What determines if a procedure can be performed laparoscopically?
The ability to perform and complete a case laparoscopically is dependent on the surgeon’s skill, past experience, training and comfort level. There is a wide variation of abilities just like in professional sports, business or any other common activity.
Surgery is both art and science. At this point, there are very few cases that have not been described in the surgical literature performed in a laparoscopic fashion. Although the procedural goals between many operations are profoundly different, the overwhelming majority of laparoscopic cases are predicated on understanding anatomy and a handful of predicate and key surgical principles.
Anatomy is the basis of all surgical procedures. A firm grasp of anatomy is paramount to performing surgery in a predictable, reproducible and safe manner. Anatomy is usually one of the first courses a medical student will face. It is a daunting task, as all areas of the body are explored and committed to memory. We are all aware that over time a great deal of what has been learned in excruciating detail gives way to a “general” understanding and less details remain in our conscious thoughts. I am a strong believer that the course on anatomy is never over. Nuances of anatomy exist between individuals just like finger prints. It behooves all surgeons and physicians alike to continuously study, review and rediscover human anatomy.
Minimally Invasive Surgery: Basic Surgery Principles + Modern Techniques
Mastery of basic surgical principles is the second component of performing safe, effective and reproducible surgery. The basic principles revolve around tissue handling, control of bleeding, sewing/stapling and obtaining appropriate exposure. The majority of these principles are taught to surgical residents during the 5 years of surgical training. Additional post residency training, a Fellowship, has also been demonstrated to strengthen a surgeon’s understanding and ability of the fundamentals and broaden the skill set required to perform advanced procedures.
When anatomy is clearly understood and technique mastered there are few if any cases that cannot be performed laparoscopically.
However, there are situations in which laparoscopic surgery is either ill advised or not safe to complete. Patients who have had previous abdominal operations are likely to have post operative scar tissue. Theses adhesive bands can hinder manipulation of tissue and limit appropriate visualization making the procedure “unsafe”. Excessive bleeding that cannot be controlled by minimally invasive means may require conversion to an open procedure. Rarely, variation of anatomy can be a cause for conversion. Any underlying condition that precludes general anesthesia is a contraindication for laparoscopic surgery. Whether open or laparoscopic, the goal of surgery is the same…keep the patient safe on the OR table and do what is necessary to achieve an optimal outcome in the safest manner.