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surgery - open vs laparoscopic

Open Surgery (Laparotomy)

  1. Surgeons started experimenting with gastrointestinal operations to induce weight loss in the 1950’s. At that time all gastrointestinal surgery was done “open” by laparotomy, by which is meant using a large incision in the anterior (front) abdominal wall to gain access to the abdominal cavity and its organs.
     
  2. Various manipulations of the gastrointestinal tract were tried and some proved to be successful while others were ineffective and some others were dangerous. Those that were ineffective and dangerous were abandoned. Those that proved to be effective were
    • the purely restrictive operation, vertical banded gastroplasty,
    • the purely malabsorptive operation of Nicholas Scopinaro (distal gastrectomy and Roux-en-Y biliopancreatic diversion) and
    • the hybrid (combined restrictive and malabsorptive)Roux-en-Y gastric bypass
       
  3. Many gastrointestinal operations are still done open by laparotomy and bariatric operations are still done that way too by some surgeons whose laparoscopic skills are not adequate or when technical factors make laparoscopic surgery impossible or unduly hazardous. If problems arise during laparoscopic surgery it is often prudent to convert to open surgery
     
  4. To do a particular operation in an obese person usually requires a longer incision than is required to do that operation in a lean person. After completing the operation the abdominal wall muscles that have been cut have to be stitched up again and then the skin wound has to be closed. An obese person has a heavier abdominal wall placing a greater strain on the sutures holding the muscles together until they heal, so there is a greater risk of the suture breaking or tearing through the tissue than in lean patients. Obese people have much thicker layers of fat between the skin and the muscle, which means that after closing the skin, there is a larger space into which tissue fluid can accumulate and if there has been any bacterial contamination of that fluid by bacteria from the skin or the intestines, the fluid becomes infected with abscess formation. If an abscess does form, the skin stitches have to be removed to open the wound to let the pus out. Many obese people are diabetic and diabetics have impaired ability to fight infections, so if a wound does become infected, the infection is often more severe and difficult to treat.
     
  5. Consequently, with open surgery, obese people are more susceptible to wound disruptions, wound infections and incisional hernias.

Furthermore, long cuts are painful and painful upper abdominal wounds tend to reduce the excursion of the chest resulting in reduced expansion of the lungs and a tendency to collapse segments at the bases of the lungs. The best way to improve the expansion of the lungs is to get up and walk, but with a long painful wound this is difficult. Collapsed lung segments can become infected, with development of pneumonia. Obese people usually already have reduced expansion of their chest walls so they are at greater risk of these complications.

Laparoscopic Surgery

  1. This is often referred to by non-surgeons as “keyhole surgery”, and by medical people as “minimal access surgery”. It involves first filling the abdomen with CO2 (carbon dioxide) gas, then making a variable number of small (5-15mm) transverse incisions in the skin and then pushing ports through those incisions into the abdominal cavity. Ports are metal or plastic tubes that have a tap on the side to allow entry of the gas and a seal at the top that allows instruments to be inserted without allowing the gas to leak. With the ports in, a telescope connected to a video camera and a light source is introduced through one of the ports so the surgeons can then see inside the abdomen by watching a video monitor positioned above and to the side of the operating table. Long instruments with very small operating tips for holding, retracting, cutting coagulating and stitching are then inserted through the other ports.
     
  2. The operations that are done laparoscopically are very similar, with minor modifications in detail, to the basic operations done by open surgery. They are just as complex and have just the same effects, side effects and potential complications.
     
  3. Advantages of laparoscopic surgery are:
    • the wounds are much smaller and less painful. Consequently, patients can mobilize much more easily and their respiration is much less restricted, so there are far fewer lung complications.
    • there is much lower risk of incisional hernias, because the ports separate the muscle fibres rather than cutting them and because they are inserted obliquely, i.e. in a slanting manner. (A hernia forms in cases where the peritoneum lining the abdominal cavity pushes through a defect in the abdominal wall, creating a potential space into which bowel can protrude and become trapped.)
    • the small, transverse skin wounds heal with cosmetic results that are superior to those resulting from long midline wound
       
  4. Disadvantages of laparoscopic surgery are:
    • Loss of both the surgeon’s sense of touch while operating, and the gentleness of the fingers holding the bowel (as opposed to metal instruments that can damage the bowel)
    • Narrow field of vision, so that instruments inside the abdomen but outside the picture on the screen can cause inadvertent injuries
    • Two-dimensional vision instead of three-dimensional vision, so depth of field is lost while viewing the inside of the abdomen on a screen.
    • Potential for injuries to intra-abdominal organs and blood vessels during insertion of the ports
    • Longer duration of anaesthetic because the operations take longer to complete than open operations.