The death of Pennsylvania Congressman John Murtha last week after gall bladder surgery has brought a new focus on laparoscopic procedures. While we don't know the details of Mr. Murtha's particular case, it's a reminder that all surgery comes with some risks.

Laparoscopic surgery, performed after the abdomen is inflated with gas to create some space for instruments and visualization, involves the use of small incisions to introduce a light source, camera and surgical instruments. The surgeon views the inside of the patient on a monitor.

Just about any surgical procedure that used to be done by opening up the patient can now be accomplished laparoscopically. Procedures range from colon resection to stomach surgery, bariatric surgery, hernia repair, appendix or gall bladder removal, and many others.
"The whole gamut of general surgery can be accomplished with minimal access techniques," said Michael Kavic, MD, program director for surgical residents at St. Elizabeth Health Center, Youngstown, Ohio. Dr. Kavic is Editor-in-Chief of JSLS, a laparoscopic surgery journal, and Professor of Surgery and Vice Chair Department of Surgery, Northeastern Ohio Universities College of Medicine.

Benefits of this approach include avoiding the risks of open surgery, notably delays in healing and the impairment of deep breathing from thoracic or abdominal incisional pain that leads to breathing problems, particularly dangerous in older patients. Add a few co-morbidities such as chronic disease, smoking or obesity, and open surgery becomes more risky. Laparoscopic surgery reduces these risks but presents some of its own.

"There are trade offs," Dr. Kavic said. "For instance, with laparoscopic surgery you use a laparoscope--a device that looks like a telescope--to visualize an organ. The laparoscope can magnify an image up to 16 times. So that is a big positive. On the other hand, when you decrease or discontinue stereoscopic views, and put three-dimensional reality on a two-dimensional monitor, you change [the way you see] things." (He noted that robotic surgery, a form of laparoscopic surgery, can provide 3-D visualization.)

The field of view is narrower in laparoscopic surgery compared to open procedures. "If you are tugging on an organ in your field of view and it is attached to something outside your field of view you would not even know if you hurt it," he said. "There are pros and cons to each approach. Each has their advantage."

Complications in surgery are rare but well enough known that they have their own names in the medical literature. For instance, an inadvertent enterotomy is an accidental tear of the bowel. This rare event occurs in less than 0.4 percent of abdominal laparoscopic surgeries, but the risk is much greater for patients with adhesions of tissue from prior procedures, disease, diverticulitis, or inflammation.

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