Patients are often told they need “keyhole surgery”, then hear the words laparoscopic, robotic and minimally invasive used as if they meant the same thing. They overlap, and the differences count when you are deciding about an operation.
I specialise in keyhole surgery, including large and complex operations, such as big fibroids and deep endometriosis, that are often done as open surgery. Since 2013, more than 99 in 100 of my abdominal operations have been keyhole rather than open (about these figures).
Open surgery
In open surgery the operation is carried out through a single incision large enough for the surgeon’s hands, usually across the lower abdomen just above the bikini line, or sometimes up and down the middle. Recovery is usually slower and the hospital stay longer than after keyhole surgery.
Keyhole surgery
Keyhole surgery is the everyday name for surgery carried out through small incisions rather than one large one. For a laparoscopy there are usually between one and four of them, each between half a centimetre and a centimetre long [1], and a slightly larger one is sometimes needed to remove tissue. A slim camera shows the inside of the abdomen on a screen, and fine instruments pass through the other incisions. The abdomen is gently inflated with carbon dioxide gas to give room to work.
“Minimally invasive surgery” is the wider medical term for the same idea: reaching the operation through the smallest possible openings. It covers keyhole surgery and also hysteroscopy, which is carried out through the cervix with no incision at all. It is where the MI in MIGynaecology comes from.
There are two forms of keyhole surgery.
Laparoscopic surgery
In laparoscopic surgery the surgeon holds and moves the camera and instruments directly, watching the screen. The camera is called a laparoscope, which gives the operation its name, and “a laparoscopy” often means a look inside without any treatment. It is well established and used for a wide range of gynaecological operations.
Robotic surgery
In robotic surgery, the surgeon sits at a console in the operating theatre and controls the camera and instruments, which are mounted on robotic arms. The da Vinci system I use gives a three-dimensional, high-definition view, magnified up to ten times, and instruments with joints that bend like a wrist. It has no independent movement; every movement follows the surgeon’s hands. A surgical team stays beside the patient throughout.
For complex operations I prefer robotic surgery, because these features help me work precisely deep in the pelvis, for example when removing large fibroids and repairing the womb afterwards, or removing deep endometriosis close to the bowel, bladder and ureters (the tubes that carry urine from the kidneys to the bladder). The evidence for robotic surgery is set out on the robotic and keyhole surgery page.
How the choice is made
In my experience, for many gynaecological operations laparoscopic and robotic surgery give similar results, and the Royal College of Obstetricians and Gynaecologists’ review of robotic surgery does not say that it is better for every operation, noting that much of the evidence is not from randomised trials [2]. The choice depends on the operation, on what your scans show and on your own circumstances. I explain which approach I recommend and why, and we then decide together.
On rare occasions open surgery may be the right answer for you, and if so I will explain why. An operation that begins as keyhole surgery very occasionally has to be changed to an open one part-way through: since 2013, this has happened in around one in a thousand of my keyhole operations (about these figures).
If you have been told that your operation can only be done through a large open incision, you may find the second opinions page useful, and my practice manager, Helen, can arrange a consultation.