What on earth is laparoscopy?
With an exciting, international conference on laparoscopy and robotics being held at the Champalimaud Foundation in June 2016, we asked a few questions to Dr Jorge Fonseca, head of the Prostate Unit at Champalimaud Clinical Centre and one of the organisers of the event.
How long have you been performing laparoscopic procedures?
I have been performing laparoscopy for about ten years – one of the very first urologists in the country to do so. Laparoscopy is essential to modern urology, as it allows us access to internal parts of the human body, without cutting superficial tissues and minimizing disturbance of surrounding organs.
When are laparoscopies performed and how are they different from open surgeries?
In modern urologic oncology, most of the localized tumours of the kidneys, bladder and prostate are removed by laparoscopy. Until a few years ago, the doctors would perform open surgery, in which they attempt to access the whole area that they need through an abdominal incision in order to treat the patient. To perform an open kidney surgery in this situation, an extremely large incision would be required, with all of the associated tissue damage and extended recovery times – in fact, with large incisions, complete recovery may never occur and the patients very frequently will experience permanent weakness of the abdominal muscles and a reduction in their well-being. With laparoscopy, four or five small incisions, not larger than one centimetre, are made in the abdomen. One hole is to insert an optic lens to allow the surgeon to see. The other holes are used for the laparoscopic instruments to have access, the surgical tools needed to perform the operation. The laparoscopic procedures are much more precise than open surgery but also more time consuming. However, in trained hands laparoscopy becomes much faster, because the incisions are smaller and therefore easier to open and close. The time taken to carry out a more precise procedure is saved during the opening and closure of the abdomen. Much more importantly, laparoscopy is a more precise surgery, lessens blood-loss and reduces the patient’s recovery time significantly.
Are there any situations where open surgery is still preferred to laparoscopy?
Nowadays, very few localized urologic tumours have to be treated by open surgery.
I remember a pregnant woman with a kidney tumour, to whom the abdominal distension couldn´t be performed. Any bleeding complication can be handled more easily in open surgery, using swabs, which is a bit more complicated in laparoscopy. Also, huge tumours can be handled more efficiently by an open operation and the abdominal incision to remove the surgical specimen can be quite large, even using laparoscopic methods.
The pros and cons of laparoscopy are two sides of the same coin: laparoscopy allows the surgeon to zoom into the treatment area with incredible levels of accuracy, allowing for precision that is extremely difficult to achieve in open surgery. However, this magnification of the treatment area does mean, of course, that the surgeon has to be extremely careful to notice any peripheral eventualities – it can be difficult for the surgeon to notice what is happening just beyond the field of the lens. This is why laparoscopy requires a lot of training and practice.
Therefore, the decision to use laparoscopic or open surgery is made on a case by case basis, deciding which will be safer and more appropriate for the patient. The key idea is to make surgery as minimally invasive as possible. However, nowadays in most situations laparoscopy is more appropriate than open surgery.
But costs are higher with laparoscopy, which is important for hospitals, patients and insurers…
In the beginning, this was true, but that was simply because the operating times were longer for laparoscopies. As surgeons become more experienced with the procedures, and the techniques are improved, the operating times have reduced significantly. An experienced surgeon now can perform a laparoscopy in the same amount of time, or even faster than, an open surgery. For example, my first prostatectomy took seven hours. The one I performed yesterday took just three!
Is quicker always better?
Not always, but generally this is true - the less time that a patient is on the surgical block, the better. There is less risk of infection, less blood-loss, less need for powerful anaesthetics, less post-operative complications and more comfort for the patient in question.
What about the latest developments in robotic laparoscopy?
The robots bring a completely new dimension. The robotic arms allow for a much higher level of flexibility inside the patient. The rigid laparoscopic instruments normally used have a limited amount of movement at the tip – the part of the instrument that is inserted into the patient’s body. Sometimes this is all that is required, but, depending on the kind of operation, the robotic arms allow the surgeon to perform laparoscopic operations that would not have been possible with the rigid straight instruments. With 3-D imaging, we also have a much better sense of depth with than before. The field of vision is the same, but the depth perception has been greatly improved recently. The gap between standard and robotic laparoscopy is huge, however we must be cautious not to overuse the new technology unnecessarily, but for certain treatments, the flexibility of the tips of the robotic instruments, and the ability to articulate and rotate forceps inside the patient’s body, allows for movements that would not be possible in a free-hand laparoscopy.
How long does it take to train to use the equipment?
It is quite complicated, but it is not really the issue – this is simply a question of practice. I spent over a year learning the free hand laparoscopic techniques before I operated on a person. As far as the robotics are concerned, the biggest difficulty is losing the sensation of touch. We say “the surgeon’s eyes are his fingers” but this is not true with laparoscopic surgery, especially robotic laparoscopy – a doctor must learn to use his eyes better, but it really is just a question of practice. Some more traditional doctors do not want to retrain in this way, especially later in their careers. But there are some young doctors who only know how to perform operations laparoscopically. For me, it is important that a surgeon knows how to trust his eyes, his hands and his intuition. This is an important combination.
On June 9/10/11 2016, the Champalimaud Centre for the Unknown will host the 2016 Challenges in Laparoscopy and Robotics meeting in Lisbon. Can you tell us a little something about that?
This will be the 13th edition of the European Congress of Laparoscopy and Robotics, and we are delighted to be hosting it here. There will be three days of live laparoscopic and robotic surgery, with some of the most skilled surgeons in the world. We hope that this will raise the profile of laparoscopic surgery in Portugal, for this reason we invited to participate in this meeting most of the Portuguese Laparoscopic Urologists and we have the endorsement of the Portuguese Urologic Association and of the Portuguese Medical Associaton.