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JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES
Volume 27, Number 12, 2017
ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2017.0529
Letter to the Editor
Laparoscopic Versus Open Surgery Still an Open Debate
Downloaded by UNIVERSITY OF FLORIDA from online.liebertpub.com at 10/25/17. For personal use only.
Francisco Schlottmann, MD,1 and Marco G. Patti, MD2
Abstract
Many would think that today minimally invasive surgery is the standard of care in the United States and that the
conventional ‘‘open’’ approach would be relegated to few complex procedures or difficult redo operations.
However, a great variability still exists in the utilization of laparoscopic surgery in the United States. 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.
Keywords: laparoscopy, minimally invasive surgery, open surgery
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 shortand 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
‘‘Only a person with brain damage would perform laparoscopic surgery’’
T
hese 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
Departments of 1Surgery and 2Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
1
2
LETTER TO THE EDITOR
Downloaded by UNIVERSITY OF FLORIDA from online.liebertpub.com at 10/25/17. For personal use only.
(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:
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.
Disclosure Statement
No competing financial interests exist.
increased costs due to longer hospital stay
References
For the society, a laparotomy incision is associated with:
1. Bhattacharya K. Kurt Semm: A laparoscopic crusader. J
Minim Access Surg 2007;3:35–36.
2. Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy.
A comparison with mini-lap cholecystectomy. Surg Endosc
1989;3:131–133.
3. Gollan J, Kalser S, Pitt H. National Institutes of Health (NIH)
consensus development conference statement on gallstones and
laparoscopic cholecystectomy. Am J Surg 1993;165:390–396.
4. Broeders JA, Rijnhart-de Jong HG, Draaisma WA, et al.
Ten-year outcome of laparoscopic and conventional Nissen
fundoplication. Randomized clinical trial. Ann Surg 2009;
250;698–706.
5. Schlottmann F, Strassle PD, Patti MG. Comparative analysis
of perioperative outcomes and costs between laparoscopic and
open antireflux surgery. J Am Coll Surg 2017;224:327–333.
6. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy
for cancer is not inferior to open surgery based on 5-year data
from the COST study group trial. Ann Surg 2007;246;312–321.
7. Crawshaw BP, Chien HL, Augestad KM, et al. Effect of laparoscopic surgery on health care utilization and costs in patients
who undergo colectomy. JAMA Surg 2015;150:410–415.
8. Schlussel AT, Delaney CP, Maykel JA, et al. A National
Database analysis comparing the nationwide inpatient sample and American College of Surgeons National Surgical
Quality Improvement Program in laparoscopic vs open colectomies: Inherent variance may impact outcomes. Dis
Colon Rectum 2016;59:843–854.
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.
Address correspondence to:
Francisco Schlottmann, MD
Department of Surgery
University of North Carolina at Chapel Hill
4030 Burnett Womack Building
101 Manning Drive, CB 7081
Chapel Hill, NC 27599-7081
E-mail: fschlott@med.unc.edu
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