Mr. Low Kah Pin

Obstetrician & Gynaecologist
MBBS (UM), MObGyn (UM), MRCOG (UK), FMAS/ART (India), MSc BHARE (Spain)

Mr Low Kah Pin is an enthusiast in Obstetrics and Gynaecology with a soft spot for laparoscopy and fertility. An avid multi-sports lover with penchant for creative literature snippets, humor, art and the occasional minute dose of politics.

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Key hole surgery is the laymen term for laparoscopy or minimally-invasive surgery where the surgeon makes a small incision of 5mm, usually at the patient’s belly button and puts a camera, called laparoscope, into the abdominal cavity to visualize the cavity via the television screen. The non-toxic and odourless carbon dioxide gas is used to create an air pocket within abdomen for the surgeon to operate. Additional small incisions are made, to insert surgical instruments into the cavity to perform the operation.

Misconception

In my clinical practice, there are a few misconceptions by the general public. Laparoscopy is incorrectly regarded as “laser” surgery although no laser equipment is being used. Laparoscopic removal of ovarian cyst are being known as “sucking” out the cyst or the tumor, not knowing that the actual procedure requires surgical dissection of the lesion, extraction out from the cavity through the key holes and prevention of bleeding from the surgical site. It is not just sucking out the lesion like using a vacuum cleaner. Lastly, the public has the idea of laparoscopy being “incomplete” or “not clean enough” surgery as the incision is small, but in actual fact, the laparoscope camera allows the surgeon to view the entire abdomen cavity, which is impossible in open surgery. Washout and suturing can be done efficiently via laparoscopic instruments.

Advantages

The glaring advantage of laparoscopy, as compared with traditional large incision surgery is less postsurgery pain. Hence, patients have less discomfort, use less painkillers, better cosmesis and able to resume activities much earlier. Indirectly, patients will less likely to develop blood clots in vessels or pneumonia as patients are ambulated earlier. Some laparoscopy surgery can be done as daycare surgery, meaning no overnight hospitalization is required. Patients are being admitted to ward in the morning, to be operated in the afternoon and walk back home in the evening.

The other benefits of laparoscopy include rare occurrence of hernia from incision and less likely to have wound infections. Therefore, patients can lift or carry objects earlier. The incisions are closed with dissolvable sutures or held together with small dressings without going through the discomfort of removal of stitches or staples.

Limitations

Laparoscopy requires patients to undergo general anaesthesia requiring patients to be put to sleep on the breathing machine during the operation. This may cause sore throat and nausea. Air pockets within abdomen cavity may lead to the feeling of belatedness and occasional neck and shoulder pain, especially when the air pockets are trapped under the diaphragm (muscle between chest and abdomen cavity).

Thus, laparoscopy surgeries are off limits to patients with severe heart or lung disease as surgeries should be safely performed in open surgery with regional anaesthesia. Laparoscopy should be done in caution for patients with multiple prior operations as built-up of previous scar tissues increases the difficulty of laparoscopy surgery as well as the risk of complications.

Evolution and the future

The first laparoscopic procedure was performed in dogs by Georg Kelling of Dresden, Germany in 1901 and in humans by Hans Christian Jacobaeus of Sweden in 1910. More than a century later, by today, laparoscopy had evolved greatly. Key hole surgery can even be performed during pregnancy ie removal of ovarian cyst. Personally, I had removed large cyst of more than 10 centimeters ie mucinous cyst, endometriotic cyst, dermoid cyst with pregnancy unaffected and progressed normally postoperatively till delivery. Laparoscopic surgeries are usually done with at least 3 small incisions, but currently many surgeons are trained in single port laparoscopy where only one incision is required or key hole surgery through natural orifices such as removal of ovarian cyst through incision in vagina, hence the incision are hidden and appear scarless!