Laparoscopic surgery: improving patient outcomes
Posted on 19 Jul 2022
A specialist surgeon at Mediclinic Morningside is at the forefront of advanced laparoscopic surgery.
Dr Pieter Marais is a specialist surgeon at Mediclinic Morningside with a special interest in laparoscopic, endocrine and hernia surgery. As an innovator in his field, Dr Marais acquired specialised international experience at L’institut de recherche contre les cancers de l’appareil digestif (IRCAD) in France, and several other institutions in Belgium. This gave him the opportunity to enhance his skills and gain exposure to the newest technology and associated surgical techniques in laparoscopic surgery.
Laparoscopic surgery is a minimally invasive surgical or diagnostic technique done with the aid of a laparoscope, a small tube with a light source and camera, which is inserted into the abdomen or pelvis through a small “keyhole” incision. The laparoscope sends images of the inside of the abdomen or pelvis to a television monitor – so doctors are able to see inside the body without having to cut it open with large incisions. They’re guided by these visuals and only need tiny keyhole incisions to insert the surgical tools needed to perform operations.
Dr Marais has performed laparoscopic surgeries with much success, together with his team of Dr Nadine Broeze, a specialist in oncological breast surgery; surgeon Dr Jo-Anne Carreira; and anaesthetists Dr Anne Kruger and Dr Maria Ortega Gonzalez. These include Whipple procedures (removal of the head of the pancreas, first part of the small intestine, gallbladder and bile duct); colectomies; gastrectomies; diaphragm repairs; bowel obstructions, and others. “In consultation with other specialities, we also do urological and gynaecological procedures using minimally invasive techniques,” he says.
“As far as minimally invasive surgical techniques go, we’re way behind in South Africa. They generally don’t get taught in government or academic centres, due to costs and other operational issues. People are scared to try these techniques mainly because they’re not exposed to them.”
Yet much research has been done around laparoscopic techniques and enhanced recovery after surgery (ERAS). ERAS streamlines patient processes before, during and after surgery. By applying a set of surgical protocols, ERAS aims to shorten the length of stay for patients, facilitating early mobility and recovery and continuously improving patient outcomes and overall experiences.
That’s precisely why laparoscopic techniques should be widely employed, says Dr Marais. “The main advantage of laparoscopic surgery revolves around pain,” he explains. “Smaller incisions equal less pain, less pain equals quicker mobilisation, which equals a shorter hospital stay. It collapses traditionally accepted norms: there are no central lines, no nasogastric tubes and no catheters.”
Smaller incisions also dramatically reduce the instances of hernia (when an internal organ or other body part protrudes through the wall of muscle or tissue that normally contains it), and wound sepsis.
“Big cuts are very prone to hernia formation and sepsis,” explains Dr Marais. “We do not have that with the laparoscopic method. For example, I do all my appendix surgery with a laparoscope and our wound sepsis rate is zero, as opposed to an open appendicectomy, where it stands at around 30%, especially if the appendix is perforated [ruptures].”
Laparoscopic surgery also allows for early enteral nutrition – tube feeding – as opposed to the past thinking where a patient would slowly work up to eating normally due to ileus (bowel paralysis). The incidence of this with a laparoscope is much less. “Early enteral feeding is in fact proven to improve outcomes,” continues Dr Marais.
His main anaesthetist, Dr Kruger, studied in Belgium, where she learnt to use highly beneficial opiate-free anaesthesia. This better facilitates normal eating and improves outcomes after surgery. “The return of gut function is much quicker, patients don’t have constipation, and we basically feed them immediately post-op,” says Dr Marais.
“I can’t explain how much better the patient does postoperatively with opiate-free anaesthesia. There’s no nausea, a common side-effect of opiate anaesthesia, less pain and we get them up and out in two days if all goes well.”
Having the same teams working together regularly also facilitates quicker surgeries with better outcomes, adds Dr Marais. That’s why he and his team approach most big cases together, with the same scrub sister, the same floor nurse, and so on. “You know each other’s routines and preferred equipment. The quicker you can do it safely and effectively, the better.”
Dr Marais is particularly proud of a recent multifaceted laparoscopic surgery he and his team performed on a female patient in her early 40s. She had multiple cancers: a primary breast cancer as well as two primary colon cancers. As the patient was also a suspected BRCA2 gene carrier, which increases the risk of contracting breast, ovarian and other cancers, she had extra organs removed as a preventative measure. The team performed a bilateral mastectomy and oophorectomy (both breasts and ovaries were removed), as well as a hysterectomy (removal of the uterus).
At the same time, Dr Marais also operated on the patient’s colon. “We removed a tumour – an invasive adenocarcinoma – as well as two thirds of her colon, as that was full of polyps,” he explains. “We did an endoscopic mucosal resection – a minimally invasive procedure for removing suspect tissue or polyps from the colon – something that’s not commonly done. If you take out the entire colon, the patient has constant diarrhoea, so we prevent that where possible from a quality-of-life perspective. Lower down she had another small tumour that we removed with the colonoscope and for the rest we then did a right hemicolectomy – a procedure to remove the right side of the colon.”
What’s more, there was no abdominal incision whatsoever. “We extracted all the internal organs vaginally – the colon, the uterus and the ovaries,” explains Dr Marais. “Through increasingly common technical innovations, you can extract bigger and bigger things trans-vaginally or through the mouth. While laparoscopic-assisted vaginal hysterectomies aren’t really something new, what makes this one different is that we pulled the colon out through the vagina, which was possible because of the hysterectomy.”
“In the old days we would have done this by cutting the patient from the breastbone to the pubis. That would be six weeks of recovery with potential hernia or wound sepsis, which we simply do not have with the laparoscopic method.” This then removes the need for extensive operations with repeated admissions and anaesthesia.
In this patient’s case, the entire surgery was done in around seven hours and she was home within 72 hours. “What she looked like on day one post-op is not what you would expect,” says Dr Marais. “She was sitting up in bed playing on her phone. This example is something that we want to try and make the norm.”
Despite her great surgery result and neat margins, the patient is going for chemotherapy, as one needs to look at the overall mortality rate of her particular cancers as well as her young age, he adds.
“As with anything in medicine you have to customise your treatment plan to the problem,” concludes Dr Marais. “Laparoscopic surgery isn’t a fix-all in every case, but certainly when it applies, it’s a great way of operating, offering undeniable advantages.”
That said, safe surgery adhering to oncologic principles always comes first.