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Patient Perspective

Surgical Spotlight
Laparoscopic Surgery: Operating Through a Tiny Incision Can Offer Advantages over Conventional Surgery
James M. Church, M.D.

“Laparoscopy:” What does it mean?
The word “laparoscopy” means the procedure of looking inside the abdominal cavity through a scope. Laparoscopy has been performed for many years, mostly by gynecologists for inspecting the pelvic organs. In the late 1980s, laparoscopic abdominal surgery began. Instead of merely inspecting the organs for diagnostic purposes, surgeons began to manipulate tissues and perform surgical procedures through tiny incisions. This advance was made possible by new, miniaturized video technology. A tiny camera is inserted into the abdominal cavity and transmits images onto a TV-like monitor screen. Now, the surgeon can actually view the internal organs and use the images to guide surgical instruments.

The first conventional surgery to be commonly performed laparoscopically was gall bladder removal. This was a revolutionary operation, as patients were able to go home the day of surgery or day after, instead of being hospitalized for 7 to 10 days. Since the early 1990s, laparoscopic instruments have been continually developed and refined, and laparoscopic techniques have been applied to all sorts of specialties and operations, including colon and rectal surgery.

How is laparoscopic bowel surgery performed?
Laparoscopic (sometimes called minimally invasive) colon and rectal surgery involves the use of a laparoscopic camera inserted into the abdomen through a small incision just below the belly button. The abdomen is inflated with carbon dioxide to provide a space for viewing and operating. Three to five small incisions are made through the abdominal wall so that instruments can be used to manipulate the intra-abdominal organs. Surgery proceeds using techniques specially developed for laparoscopic surgery. Sometimes one of the tiny incisions needs to be enlarged to allow removal of a segment of bowel, or so that anastomosis (connection) of two bowel ends can be easily performed. Some operations can be done completely laparoscopically and others partly. Remarkably, it is possible to remove the entire colon and to connect the small intestine to the rectum through 4 half-inch incisions and one 3-inch incision.

What are the advantages of laparoscopic bowel surgery? Are there any disadvantages?
The advantages of laparoscopic surgery over conventional surgery are, in general, based on the concept that smaller incisions cause less pain and less trauma to the body – particularly to the abdominal contents. In turn, less pain means less need for narcotic pain medication. And less surgical trauma and handling of the bowel means a quicker recovery of bowel function and of the patient overall.

Typically, laparoscopic surgery translates into an earlier discharge from hospital and an earlier return to work.

These potential advantages, however, are balanced by some disadvantages. Laparoscopic techniques are difficult to perform, and extensive training and experience are needed to do them well. Also, operations take longer and may cost more, because of the specialized instruments needed. And if difficulties arise during the laparoscopic approach, the procedure must be changed to a conventional “open” surgery. Furthermore, the potential advantages of laparoscopic surgery are not always realized by all patients, as a recent Cleveland Clinic study showed.

Are there conditions more amenable than others to laparoscopic bowel surgery? For whom is it suitable?
Laparoscopic surgery does have benefits for patients with colorectal diseases, especially those with familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC). The most common surgery performed in patients with these conditions is removal of the entire colon (colectomy), with either anastomosis of the small bowel to the rectum, or the small bowel to the anus with an ileal “J” pouch. Because the colon lies completely around the outer limits of the abdominal cavity, incisions must be long to allow safe mobilization. Laparoscopic techniques are a way of mobilizing the colon without making large incisions.

Patients having surgery for FAP and HNPCC are often young. Young patients are good candidates for laparoscopic surgery because they can better tolerate the lengthier procedures; they typically are more concerned with the cosmetic appearance of the resultant abdominal scar; and being more active, are more likely to be hindered by the weakness associated with a long abdominal incision.

For most patients having colectomy for FAP or HNPCC, it is their first abdominal operation. This is an advantage, because they have no adhesions from a prior surgery, which can make laparoscopic procedures more difficult and lengthy.

What is the Cleveland Clinic’s experience?
Over the last seven years surgeons here at the Cleveland Clinic have led the way in offering laparoscopic colectomy to patients with FAP and HNPCC. Our experience is the largest yet published, with over 35 patients having laparoscopic colectomy or proctocolectomy. Patients stay in the hospital an average of five days, are active within two weeks and have minimal scarring in their abdominal walls.

If you or a family member are interested in exploring the possibility of laparoscopic surgery for yourself or for a family member, please call the David G. Jagelman Registries at the Cleveland Clinic at 216/444-6470 or toll-free 800/998-4785.