Minimal Access Surgery
Minimal access / laparoscopic / keyhole surgery is accomplished by performing procedures through multiple small incisions (5-12mm in size) rather than one large incision. Special tubes called “access ports” are then placed 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 a laparoscopic cholecystectomy was first performed to remove a diseased gallbladder. The technique was initially met with skepticism 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 procedures 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.
- Less 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 my main areas of interest and expertise. My interest began as a surgical trainee at Tygerberg Hospital. After qualifying as a surgeon I attended numerous local and international training courses and workshops and honed my skills as a consultant surgeon at Tygerberg where I was also in charge of the minimal access bariatric (weight loss) surgery programme. My enthusiasm for minimal access surgery was recognized in 2011 when I was awarded the SASES / Karl Storz Travelling Fellowship. In 2012 I spent 2 months in Straubing, Germany under the tutelage of prof Robert Obermaier and Dr Markus Walz. Here I gained valuable exposure to ‘state of the art’ minimal access procedures which I have embraced and incorporated into my own practice.
I can now offer the following laparoscopic/minimal access procedures:
- Cholecystectomy
- Bile duct exploration
- Choledocho-duodenostomy (anastomosis of bile duct to duodenum)
- Anti-reflux surgery (Nissen, Dor, Toupet fundoplications)
- Repair of hiatal hernia
- Gastro-jejenostomy (anastomosis of stomach to small bowel)
- Adrenelectomy
- Splenectomy
- 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
- Abdomino-perineal resection (resection of the rectum and anus with permanent stoma)
- Stoma formation
- Rectopexy (repair of rectal prolapse)
- Inguinal hernia repair
- 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 surgical technique 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 anesthetic and theatre time.
Some important issues regarding minimal access procedures:
- These procedures require more specialized equipment than open procedures and are 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 a minimally invasive procedure will be offered to you if appropriate.
- Once it is decided that you will have a laparoscopic / minimal access procedure 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 work up.
