Patient positioning

Minimally invasive surgery – primum non nocere

Laparoscopy as a surgical technique was made popular thanks to pioneers such as Palmer, Frangenheim or Semm. However, let us remember that one of the fathers of laparoscopy was Georg Kelling. It was on his operating table that, over 120 years ago, a dog was placed and operated on using that method[1]. While the first appendectomy was performed laparoscopically more than 40 years ago, that technique is used not just for abdominal surgery today. And this, despite the fact that the pioneer of laparoscopic appendectomy was threatened with the withdrawal of his right to practice the profession[2]. Presently, the development of technology and the constant expansion of qualifications of physicians make it possible for that technique to be used in many fields. Nowadays, no one is surprised that a patient who ends up on the operating table with a lumbar hernia goes home after a few days. Is laparoscopy the future?

Minimally invasive procedures have become routine

Minimally invasive procedures are now routine surgeries with a low risk of complications, and are popular around the world thanks to the patient’s faster recovery. Faster patient recovery means that the hospital can take on more patients. Obviously, this depends on the availability of staff and appropriate medical equipment. Laparoscopic surgery is not just an operating table and a scalpel in the hand of the surgeon. It is primarily a series of tools that allow access to the operated area through several incisions in the patient’s skin. Of course, the equipment in the operating room depends on the type and level of complexity of a given procedure. Minimally invasive procedures still require the involvement of a team of doctors, surgical instrument technicians or nurses.

What is laparoscopy?

As previously mentioned, laparoscopy allows the patient to be operated on without the need to open, e.g. the abdominal cavity. The disruption of the patient’s body on the operating table is reduced to just a few incisions through which the laparoscope is inserted along with other instruments being part of the operating theatre equipment. Nowadays, laparoscopy is used to treat many conditions, e.g.: removal of the gallbladder, removal of the appendix or treatment of obesity. Hernia, prostate or kidney surgery can also be performed laparoscopically[3].

Wyposażenie sali operacyjnej w stół operacyjny

The main advantage of using that minimally invasive method is the shortened recovery time. A patient brought to the operating table and operated on in this way can expect a quicker recovery. Other benefits of using that method in the operating theatre:

  • smaller surgical wound;
  • significantly less pain than with traditional surgery;
  • faster recovery and ability to return to daily activities;
  • small scares after the surgery;
  • lower rate of hospital-acquired infections;
  • economic benefits due to a shorter hospital stay of the patient[4].
Wyposażenie sali operacyjnej

Another advantage of using laparoscopy to treat patients is also the relatively low number of complications. Minor complications are estimated at approximately 1-2 cases per 100 surgeries, and serious complications are only 1 case per 1,000 interventions, which include:

  • organ damage (bowel, bladder),
  • damage of arteries,
  • complications due to the use of carbon dioxide (gas entering veins or arteries),
  • allergic reaction to general anaesthesia,
  • a blood clot (usually deep veins in the legs) which causes pulmonary embolism[5].

Changing the approach to appendectomy

On the example of appendectomy surgery, one can see how the approach to that procedure has changed over the years. Let’s look at how the approach to appendectomy has changed since 2003 – only 38% of all procedures were performed laparoscopically at that time (data from the ACGME system for the United States), it was already 93% in 2018 [6]. (chart below).


Number of laparoscopic appendicectomy procedures in the years 2003-2018 according to data from the ACGME system for the United States.

Significant increase in laparoscopic surgery

The next chart shows the changing trend in surgeries in the years 2003-2018, by several popular techniques[7]. During the period under study, in the surveyed facilities, the number of surgeries increased by as much as 40%. Researchers attribute that increase primarily to the ageing of the population and the reduced length of stay of a patient in the hospital. The result is also influenced by the reduction in the number of deaths due to surgeries and the increased number of outpatient surgeries. At this point, it is important to remember that the growth is also related to the technological advancement. The equipment in the operating theatre has changed dramatically over that period. Today, laparoscopes allow surgeons to see and do more. The manufacturer of medical equipment knows perfectly well which operating table to offer a hospital to facilitate the work of medical staff and patient positioning. Over the years, the approach of surgeons and medical equipment manufacturers has changed, they often cooperate to create solutions dedicated to laparoscopy, inter alia.

A chart showing the change in the trend in the approach to surgery in the years 2003-2018, according to data from the ACGME system for the United States.

Laparoscopy for medical staff training

Although the total number of interventions undertaken by resident medical practitioners has remained constant, their level of education, given the breadth of the spectrum of surgeries performed, has deteriorated. In an extensive study spanning 27 years (again in the US), researchers came to the conclusion that the variety of surgeries is narrowing[8]. Researchers point to the need to be aware of these changes and to guide their students in such a way that they can develop in a broad spectrum of their technical competencies, not only in mainstream, core procedures.

laparoskopia

The state-of-the-art Famed OPTIMA operating table can be lowered extremely low to allow the instruments used for laparoscopic access to be held comfortably, while maintaining a comfortable spinal position. Positioning the table as low as 55 cm of height also makes it possible to operate on patients with morbid obesity.

Can laparoscopy pose a risk?

Often, appendectomy of a patient on the operating table is the foundation for learning about laparoscopic surgery. Researchers note that over a short period of time, the experience of surgical residents has been almost exclusively represented by minimally invasive surgery. Laparoscopy replacing open surgery therefore poses a certain risk. In the study itself, it can be observed that trainee doctors in 2003 had significantly more frequent exposure to open surgery for appendectomy than in the final year of the study. The researchers note that surgical graduates, between whom there is a gap of only 16 years, can have radically different experiences, level of education and practice in the operating theatre itself. They imply major concerns about training in traditional surgical access.

— A recent review of open artery procedures showed a significant decline in the number of procedures performed over the past decade and a half, leading the authors to question whether vascular surgery can remain a relevant discipline in general surgical training [9].

Sources:

[1] The Development of Laparoscopy – A Historical Overview, Front. Surg., 15 December 2021

[2] Tamże.

[3] https://www.medme.pl/choroby/chirurgia-laparoskopowa,59.html

[4] Tamże.

[5] https://www.nhs.uk/conditions/laparoscopy/

[6] St John A, Caturegli I, Kubicki NS, Kavic SM. The Rise of Minimally Invasive Surgery: 16 Year Analysis of the Progressive Replacement of Open Surgery with Laparoscopy. JSLS. 2020 Oct-Dec;24(4):e2020.00076. doi: 10.4293/JSLS.2020.00076. PMID: 33510568; PMCID: PMC7810432.

[7] Tamże.

[8] Cortez AR, Katsaros GD, Dhar VK, et al.. Narrowing of the surgical resident operative experience: a 27 year analysis of national ACGME case logs. Surgery. 2018;164:577–582.

[9] St John A, Caturegli I, Kubicki NS, Kavic SM. The Rise of Minimally Invasive Surgery: 16 Year Analysis of the Progressive Replacement of Open Surgery with Laparoscopy. JSLS. 2020 Oct-Dec;24(4):e2020.00076. doi: 10.4293/JSLS.2020.00076. PMID: 33510568; PMCID: PMC7810432.

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