Improving Minimal Access Surgery

There has been a quantum jump in the application of laparoscopic surgery to include diverse therapeutic surgical procedures

Dr Pradeep Chowbey

Laparoscopy today is firmly established in the armamentarium of surgeons worldwide. Laparoscopic or endoscopic surgery is essentially performed by tiny incisions of around five to ten mm to introduce a camera and small surgical instruments into the body.

Over the years, there has been a quantum jump in the application of laparoscopic surgery to include diverse therapeutic surgical procedures.

Laparoscopy in Hernia

Endoscopic hernia repair, initially promulgated enthusiastically by a small group of surgeons, has established itself as a widely performed and extremely beneficial procedure. Laparoscopic repair can be performed for most hernias today. It is commonly performed for groin hernias, ventral hernias and diaphragmatic hernias.

Various innovations in laparoscopic hernia surgery include improved prosthetic meshes, better biomaterials and newer fixation devices:

• Newer light-weight meshes provide better patient comfort and reduction of chronic pain following groin hernia surgery.
• High generation meshes provide better tissue incorporation as well as reduced adhesion to the intestines, augmenting the safety of the procedure.
• Penetrating metallic fixation device (tacks) facilitate easier and faster application, along with permanent mesh fixation.
• Adhesive glue available in spray form, made from natural products, is a promising new product for sticking the mesh. It is expected to further reduce postoperative pain.
• Special meshes of suitable biomaterial and beautifully tailored to the shape of the hiatus are now available for repair of diaphragmatic hernias.
• Breakthrough improvements in cameras, imaging technology and magnification allow excellent exposure to perform a more delicate and precise dissection.

When it comes to laparoscopy vis-à-vis normal surgery, it scores in many areas:

• Smaller incisions (five to ten mm), less pain and early recovery.
• Tension-free mesh reinforcement of the hernia defect.
• Size of mesh used is much larger than size of hernia defect, all potential sites of hernia formation are reinforced.
• Low possibility of developing a hernia again in the future.
• Right and left side groin hernias can be repaired at the same time.
• Normal anatomy is not disturbed.
• Lower risk of damage to the male genitalia.
• The procedure is technically easier and better in obese patients.
• Very low rates of the mesh getting infected.
• Very low complication rate.
• Feasible in most large, irreducible, recurrent or complex hernias.

Innovations in technique and product design will continue to spur advances in laparoscopic hernia surgery and improve overall outcomes. The advent of robotic surgery is a step ahead which would enhance the feasibility and results of this procedure.

In Bariatrics

Today, obesity is a major public health problem, which has reached epidemic proportions. India alone accounts for 25 million people suffering from obesity with five million suffering from morbid obesity. All this simply means rise in popularity of bariatric surgery. Medical treatment for this disease includes dietary manipulation, behavior modification and medications, but with only limited long-term success. The only time-tested method which has yielded results is bariatric surgery. The advent of laparoscopy has brought about a revolution in bariatric surgery bringing about reduced pain, reduced complication rates and improved outcome.

Laparoscopic bariatric procedures rely on two primary mechanisms to promote weight loss. First is restrictive procedures that enable limited food intake by reducing the size of the stomach. Restrictive procedures include gastric banding and sleeve gastrectomy.

The second one is mal-absorptive procedures by which the surgeon reduces the body's ability to absorb calories from food by directing food past a large part of the stomach and a portion of the small intestine. Advantages of restrictive procedures include reversibility, minimal impact on the anatomy, a shorter recovery period and allows normal digestion and absorption of food.

Amongst malabsorptive procedures these, gastric bypass (GBP) is the most widely performed and has been called the gold standard procedure. Prime advantages include sustained and substantial weight loss. Almost 70 per cent loss in excess weight is seen in one year post surgery. There is also a significant improvement in co-morbidities including diabetes. Laparoscopic bariatric surgery is therefore, the most effective means to achieve significant, sustained weight loss, improve quality of life and reduce obesity associated morbidity and mortality.

When it comes to the future, gastric pacemaker is an experimental but promising stomach stimulation device which can potentially improve glucose levels and induce weight loss in obese patients with diabetes.

Thoracoscopic Surgery

Thoracoscopy literally means visualising the thoracic cavity using an endoscope. It is used for diagnostic as well as for treatment purposes. The minimal access approach to the chest has been a major advancement for treatment of patients with chest ailments. An endoscope is an illuminated optic instrument that is inserted through a small cut. This procedure can be done under general anaesthesia as well as local anaesthesia. Hence, the procedure can be performed on patients who are critically ill and cannot be administered general anaesthesia.

Thoracoscopy is performed on patient who are subjected to:

• Pleural effusion.
• Pleural pathology requiring biopsy.
• Spontaneous pneumothorax.
• Empyema.
• Large emphysematous bullae.
• Lung collapse requiring pleurodesis.
• Cervical sympathectomy for hyperhidrosis.
• Lung disease requiring lung biopsy.
• Thymectomy for thymomas and hyasthemia gravis.

Apart from being minimally invasive, the prime advantage about laparoscopy includes lesser postoperative pain, fewer postoperative complications, shorter hospital stay, cost effective and importantly better cosmetic appearance.

The writer is Chairman Minimal Access, Metabolic & Bariatric Surgery Centre Sir Ganga Ram Hospital New Delhi
E-mail: chowbey1@vsnl.com