Minimal access surgery

What is minimal access surgery?

Minimal access / laparoscopic / keyhole surgery involves the surgeon making multiple small incisions (5-12mm in size) rather than one large incision. Dr Cooper will place special tubes called "access ports" into the abdominal cavity, and carbon dioxide gas is used to inflate the abdomen and create a space to work in. A special telescope or lens is then introduced which transmits a magnified image from inside the abdominal cavity onto a monitor inside the theatre. While observing the monitor, the surgeon then performs the necessary procedure using a variety of specialized instruments that are passed through the ports as and when needed.

The introduction of minimal access surgery began in 1985 when laparoscopic cholecystectomy was first performed to remove a diseased gallbladder. The technique was initially met with scepticism and resistance because of the degree of difficulty, longer learning curves, higher initial procedural costs and loss of tactile sensation. When minimal access principles were applied to cancer procedures, there were also initial concerns regarding the adequacy of specimen resections and the theoretical risk of port site cancer recurrences. However, those initial misgivings have now all fallen by the wayside. Numerous randomized controlled trials have validated the effectiveness and safety of minimal access surgery, and the advantages are well documented:

• Less intra-operative fluid losses.
• Less post-operative pain.
• Less chance of wound sepsis
• Faster return of bowel function.
• Faster recovery and decreased length of hospital stay.
• Fewer adhesions and less chance of adhesive small bowel obstruction
• Less incisional hernias
• Better cosmetic results
• Higher initial procedural cost is offset by shorter hospital stay and less short and long term complications

Minimal access surgery is one of Dr Charl Cooper’s main areas of interest and expertise. His interest began as a surgical trainee at Tygerberg Hospital. After qualifying as a surgeon, he attended numerous local and international training courses and workshops and honed his skills as a consultant surgeon at Tygerberg where he was also in charge of the minimal access bariatric surgery (also known as weight loss surgery) programme. Dr Cooper’s enthusiasm for minimal access surgery was recognized in 2011 when he was awarded the SASES / Karl Storz Travelling Fellowship. In 2012 he spent 2 months in Straubing, Germany under the tutelage of prof Robert Obermaier and Dr Markus Walz. Here Dr Charl Cooper gained valuable exposure to ‘state of the art’ minimal access procedures which he has embraced and incorporated into his own practice.

Dr Charl Cooper can now offer the following laparoscopic/minimal access procedures:

• Cholecystectomy
• Bile duct exploration
• Choledocho-duodenostomy (anastomosis of the bile duct to the duodenum)
• Roux en Y choledocho-jejenostomy (anastomosis of the bile duct to the jejunum)
• Anti-reflux surgery (Nissen, Dor, Toupet fundoplications)
• Repair of hiatal hernia
• Gastro-jejunostomy (anastomosis of stomach to small bowel)
• Total / Subtotal gastrectomy with Billroth I / Roux en Y anastomosis
• Adrenalectomy
• Splenectomy
• Bariatric surgery: Sleeve gastrectomy and Roux en Y Gastric Bypass
• Heller’s myotomy for the treatment of Achalasia
• Distal pancreatectomy with splenic resection or spleen preserving
• Cyst-gastrostomy or cyst-enterostomy (for treatment of pancreatic pseudocysts)
• Resection of small bowel tumours
• Appendicectomy
• Total colectomy
• Segmental colectomy (right, transverse, left, sigmoidectomy)
• Rectal resection
• Abdominoperineal resection (resection of the rectum and anus with a permanent stoma)
• Stoma formation
• Rectopexy (repair of rectal prolapse)
• Inguinal hernia repair (TEP or TAPP)
• Incisional hernia repair
• Transanal endoscopic microsurgery (TEM- resection of small/early rectal lesions via the anus)
• Single-incision laparoscopic cholecystectomy (see below)

Single-incision laparoscopic surgery (SILS):

SILS is a relatively new minimal access surgery where the whole procedure is performed using a single highly modified port placed via the umbilicus. The advantage is that scarring is virtually eliminated because the port is placed in the umbilicus. It is, however, technically much more challenging to perform and does require longer anaesthetic and theatre time.

Some important issues regarding minimal access procedures:

• Minimal access surgery requires more specialized equipment than open procedures and is, therefore, more expensive. Medical schemes have different options with different benefits. Depending on the scheme and option that you have chosen, there may be co-payments required for a procedure to be done in a minimally invasive manner.
• Not all patients are candidates for minimal access surgery. You will be evaluated, and the option of minimally invasive surgery will be offered to you if appropriate.
• Once it is decided that you will have a laparoscopic/minimal access surgery, there is a > 95% chance that the procedure will be completed laparoscopically. However, it may occasionally be necessary due to technical issues or safety concerns to convert a minimal access procedure to an open one.
• Minimal access procedures have many advantages but are by no means free of complications. The potential complications relative to your procedure will be discussed with you in detail during your pre-operative workup.