KEY FACTS - A GUIDE TO KEYHOLE SURGERY

This guide has been written to provide general information about keyhole surgery. If about to have an operation which may involve keyhole surgery, you can use this guide to discuss the operation with your GP or consultant. It is important to ask the right questions, as this will help you make the best decision about the kind of surgery you want and to understand what is involved in the operation.

Introduction

In traditional or "open" surgery, the surgeon makes a cut in the body to expose the organs or part of the body that he is operating on. With keyhole surgery the operation is carried out inside the body. Only a small incision is made into which a special tube or channel, known as a port, is inserted. It is through these that the special surgical instruments used in keyhole surgery are passed. In some operations it is on necessary to use one incision, but in others it may be necessary to use several incisions. Because the incisions are so small, normally around 10mm, there is minimal scarring, less pain, and faster recovery than with open surgery.

The surgeon is able to see inside the body using a special viewing instrument called an endoscope. Endoscopes have a powerful light source and can be used as a form of telescope, or connected to a highly specialised miniature video camera which projects a clear image from inside the body onto a television screen. The endoscope can be moved about, so that the surgeon can see the area of the body on which he is working.

A range of special, miniature surgical instruments can be inserted either through the same port as the endoscope, or through separate ports, depending on the requirements of the operation. The surgeon controls these surgical instruments from outside the patient's body to carry out the surgical operation from within.

Different types of endoscopes are used for different areas of the body. Some are rigid and some flexible. Each specialist type of endoscope has its own name (for example, the endoscope used in abdominal surgery is called a laparoscope). As keyhole surgery is most commonly carried out in the abdominal area, operations performed in this region of the body are frequently referred to as laparoscopic surgery.

Keyhole surgery has been called the greatest surgical advance since anaesthesia. The result of keyhole surgery is to make the procedure less traumatic for patients as a result of:

• less pain
• faster recovery
• minimal scarring
• a quicker return to normal activity
• a reduced risk of infection

Safety In Keyhole Surgery

Keyhole surgery is a major modern scientific achievement. It uses the most advanced cameras and surgical instruments, many of which are now disposable. As technology is advancing all the time, keyhole surgery is becoming applicable to many different areas of surgery.

Because keyhole surgery requires a different set of skills from traditional surgery, training centres have been set up and are being run by the Royal College of Surgeons. The RCS has also introduced guidelines for the additional training required for keyhole surgery. Surgeons begin their training in keyhole surgery using simulators. After the initial training, surgeons who are new to the technique work alongside an experienced surgeon to perfect the new procedure - as they do when learning any type of surgery.

There are certain operations which are now actually safer if they are done using keyhole surgery (for example, removal of the gall bladder, known as cholecystectomy). Apart from endoscopy used for examining inside the body so that doctors can diagnose illnesses or defects, there are a growing number of operations that are now regularly carried out using keyhole surgery. Some of the more common of these operations are explained in more detail in the series of accompanying guides.

Gall Bladder Removal (Cholecystectomy)

When gall stones develop they can cause pain. The treatment for this is to remove the gall bladder. The body functions just as well without the gall bladder. Ninety percent of cholecystectomies are now carried out laparoscopically, using keyhole surgery. Instead of one major incision the surgeon works through three small incisions in the abdomen and removes the gall bladder through one of them. The operation usually requires an overnight stay in hospital but is sometimes performed in day surgery. The patient can be back at work within 7 to 10 days.

Hernia Repair

A hernia is a protrusion of intestine or fat through a weakness in the muscles of the abdominal wall. This causes a bulge and often leads to pain. if untreated some hernias can lead to a blockage in the intestine which need emergency surgery. Repairing a hernia is a routine operation and can be done very successfully laparoscopically (by keyhole surgery) with minimal scarring, less pain and quick recovery.

Hysterectomy

Hysterectomy (removal of the uterus) can, in some cases, be carried out using keyhole surgery. The uterus can be detached from the surrounding tissue through three small incisions in the abdomen. The uterus is then removed through the vagina, thus avoiding the need to make a large incision. Some surgeons call this technique Laparoscopically Assisted Vaginal Hysterectomy (LAVH).

The advantages of LAVH are less pain, a shorter recovery time, faster return to normal activity, as well as much less scarring. This operation usually involves a two to three day stay in hospital and most people return to full activity within three weeks. These days most gynaecological problems are diagnosed using a laparoscope and many operations are carried of using keyhole surgery, including; some treatments for infertility, the removal of ovarian cysts and emergencies such as treating an ectopic pregnancy.

Appendicectomy

An appendicectomy (removal of the appendix) can be performed using keyhole surgery. A laparoscope may also be of great use in the diagnosis of appendicitis.

Hiatus Hemia

A hiatus hernia allows the acid juices in the stomach to pass up into the gullet (oesophagus). This results in a number of symptoms that are usually treatable with drugs. For some people the symptoms are so severe, or the prospect of being on long-term drug therapy so daunting, that surgery is the best solution. Hiatus hernias are not usually repaired using open surgery because of the extent of the chest incision. However they can now be repaired very successfully by keyhole surgery.

Leg Ulcers

When veins in the legs become old they move the blood around the leg less efficiently. This causes the surrounding tissue to become damaged and ulcers can develop which do not heal. There is a simple keyhole operation available that can seal off the veins that are causing the damage and help the ulcer to heal.

Making A Decision

If about to have keyhole surgery or interested in the technique, start by discussing it with your GP or specialist. Asking your GP or specialist the, following questions may help to find out more:

• can my operation be carried out by keyhole surgery?
• would it be better for me to have my operation laparoscopically or using open surgery? - what are the known complications or risks associated with both keyhole and open surgery?
• how many cases of this type of procedure has my surgeon carried out, and with what success?
• do you have any more written information about this procedure?

The Keyhole Opration

Many hospitals now have day surgery units. Depending on the operation, you may be sent to one of these. This means entering and leaving hospital in one day. Whether arriving for surgery the night before or on the morning of the operation, you will be told by the nurses when to stop eating and drinking. This is usually 6 to 12 hours before the operation.

The operating procedure varies according to the condition being treated, but generally speaking the surgeon makes three to four small incisions through which he will put the endoscope and surgical instruments.

In order to carry out operations in the abdominal area, the surgeon needs to create space around the internal organs. To this carbon dioxide gas can be introduced into the abdomen which inflates it, giving the surgeon a clear view when he is operating. Patients often notice an ache in their shoulder and upper chest area after abdominal surgery. This is caused by the gas which has been used to inflate the abdomen, and soon passes.

Occasionally, during an operation, the surgeon may discover an additional problem which complicates the procedure. In this situation, the surgeon will need to make a number of decisions, which might include converting from keyhole to open surgery. Ask your surgeon to explain the surgical procedure and any possible complications before your operation.

After the Operation

If possible, find somebody to look after you for a day or two after you come home.

Pain

The scarring from keyhole surgery is minimal, so the wounds should heal quickly. If there is any discomfort, it is possible to take pain-killers for the first day or two after the operation. If the pain becomes more severe, then contact the surgical unit. It is not unusual to have swelling or bruising around the wound, but an unpleasant discharge or infection is noticed, then contact your GP.

Care Of The Wound

It is safe to shower or wash the wound after the first day, but do not soak in the bath for the first few days. Some stitches dissolve after about a week to ten days, but non-absorbable stitches need to be removed about a week after the operation. It is not unusual to have a watery discharge from the wound for a week or two. This should be treated by applying a gauze dressing.

Eating And Drinking

Depending on the type of operation it is usually possible to resume normal eating and drinking within 24 hours of the operation. However, if nausea is felt after the anaesthetic, do not force yourself to eat or drink until you feel ready.

Work

In general, people who have keyhole surgery are able to go back to work quicker than those who undergo traditional surgery. Depending on the type of operation it may be possible to resume work within the week. If your job involves heavy manual work then it may be longer before you are ready to work. Your surgeon will advise you on this.

Driving

As with any procedure which involves a general anaesthetic, you must not drive for 24 hours and should be accompanied home by a responsible adult. Your doctor will advise you how long to wait, but as a general rule if you are comfortable stamping your feet, you are ready to drive.

Returning To Normal Activities

You will probably find it too uncomfortable to do any heavy work or exercise (e.g. moving furniture, hoovering, carrying heavy shopping, aerobics, football, etc.) for a while. Recovery time depends on the individual, but if worried, consult your doctor.

Sex

After most laparoscopic surgery, the wound will not be harmed or weakened, so if it is comfortable there should be no problems. However, after an LAVH, the scar at the top of the vagina takes some time to heal and it is generally advisable to avoid intercourse for about four weeks. Again, your doctor will be able to advise you.