Is the laparoscopic bubble bursting?

Abstract

The watchword for 1995 has been evidence-based medicine. After several years of euphoria with the laparoscope, surgeons have started to look critically at the extravagant claims of minimal-access surgery. The laparoscopic bubbles of less pain, smaller scar, quicker recovery, and saving of money led to speculation that as many as 80% of operations will be performed laparoscopically. But now the bubbles are bursting, not only with reports of serious complications such as major vascular (Am J Surg 1995; 169: 543) and bileduct injuries (Ann R Coll Surg Engl 1994; 76: 269), deep venous thromboses (Arch Surg 1993; 128: 914), and even portsite metastases (Br J Surg 1995; 82: 295), but also with the realisation that many common operations can readily be carried out through small (minimally invasive) incisions. Both laparoscopic cholecystectomy and fundoplication have been accepted, partly because the internal procedure is the same as the tried and proven open procedure. Less impressive results have emerged when the operation is modified to make the laparoscopic hardware fit. Randomised trials of hernia repair (MacIntyre) give conflicting results in terms of postoperative pain and recovery rates, but show that costs are increased. Laparoscopic appendicectomy had initial appeal (Martin), but has also failed to catch on. Laparoscopic colorectal surgery has spread slowly, owing to requirements of advanced laparoscopic skills and deficiencies in instrumentation. Major complication rates of 24% and conversion to open surgery in 41% (Dis Colon Rect 1993; 36: 28) should be a warning. In defence of laparoscopy, it has made surgeons more aware of cosmetic considerations and metabolic responses to surgery. There is a paucity of publications to support laparoscopic cholecystectomy. To date over 800 articles have addressed laparoscopic cholecystectomy, but only 15 are randomised controlled trials of laparoscopic versus open cholecystectomy. Only McGinn, McMahon, and Majeed have compared laparoscopic and small-incision (mini-laparotomy) cholecystectomy with adequate patient numbers (over 50 in each group). Of these three, only one (Majeed) has been blinded to postoperative carer bias, and preliminary results show similar times to first solid feed, hospital discharge, and return to work. The laparoscopic procedure took longer to perform. Belief in laparoscopy has lead to an increased rate of cholecystectomy (JAA4A 1995; 273: 1581), owing to increased referrals and lowered surgical thresholds, so increasing overall health expenditure. In the future, new technology such as virtual reality environments may perfect surgeons' laparoscopic skills on computer-generated models. However, we believe the coming year will direct evidence-based surgery away from