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Consultant Laparoscopic Colorectal and General Surgeon

Laparoscopic general surgery

Laparoscopic surgery – benefits for patients

The quality of evidence

“The highest level of evidence comes from analysing as many clinical trials as possible. Comparing open surgery with laparoscopic techniques across thousands of patients means that our conclusions are likely to be accurate and reliable.”

Mr Jonathan Wilson has been trained in laparoscopic colorectal surgical techniques at the world-famous St Mark’s Hospital, Harrow. Also, during a specific Laparoscopic Colorectal and General Surgical ACPGBI-Fellowship at the East and North Hertfordshire NHS Trust.

Patients today are generally informed that laparoscopic general surgery and laparoscopic bowel surgery results in:

  • A shorter stay in hospital – most laparoscopic general surgical procedures can now be performed as a day case, with no overnight stay.
  • A significantly faster recovery – days not weeks.
  • Less post-operative pain – patients cope with paracetamol and do not usually need strong analgesia.
  • Reduced risk of complications – fewer wound infections, less bleeding.
  • Less abdominal scarring.

This advice is based on current, published evidence. If you or someone you know needs this surgery for an abdominal condition, you may want to know more about that evidence.

This is a summary of key studies that have been published up to May 2012. Mr Jonathan Wilson has added his insights to help you understand the importance and relevance of the conclusions.

Why evidence-based medicine is important

People today no longer find it acceptable just to be told that one treatment is better than another.

It is up to doctors to explain why, to show that clinical decisions are made on the basis of solid evidence. The documents that describe clinical studies are not, however, the easiest things to read. Doctors need to be proactive in explaining them clearly, so that patients can be more informed.

Laparoscopic gallbladder removal

A study published in 2010 looked at three large reviews of 56 randomised controlled trials. It involved 5,246 patients who had open, small-incision or laparoscopic gallbladder removal.1 The authors concluded that patients having laparoscopic surgery:

  • Had a much shorter stay in hospital than patients having open surgery
  • Needed a shorter convalescence
  • Had the same risk of complications
  • Needed about the same amount of time as for their surgical procedure

Inguinal hernia repair: comparing laparoscopic surgery with open surgery

A review in the British Journal of Surgery published in 2008 described its analysis of four large trials2, concluding that:

  • Laparoscopic repair of an inguinal hernia produced significantly less pain after surgery
  • Recovery time was faster than with open surgery
  • Patients having laparoscopic surgery had fewer wound infections
  • The operation time using laparoscopy was slightly longer

Laparoscopic hernia surgery

“Laparoscopic techniques are now well accepted for patients who need a cholecystectomy or inguinal hernia repair. Unless there is a complication that prevents a patient having laparoscopic surgery, we use minimally invasive techniques.

The surgery is much less traumatic, with less pain afterwards and patients can get back to normal activities much quicker. I recommend keyhole techniques to patients with more complex hernias such as incisional hernias, but we are still assessing the long-term success of minimally invasive surgery in terms of recurrence rates (see below).”

Laparoscopic hernia repair for complex hernias

In 2011, a group of German scientists from the Institute of Quality and Efficiency in Health Care (IQWiG, the German equivalent of the National Institute of Clinical Excellence [NICE] in the UK), published a Cochrane review looking at how these techniques for hernia repair compared to open surgery.3

They studied the results of ten randomised controlled trials, in which 880 patients had either laparoscopic hernia repair or open surgery. Their conclusions were that:

  • Patients having this surgery had a lower risk of wound infection after their operation.
  • Most trials showed that laparoscopic surgery reduced time in hospital.
  • The cost of laparoscopic hernia repair for the hospital was higher than for open surgery.
  • There was not enough data to show whether patients having laparoscopic hernia repair experienced less pain after surgery, or whether their rate of recurrence was lower over time.

Surgical training and skills

“Laparoscopic bowel surgery, hernia repair and gallbladder removal have advantages for patients, but only when they are performed by a surgeon with a high level of skill.

That means someone who has been extensively trained and mentored in these techniques, and someone who does many operations each year. It is particularly important for patients looking for a private bowel surgeon to find out about their level of training and experience.”

The evidence in more detail

1 Keus F, Gooszen HG, van Laarhoven CJ. Open, small-incision, or laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis. An overview of Cochrane Hepato-Biliary Group reviews. Cochrane Database Syst Rev. 2010 Jan 20; (1): CD008318. Review.

2 Karthikesalingam A, Markar SR, Holt PJ, Praseedom RK. Meta-analysis of randomized controlled trials comparing laparoscopic with open mesh repair of recurrent inguinal hernia. Br J Surg. 2010 Jan; 97 (1): 4-11.

3 Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database of Systematic Reviews?2011, Issue 3. Art. No.: CD007781. DOI: 10.1002/14651858.CD007781.pub2.

4 Martel G, Crawford A, Barkun JS, Boushey RP, Ramsay CR, et al. Expert opinion on laparoscopic surgery for colorectal cancer parallels evidence from a cumulative meta-analysis of randomized controlled trials. 2012 PLoS ONE 7(4): e35292. doi:10.1371/journal.pone.0035292.

5 NICE Technology Appraisal Guidance 105 Laparoscopic surgery for colorectal cancer. www.nice.org.uk/TA105 2006.

Laparoscopic colorectal surgery

A study published in April 2012 described the overall findings of 23 clinical trials comparing 5,782 patients who had laparoscopic bowel surgery with 2,751 patients who had open surgery.4

The survey concluded that patients having this surgery did just as well as patients having open surgery, and this has been true since 2004.

The research also found that expert physicians now fully accept that laparoscopic bowel surgery for bowel cancer, rectal cancer and other bowel conditions is equivalent to open surgery in terms of how long the treatment extends patients lives.

The use of laparoscopic surgery in cancerous bowel conditions has been more controversial than its use in patients with non-malignant diseases.

Surgeons realised the benefits of minimally invasive surgery for patients in terms of hospital stay, post-operative pain and recovery time. But they wanted to make sure that laparoscopic surgery achieved the same long-term results in cancer patients. The evidence now supports this.

This view is shared by NICE, who recommend laparoscopic bowel surgery for patients with colorectal cancer when both open surgery or laparoscopic surgery are suitable.5

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