Why Can’t My Surgery Be Laparoscopic?

One of the clever advertising campaigns at a hospital I trained in featured an open pack of lifesavers on a billboard. The tag line was “have surgery through an incision this big.” There are some key factors you should know about how a laparoscopic surgery is carried out, the risks associated, and why sometimes an open surgery might still be necessary.

Laparoscopic surgery has evolved tremendously because of the technology available and the number of surgeons comfortable with the techniques. The basic components remain the same from when it was first adopted in the 1980s. The patient goes to sleep under general anesthesia. Their belly is filled with carbon dioxide to create space in which the surgeon can operate. Small incisions about the size of the tip of your thumb are made. Special holders called trocars are placed through the incisions that hold long, straight instruments in place as the surgeon does the operation. If an organ like the gall bladder or appendix is to be taken out it is removed through one of these trocars using a specialized plastic bag. The instruments are removed, the gas is allowed to leave the belly, then the incisions are closed and the patient wakes up in the recovery room.

Ideally all surgery would go that smoothly. Sometimes the conditions are not ideal for long, straight instruments. My instruments have such a limited range of motion I tell my patients it’s like I am operating with chopsticks. My camera can also be a limiting factor. The lens can be as big as a dime and gives me a magnified picture of where I am working. It, too, is mounted on a long straight tube so only its very tiny end is angled. If I get to a tight corner I may not be able to see or safely perform the critical portion of the operation.

Surgery is always tailored to the patient, their anatomy, their medical conditions. Some patients have heart or lung conditions that make general anesthesia unsafe. Many have had prior surgeries so there is a lot of scar tissue that puts them at risk for unintentional injury. For example, the appendix might be so friable or the gall bladder so inflamed that the laparoscopic equipment is too rough and would cause more harm to those tissues no matter how careful the surgeon is.

At the end of the day the best surgery is the one the safest one for the patient. While I would love to tell my patients their incisions will be very small, their recovery quick and pain free, the reality is that sometimes an open surgery might be their best options.