Editorials
Volume 165 - Issue 7

Laparoscopic surgery: time for re-evaluation

Author:  William R Johnson

Med J Aust 1996; 165 (7): 355.
Published online: 7 October 1996
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Laparoscopic surgery: time for re-evaluation

In the era of evidence-based medicine, the time has come for rigorous evaluation of laparoscopic surgery

MJA 1996; 165: 355

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The laparoscopic surgical revolution in Australia began in 1989. The aggressive marketing of innovative technology with advanced optics, and a receptive surgical fraternity, ensured that virtually no area of surgery was immune from the laparoscopic onslaught. It was predicted that 80 percent of surgery would be performed laparoscopically, a claim that proved to be optimistic. 1 An eager media reported laparoscopic surgery as quick, painless and safe. Patients asked "Am I having the easy or hard operation?", not "Am I having the safe operation?". With the enthusiastic implementation of the laparoscopic technique by surgeons, reports on personal and institutional series soon appeared, with the superiority of the new technique over open surgery held to be self-evident. The more cautious called for prospective randomised controlled trials comparing open and laparoscopic procedures, but these proved difficult to establish. 1-3

It has been suggested that laparoscopic surgery may be inherently more dangerous than open surgery. 3 It carries the risks of open surgery together with the risks specific to the technique. Injuries to vascular structures and the intestine resulting from the introduction of needles and trochars or from electrical arcing of instruments, while uncommon, are not rare, 4 and CO 2 gas embolus is unique to laparoscopy. Open cannula placement, rather than the blind stab to produce a pneumoperitoneum, 5 and the introduction of trochars under the guidance of various imaging methods, may reduce, but will not eliminate, the risk of injury.

The rate of bile duct injury of 0.5% reported by the Health Department of Western Australia audit (1988-1993) of laparoscopic cholecystectomy was two to three times higher than that for open surgery. 6 While this may be dismissed as representing the "learning curve", in such a common operation it cannot be ignored. There have been delays in the diagnosis of both bile duct and intestinal injuries. 4 These injuries can be explained, in part, by the limited field of view, lack of depth perception and off-camera incidents (where an instrument not under vision can cause unrecognised damage) that are characteristic of laparoscopic imaging systems. The delays indicate the need for a high index of suspicion in the postoperative phase and the realisation that repeat laparoscopy to identify complications may be inadequate. 4

In 1996 it is possible to say that some laparoscopic procedures, such as cholecystectomy, have lived up to expectations, in that most patients can be offered a procedure which is safe and allows early discharge and return to normal activity. Reports on laparoscopic fundoplication for the treatment of oesophageal reflux look promising, as the early results appear similar to those achieved by open surgery, but the results of long term studies with adequate numbers are required. Both these procedures reproduce, laparoscopically, the successful open techniques. 7 The results of other procedures, such as laparoscopic inguinal hernia repair, have been mixed. 8 There is still debate about the place of laparoscopic hernia repair, but it may be more expensive than open surgery.

The role of laparoscopic surgery in malignancy has yet to be established. Experience with cancer of the gallbladder and the ovary has led to the recommendation that, if they are recognised, open surgery is the appropriate manage ment. 9-11 Early enthusiasm for laparoscopic colon and rectal surgery for malignancy has been tempered by reports of port-site recurrence 12 and early dissemination in apparently curative resections of colon and rectal cancer. 13 The role of laparoscopic surgery in colon and rectal malignancy remains to be defined, but the warning is clear.

The importance of trials is demonstrated by the results of a recently reported prospective randomised trial that compared laparoscopic with small-incision cholecystectomy. 14 The strengths of this study were that an adequate number of patients were enrolled, both the patients and their carers were blinded to the operative procedure, and three weeks after the operation the patients were reviewed by a research nurse similarly blinded to the type of operation. No indication of likely length of convalescence was given to patients in either group, and their general practitioners were specifically requested not to take any steps to influence the time they took to return to work. Patients were encouraged to begin full activity as soon as they felt fit enough. (These steps help to remove or reduce the influence of observer bias on patient outcome.) The study showed no difference between the two groups in time to first meal, complications, time to discharge and time to return to work. 14 This finding does not diminish the importance of laparoscopic cholecystectomy and is a victory for minimal-access surgery, whether laparoscopic or open. One benefit of this study may be to encourage early conversion from laparoscopic to open cholecystectomy when difficulties are encountered, in the realisation that the patient will not be significantly dis advantaged.

There is, however, a lack of good quality prospective randomised trials. 3 The challenge ahead, as laparoscopic surgery advances, is to evaluate critically the advantages compared with open surgery, and, where appropriate, when compared with minimal-access open surgery. In this context, historical controls are of limited value, as, historically, incision size was not considered to be a critical factor in postoperative morbidity and small-incision surgery was not generally done. 14 Personal audit, which is now a requirement of the Royal Australasian College of Surgeons for recertification, is one way. However, in personal audits problems can be ignored or forgotten. 3

Clinicians must have an accurate picture of trends as new procedures develop so that they are informed and can, in turn, accurately inform their patients. Cost must also be a factor in any study, both in terms of instruments, which, despite their technological sophistication, are increasingly being manufactured as disposable, and operating time, which has a cost. If outcomes are similar, the purchaser (i.e., the patient) will choose the cheapest procedure. The College of Surgeons must become involved in multicentre trials to answer the questions, so that the profession possesses the information to lead the debate rather than have it run by governments or health funds. The prospective randomised trial remains the best method of comparison. Trials such as the proposed Royal Adelaide Multicentre Study comparing open and laparoscopic fundoplication, while difficult and expensive, must be supported. 3 Such studies of laparoscopic surgery are of crucial importance to the quality of patient care and outcome. This is patient-centred research worthy of support.

  1. Treacy PJ, Johnson AG. Is the laparoscopic bubble bursting? Lancet 1995; 346 (Suppl): 23.
  2. Watson DI, Johnson AG. Randomized trials for laparoscopic surgery. Aust N Z J Surg 1994; 64: 813-814.
  3. Edis AJ, Sheiner HJ. Laparoscopic surgery: an ethical dilemma. Aust N Z J Surg 1996; 66: 201.
  4. Hayes C, Ambazidis S, Gani JS. Intensive care admissions following laparoscopic surgery: what lessons can be learned. Aust N Z J Surg 1996; 66: 206-209.
  5. McMahon AJ, Baxter JN, O'Dwyer PJ. Preventing complications of laparoscopy. Br J Surg 1993; 80: 1593-1594.
  6. Hockey RL, Thomson N. Laparoscopic cholecystectomy: morbidity and mortality, Western Australia, 1988-1993. Perth: Health Department of Western Australia, 1995.
  7. Jamieson GG. Recent developments in upper gastrointestinal surgery. Aust N Z J Surg 1996; 66: 46-49.
  8. MacIntyre IMC, Miles WFA. Critical appraisal and current position of laparoscopic hernia repair. J R Coll Surg Edinb 1995; 40: 331-336.
  9. Wibbenmeyer LA, Wade TP, Chen RC, et al. Laparoscopic cholecystectomy can disseminate in-situ carcinoma of the gallbladder. J Am Coll Surg 1995; 181: 504-510.
  10. Clair DG, Lautz DB, Brooks DC. Rapid development of umbilical metastases after laparoscopic cholecystectomy for unsuspected gallbladder carcinoma. Surgery 1993; 113: 355-358.
  11. Blanc B, D'Ercole C, Nicoloso E. Laparoscopic management of ovarian cysts: a 78-case national survey. Part 2: follow-up and final treatment. Eur J Obstet Gynecol Reprod Biol 1995; 61: 147-150.
  12. Wexner SD, Cohen SM. Port site metastases after laparoscopic colorectal surgery for cure of malignancy. Br J Surg 1995; 82: 295-298.
  13. Jacquet P, Averbach AM, Jacquet N. Abdominal wall metastasis and peritoneal carcinomatosis after laparoscopic-assisted colectomy for colon cancer. Eur J Surg Oncol 1995; 12: 563-570.
  14. Majeed AW, Troy G, Nicholl JP, et al. Randomised prospective single-blind comparison of laparoscopic versus small-incision cholecystectomy. Lancet 1996; 347: 989-994.

William R Johnson
Senior Surgeon, Alfred Hospital, Melbourne, VIC

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  • William R Johnson