What is keyhole surgery?
Laparoscopic surgery or minimally invasive surgery is better known as keyhole surgery. It is a technique using modern technology and surgical innovations which aims to accomplish surgical therapeutic goals with minimal interruption to the body’s natural state.
Carbon dioxide gas is introduced in to the abdominal cavity to create a working and viewing space. A laparoscope connected to a video camera is then inserted into the abdominal cavity. Additional five to ten mm thin instruments can be introduced by the surgeon through side ports to allow operative procedures to be carried out. Rather than producing a large abdominal incision, as in traditional surgery, four or five cuts of five to 15mm in size will be sufficient to perform a laparoscopic procedure on the bowel.
A whole new operative environment is created that requires the surgeon to have good hand-eye coordination. Access to the abdominal cavity in this way allows surgery to be performed on any part of the gastrointestinal tract that is within the abdomen. This approach is intended to minimise operative blood loss and post-operative pain, and speeds up recovery times. Patients are out of hospital quicker with an earlier return to normal function.
The majority of colorectal surgery at the Royal Marsden is for cancer. The basic principles of cancer surgery are removal of the affected area of bowel together with adequate segments, around five to ten cm, of ‘normal’ bowel either side of the tumour. The artery supplying the affected segment of bowel is also removed close to the arterial origin from the main blood vessel in the abdomen, the abdominal aorta. The draining glands (lymph nodes) are located along the main feeding artery to the bowel and are removed, together with the artery, in all cancer operations.
Depending on the position of the tumour, different procedures will be carried out.
Left hemicolectomy
The operation involves removal of the descending colon. In most instances the ends are joined together, so that bowel continuity is restored. The surgeon may decide to protect a join with a temporary ileostomy. This may be reversed at a subsequent operation some weeks later.
Right hemicolectomy
The operation involves removal of the end of the small bowel and ten to 100cm of the colon (including the appendix). The ends are joined together so that bowel continuity is restored.
Anterior resection
The operation involves removal of the rectum and part of the sigmoid colon. In most instances the ends are joined together, so that bowel continuity is restored. In some cases, it may not be possible to join the ends together. The end of the bowel will then be brought through the abdominal wall and opened as a colostomy. If bowel continuity is restored the surgeon may decide to protect the rectal join with a temporary ileostomy. This may be reversed at a subsequent operation some three to six months later.
Abdominoperineal resection
The operation involves removal of the anus, rectum and part of the sigmoid colon. The end of the bowel will then be brought through the abdominal wall and opened as a permanent colostomy. The area where the anus has been removed will be closed with stitches.
Transrectal Endoscopic Microsurgery (TEM)
Transrectal Endoscopic Microsurgery is a minimally invasive technique used to remove tumours from the rectum. These are usually located 8 to 15 cm from the anal opening. The surgeon performs the operation through a scope placed into the anal canal. A smaller telescope used in laparoscopic surgery is used to locate the tumour. Rectal surgery to remove tumours is routinely performed using standard laparoscopic instruments. Gas is introduced into the rectum to allow a good view in order to perform the surgery through the anus. This means that patients may be able to avoid traditional, open surgery and an abdominal incision. This will allow them to resume normal activities much sooner. This technique is used for low rectal tumours that have been identified early avoiding major surgery. TEMs can also be employed for local control of symptoms in patients unable to undergo prolonged surgery.
TransAnal Resection of Tumour (TART)
Transanal resections of tumours are reserved for growths that are up to 5cm from the anus. They are easily accessible through the anus and are removed using conventional surgical instruments. The benefits are similar to those for TEMs. Once again this technique is reserved for early tumours or pre-malignant conditions and can also been employed for local control of symptoms in patients unable to undergo prolonged surgery.