Laparoscopic Versus Open Surgery Still an Open Debate

“Only a person with brain damage would perform laparoscopic surgery”

These words were used by Kurt Semm's coworkers in the 1970s to criticize their colleague's early investigation in therapeutic laparoscopy for the treatment of ovarian cysts. ¹ In 1980, this German gynecologist performed the world's first laparoscopic appendectomy, beginning the minimally invasive surgery (MIS) era in general surgery. Surgeons in France performed the first laparoscopic cholecystectomy in 1987, and this procedure was introduced in the United States in mid-1988. ² This began a laparoscopic revolution, and it did not take long for the National Institutes of Health to pronounce in 1993 laparoscopic cholecystectomy as “the treatment of choice for many patients with symptomatic cholelithiasis.” ³ The idea of reduced postoperative pain, shorter hospital stay, and faster recovery was clearly very appealing to both patients and surgeons, and slowly minimally invasive techniques were adopted for many procedures, particularly in tertiary and quaternary care centers in the United States.

Many would think that today MIS is the standard of care across the country and that the conventional “open” approach would be relegated to few complex procedures or difficult redo operations. Unfortunately, this is not the case. While appendectomies and cholecystectomies are mostly performed by a laparoscopic approach, the embracement of MIS for other procedures has been quite different. Laparoscopic anti-reflux surgery (LARS), for instance, has shown to be associated with significant better postoperative outcomes and better long-term reflux control compared to open surgery. ⁴ Broeders et al. reported the 10-year outcome of a randomized clinical trial comparing laparoscopic and conventional Nissen fundoplication. While the results were similar in terms of improvement of symptoms, quality of life, and reflux control, the conventional fundoplication was associated to a higher risk of another operation, mostly for correction of incisional hernias. Therefore, they concluded that their trial provided Level I evidence to support the use of laparoscopic fundoplication for the treatment of gastroesophageal reflux disease. ⁴ Schlottmann et al. ⁵ recently compared the perioperative outcomes and costs between laparoscopic and open anti-reflux surgery using the National Inpatient Sample (NIS) database. They found that LARS was associated with significantly less postoperative morbidity and mortality and shorter length of hospital stay. In addition, LARS was more cost-effective compared with open fundoplication, with a reduction on hospital costs of $9530 per patient. Regardless of these well-known advantages of LARS, in the period 2000–2013, 41.6% of the anti-reflux operations in the United States were still performed either through a laparotomy or a thoracotomy. ⁵

Colorectal surgery is another important example. Laparoscopic colectomy for colon cancer has been shown to have the same oncologic profile as open colectomy. The 5-year data of the COST study—randomized trial of 872 patients with curable colon cancer—showed that survival after laparoscopic colectomy for cancer is not inferior to open surgery compared to open colectomy. ⁶ Other studies have shown that a laparoscopic colectomy is associated with less postoperative morbidity and a shorter hospital stay. In addition to the advantages for the patients, laparoscopic colectomy results in a significant reduction in healthcare costs and utilization in the short- and long-term postoperative periods. ⁷ Regardless of these data, a recent study showed that the percentage of open colectomies in the United States is still 64.3% with NIS data (period 2006–2012) and 51% with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data (period 2006–2013). ⁸

A great variability still exists in the utilization of laparoscopic surgery in the United States, and this variability in surgical care of common diseases raises important ethical and economic issues and warrants a serious look by healthcare providers, insurance companies, and patients:

For patients, a laparotomy incision is associated with:

• a 10%–15% risk of incisional hernia development with need for a second operation

• the potential for body image problems

• longer hospital stay and slower recovery

• longer need for pain medications

• longer disability time and return to regular family life

• longer use of opioids with increased risk of dependence

For hospitals, a laparotomy incision is associated with:

• longer hospital stay with decreased availability of beds for other patients

• increased risk of readmission for wound complications

For the healthcare system, a laparotomy incision is associated with:

• increased costs due to longer hospital stay

For the society, a laparotomy incision is associated with:

• increased costs due to the longer hospital stay and the treatment of complications such as wound infection and incisional hernia more often associated to open surgery and longer time off work

Considering the unquestionable advantages for patients, hospitals, and society of a laparoscopic operation, what can be done to improve the broader utilization of this technique?

The use of laparoscopic surgery cannot be imposed or legislated. Open procedures still meet the criteria for “standard of care,” and a surgeon cannot be accused of malpractice for performing an open fundoplication or colectomy, as long as the alternatives, benefits, and risks of such an approach have been discussed with the patient. This conversation, essential part of the informed consent, should underline that while the efficacy of the open and laparoscopic approach is comparable, laparoscopy is associated with a decrease in length of hospital stay, morbidity, costs, and time off work.

The low use of laparoscopic surgery is probably due to surgeons who have never embraced laparoscopic surgery, either because of age, lack of training, or because of complications. We hope that these factors will become obsolete over time. Attrition will play a role as surgeons who trained decades ago and never fully embraced MIS will eventually retire. At the same time training in most general surgery programs includes today more advanced procedures and not only laparoscopic appendectomies or cholecystectomies. In addition, most residents today seek further training after completion of their residency, such as fellowships in MIS or colorectal surgery. Simulation—using virtual simulators, live animals, perfused tissue blocks, or cadavers—also offers the possibility of learning without stress. The adoption of robotic surgery has the potential to allow more surgeons to perform procedures such as fundoplications and colectomies using a minimally invasive approach, thanks to better visualization and freedom of movements.

We also hope to witness a stronger role of leading Surgical Societies such as the Society for Surgery of the Alimentary Tract (SSAT), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and the American College of Surgeons in providing hands on courses to help surgeons who need additional training and want to incorporate new laparoscopic procedures to their practice. In addition, coaching should be used more extensively. The less experienced surgeons should observe experts performing these operations or have the expert travel to assist them in their own operating rooms. The request for coaching should come not only from surgeons who realize the need but also should be requested by hospital boards when there is recognition of a surgeon who has a very high complication rate, as a requisite for privileges to perform a procedure.

We are confident that time will redefine the debate between laparoscopic and open surgery as “an old-fashioned debate,” so that the new generations of surgeons will be able to safely implement modern surgical technology for the benefit of patients and society.