons in the developed world and in 1992 the American National Institute of Health published a consensus statement supporting laparoscopic cholecystectomy as the treatment of choice for symptomatic gallstones. As surgeons have become more proficient in minimally invasive surgery, application of laparoscopic techniques to other gastrointestinal operations has increased.

Computers and animals

Increasingly, clinical skills are being acquired in skills laboratories, rather than on patients. Laparoscopic surgery has been likened to computer games and a number of surgical computer simulations have been developed (MIST VR, LapSim, SINERGIA). Unfortunately, this is expensive and not widely available in UK hospital postgraduate education centres. Video-endoscopic training models are commercially available, allowing trainees to improve motor skills by performing repetitive tasks, and develop hand-eye coordination (www.simulab.com). More complex skills can also be practised, such as laparoscopic suturing and construction of anastomoses.

Courses

Several centres around the United Kingdom provide courses in basic laparoscopic skills aimed at senior SHO/specialty training 2-3 level. These courses give a good introduction and overview, with lectures on equipment, safety, set-up, and an opportunity to practise on laparoscopic simulators (box 2).

Box 2: Possible training curriculum for a general (gastrointestinal) surgical trainee

Specialty training (ST)1/ST2)

  • Understand the basic principles of safe laparoscopy, indications for surgery and specific complications

  • Understand the equipment set-up

  • Placement of peripheral ports

  • Safe placement of first port and creating a pneumoperitoneum

  • Handling bowel with atraumatic graspers

  • Developing hand-eye coordination

  • Practising in learning centres

ST3/ST4

  • Laparoscopic appendicectomy

  • Laparoscopic cholecystectomy

  • Laparoscopic hernia repair

ST5/6

  • More advanced laparoscopic assisted procedures

  • Upper GI: Nissen's fundoplication, gastrectomy, oesophagectomy, splenectomy

  • Laparoscopy for the acute abdomen, for example, perforated peptic ulcer repair

  • Intracorporeal suturing and anastomoses

  • Lower GI: right hemicolectomy, sigmoid colectomy, total mesorectal excision, abdominoperineal excision of rectum, restorative proctocolectomy

Beyond

  • Advanced laparoscopic procedures

  • Vascular: laparoscopic aorto-iliac bypass, laparoscopic abdominal aortic aneurysm repair

  • Urology: laparoscopic radical cystectomy, prostatectomy, nephrectomy, stone retrieval, pyeloplasty

  • Upper GI: laparoscopic gastrectomy, liver resection, common bile duct exploration

  • Lower GI: laparoscopic anterior resection, restorative proctocolectomy with ileoanal pouch

For advanced trainees, live animal operating, usually on pigs, is available in various surgical training centres around Europe (but not within the UK). These courses provide opportunities for interactive training with experts in the field (European Institute of TeleSurgery, Strasbourg; European Surgical Institute, Hamburg).

There is no substitute for one to one training in the operating theatre with an experienced laparoscopic surgeon and this remains the mainstay of all surgical training, including laparoscopy.

Box 3: Being a laparoscopic colorectal trainee

The laparoscopic colorectal fellowship is focused solely on becoming competent at laparoscopic colorectal surgery as well as cholecystectomy and totally extraperitoneal (TEP) hernia repairs. There is no involvement in ward rounds or the on-call rota. There are three full days of laparoscopic colorectal surgery lists each week where the trainee participates in procedures such as right hemicolectomies, sigmoid colectomies, anterior resections of the rectum, abdominoperineal resection of the rectum, and restorative proctocolectomy. Trainees learn the importance of case selection and not to take on hazardous cases, such as diverticular disease and very obese patients, at an early stage. The remaining sessions are spent performing colonoscopy, or the laparoscopic fellow is welcomed into other consultants' theatre lists to perform laparoscopic cholecystectomies and totally extraperitoneal hernia repairs. An average week would involve performing three laparoscopically assisted colorectal resections, two laparoscopic cholecystectomies, and two totally extraperitoneal (TEP) hernia repairs.

The future

Laparoscopic approaches are increasingly being applied to many abdominal surgical procedures. Demand for consultant gastrointestinal surgeons with laparoscopic skills is high. Laparoscopic resectional surgery is rapidly becoming the treatment of choice for colorectal cancer and demand for antireflux and bariatric surgery is increasing. It is difficult for trainees to acquire sufficient surgical experience and in future, trainees must be proactive in ensuring they also acquire laparoscopic skills.

FURTHER INFORMATION

  • www.websurg.com—a comprehensive video library of laparoscopic procedures, with links to relevant courses and didactic teaching materials

  • www.alsgbi.org—the website of the Association of Laparoscopic Surgeons of Great Britain and Ireland, with links to UK centres of training, recent guidelines and details of relevant national meetings

  • www.SAGES.org—The Society of American Gastrointestinal and Endoscopic Surgeons, with the latest consensus policy documents and links to worldwide laparoscopic training centres

Ajay Belgaumkar SpR general surgery  Ajay.Belgaumkar@mayday.nhs.uk  South West Thames Rotation
Dominic Coull SpR general surgery  Frimley Park Hospital
RI Swift consultant colorectal surgeon  Mayday University Hospital
PR Hurley consultant upper gastrointestinal surgeon  Mayday University Hospital

Cite this as BMJ Careers ; doi: