Why keyhole surgery may not be your best choice
22:53 GMT, 12 March 2012
22:53 GMT, 12 March 2012
When Dr William Davis was told he’d need surgery for prostate cancer, he hoped to have it done using a keyhole procedure and chose urologist Alan Doherty, a surgeon renowned as a pioneer of the keyhole technique.
As a GP, Dr Davis knew the benefits of this less-invasive approach — instead of opening him up with an incision up to six inches long, the surgeon would make six tiny incisions or ‘keyholes’ and operate through these. The promise was an easier and speedier recovery, as well as reduced blood loss and smaller scars.
‘I didn’t like the idea of open surgery,’ says Dr Davis, 65. ‘I saw keyhole surgery as the newer procedure with clear benefits.’
Dr Davis says it is more important to consider the surgeon and their experience – not just the procedure
So he was surprised — and not at all keen — when two days before his operation, Mr Doherty suggested it would be better to have an open procedure.
What prompted the change of plan Mr Doherty had been weighing up the advantages and disadvantages of the ‘new’ keyhole procedure compared with the standard operation. He’d analysed his own results and found the old op was better in terms of reducing the risk of long-term complications, specifically incontinence and erectile dysfunction.
‘It’s a major life event for a man to have prostate surgery,’ says Dr Davis, who lives in Bridgnorth, Shropshire. ‘Looking at it in terms of how quickly you can get out of hospital or back to work is rather narrow.
‘Mr Doherty said he expected to be able to do a better job of reducing damage to the nerves (and so reduce the risk of incontinence and impotence) with open surgery. It seemed to me to be far more important to reduce the risk of serious, long-term problems than to focus on the days after surgery.’
Ironically, I often see patients who are
referred to me because I am known for laparoscopic surgery. I end up
telling them about the benefits of an open approach…
Dr Davis had a prostatectomy (prostate gland removal) 11 months ago at the BMI Priory Hospital, Birmingham. ‘I
didn’t find the recovery a big deal,’ he says. ‘I didn’t want to have
morphine because it can cause constipation. I had paracetamol and
anti-inflammatories for pain relief. I was able to walk around the
hospital gardens three days after surgery and went home after a week.’
Davis returned to full-time work five weeks after the operation. ‘The
main worry for me was incontinence,’ he says. ‘I recovered pretty
quickly and four months after surgery I was back to normal. Erectile
function took four to six months to recover — I have 90 to 95 per cent
of the function I had before.
is tempting to think the newest operation must be the best. But the
choice I made has worked out well and I would say it is more important
to consider the surgeon and their experience, not just the procedure
they want to do.’
what’s so surprising is that Mr Doherty is widely known for keyhole (or
laparoscopic) surgery. In 2003, he was one of the first surgeons in
Britain to perform a prostatectomy this way — he has since carried out
1,100. But Mr Doherty, who also
works at University Hospital Birmingham NHS Foundation Trust, started to
question the keyhole technique two years ago.
says that while he was getting good results with keyhole, he wasn’t
improving in terms of how quickly men recovered continence and erectile
function. Erections are controlled by bundles of nerves running from the
bladder, across the prostate and down to the penis.
‘They are like a spider’s web wrapped
around blood vessels,’ he says. ‘To do nerve-sparing surgery, you need
to remove the prostate carefully while doing as little as possible to
disturb these two spider web nerve bundles.
trying to do this using your hands with the area open, compared with
doing it with chopsticks, which is effectively how you work
The Cochrane review showed that women having keyhole hysterectomy were three times as likely to suffer a urinary tract injury
‘By scrutinising my results, it became clear open surgery was a better way of nerve sparing. Ironically, I often see patients who are referred to me because I am known for laparoscopic surgery. I end up telling them about the benefits of an open approach.’
Clearing cancer is always the first priority, he adds, but if a normal sex life is important, he recommends open surgery. ‘I say: “You can leave hospital earlier and have a quicker short-term recovery, but I believe your best chance of returning to a normal sex life and avoiding incontinence is open surgery.”
‘But if a patient is older, no longer having sex, nor seeing it as a priority and is less able to cope with open surgery due to serious medical problems, for instance, then a laparoscopic approach is the best one.’ Mr Doherty adds: ‘A surgeon has enormous power over the patient. There is no doubt surgeons can become obsessed with a particular technique, but we need to think first and foremost about the outcomes that matter to patients, rather than the technique.’
Another surgeon in a different field has also been considering the benefits of the old open technique vs keyhole. His interest is in the way surgeons ‘sell’ operations. Professor Janesh Gupta, an obstetrician and gynaecologist at Birmingham Women’s Hospital, carries out 100 hysterectomies a year — with 40,000 performed in Britain every year, it’s one of the most common operations.
A day or two extra in hospital is not
significant. What matters to the patient is returning to work, driving,
shopping – what we call getting back to normal.
There are three techniques: via the vagina, laparoscopic surgery using four ‘keyholes’ in the stomach, and open abdominal surgery, through an incision running from the belly button. Recovery times vary from two to 14 weeks. Observing how his patients recovered from open or keyhole surgery, Professor Gupta was surprised to find there was no significant difference. ‘On the whole, both groups spent the same time in hospital and took the same amount of time to get back to normal.’
This was at odds with published studies. A review by the authoritative Cochrane Collaboration (a non-profit group who analyse evidence from the world’s best medical studies) involving 3,643 patients worldwide showed those having an abdominal hysterectomy spent one to two days longer in hospital and it took seven more days to recover. Professor Gupta believes the way a procedure is ‘sold’ to a patient is the key.
‘I tell both groups of patients the same thing. I say: “We will get you out of bed quickly.” This contrasts with other surgeons who favour a laparoscopic hysterectomy — they will emphasise how quickly the patient will leave hospital and return home. That is a big part of the marketing.
‘The surgeon tells the patient they are having a “special” and “new” operation and motivates them to return home quickly. If the patient having the abdominal hysterectomy is less well prepared or has a sense she is having the “old” or “bog standard” procedure, this can affect the way she recovers.’
Significantly, the Cochrane review showed that women having keyhole hysterectomy were three times as likely to suffer a urinary tract injury. Like Mr Doherty, Professor Gupta believes medical studies often fail to focus on what is important to patients. ‘A day or two extra in hospital is not significant. What matters to the patient is returning to work, driving, shopping — what we call getting back to normal.’
To test his theory, Professor Gupta has commissioned a DVD showing the progress of two patients following an abdominal hysterectomy. They will be filmed doing things such as wallpapering and hanging out the washing within a few days of surgery.
Over the next six months, 200 women having the ‘old’ procedure at the hospital will be randomly divided into two groups — one group will see the DVD while the other won’t. Professor Gupta believes the first group is likely to get back to normal at least one week earlier than the others. But other surgeons using keyhole insist the technique’s advantages remain clear.
‘In surgery, you’re trying to achieve a particular objective and if you can do that in a less invasive way, it makes sense to do so,’ says David Redfern, an orthopaedic surgeon at Brighton & Sussex University Hospital and the London Foot and Ankle Centre. He has led the introduction of the keyhole technique for bunion surgery and says his results show patients experience less stiffness and soft tissue injury.
Another keyhole proponent is Mike Parker, chairman of the Royal College of Surgeons’ examination and assessments committee. He was one of the first surgeons to travel to Germany in 1987 to learn how to use the technique to remove gall bladders.
‘British patients would struggle to drink a glass of water after open surgery. I was astounded to see a German patient tuck into a huge breakfast after keyhole surgery. I was convinced of the benefits and remain so today.’ But he acknowledges patients can find it difficult choosing between different surgeons’ approaches.
‘You should feel able to ask your surgeon whether they feel confident in the procedure they’re offering. Ask them how many operations they’ve carried out and what their outcomes are. Ask them about any problems they have encountered. If they tell you, “I’ve never encountered any,” then they are being dishonest or haven’t done enough operations.’