Keyhole surgery in plain language
Keyhole surgery is surgery carried out through several small incisions rather than one large one. A slim camera, passed through an incision in or near the navel, shows the inside of the abdomen on a screen, and fine instruments are passed through the other incisions. The abdomen is gently inflated with carbon dioxide gas to create space to work safely. My article keyhole, laparoscopic, robotic: what the words mean explains the differences, with diagrams of each.
There are two forms of keyhole surgery, and I use both:
- Laparoscopic surgery, in which I hold and move the camera and instruments directly.
- Robotic surgery, using the da Vinci system, in which I control the camera and instruments from a console beside you in the operating theatre.
For most women, keyhole surgery means smaller scars, less pain, a shorter stay in hospital and a quicker return to normal life than open surgery. It is not right for every operation or every patient, and I will tell you honestly whether it is right for you. In my own practice since 2013, more than 99 in 100 of my abdominal operations (not counting hysteroscopies) have been keyhole rather than open, and around one in a thousand has needed to be changed to open surgery (about these figures).
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Open surgery
One incision, usually across the lower abdomen and typically 10 to 15 cm long, or sometimes up and down the middle.
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Laparoscopic (keyhole) surgery
Usually three or four small incisions of 5 to 12 mm: one in the navel for the camera and two or three lower down.
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Robotic (keyhole) surgery
Usually three small incisions of around 8 to 12 mm: one in the navel and one on each side at the same level, sometimes with a fourth higher up on your left (shown dashed).
What da Vinci surgery means for you
In robotic surgery I sit at a console in the operating theatre, a few metres from you, viewing a high-definition three-dimensional image of the inside of the pelvis, magnified up to ten times. The instruments are mounted on robotic arms and follow the movements of my hands precisely, with wrist-like joints that can turn in ways a straight laparoscopic instrument cannot. The system filters out the small natural tremor of the hand. It has no independent movement of its own, and a full surgical team is beside you throughout.
These features are most useful in complex operations deep in the pelvis, which is why robotic surgery is my preferred approach for them: removing large or awkwardly placed fibroids and repairing the womb afterwards, freeing organs that are stuck together, and removing deep endometriosis close to the bowel, bladder and ureters. I will recommend the approach that suits your operation and explain my reasons.
In a randomised trial we published in 2016, surgeons new to both techniques made fewer errors and completed simulated surgical tasks more quickly with the robot than with conventional keyhole surgery using a three-dimensional screen [1]. In an earlier study I published in 2013, knots tied with the robot under test conditions were as tight as knots tied by hand, and more secure [2].
The wider evidence points the same way. The Royal College of Obstetricians and Gynaecologists’ 2022 review of robotic surgery in gynaecology concluded that, compared with conventional keyhole surgery, robotic surgery improves surgical performance without lengthening operations, reduces blood loss and complications during and after surgery, and lowers the chance of having to switch to open surgery [6].
It also concluded that robotic surgery can be considered safe and a more effective tool for women having complex surgery, or with medical issues such as a BMI of 30 or more or lung problems. Much of this evidence comes from studies other than randomised trials.
My robotic operating lists run at Spire St Anthony's Hospital in Sutton and Nuffield Health Parkside Hospital in Wimbledon. On average I carry out more than 120 robotic operations a year, and I have carried out more than 2,000 keyhole operations in total.
Operations I carry out by keyhole surgery
Hysterectomy
A keyhole hysterectomy removes the womb, and usually the cervix, through small incisions, with the womb removed through the vagina. It may be recommended for heavy bleeding, fibroids, adenomyosis or endometriosis when other treatments have not helped, and it is a decision I never rush. Whether to remove the ovaries is a separate decision that depends on your age and circumstances, and we will make it together.
In complex operations I first free the ureters (the tubes that carry urine from the kidneys to the bladder) from the tissue around them, so that I can see and protect them throughout, an approach I developed and published [3]. You can read more about the alternatives on the pelvic pain, periods and general gynaecology page.
Myomectomy
A myomectomy removes fibroids while keeping the womb, for women who wish to preserve their fertility or their womb. Robotic myomectomy allows me to remove large fibroids and to stitch the muscle of the womb in layers. You can read more on the fibroids page.
Excision of endometriosis
I remove endometriosis by excision, cutting it out, wherever it is safe to do so, including deep endometriosis affecting the bowel, bladder and ureters. You can read more on the endometriosis page.
Other operations
I also carry out keyhole surgery for ovarian cysts, adhesions, hydrosalpinx (a blocked, fluid-filled fallopian tube) and caesarean scar niche repair, and complex prolapse surgery, including sacrocolpopexy and sacrohysteropexy. Rarer operations include removing cysts from behind the lining of the abdomen (retroperitoneal cysts), for which we have published a step-by-step keyhole technique [4].
Recovery after keyhole surgery
Recovery depends on the operation and on you, and I will give you a personal estimate before you decide. As a guide:
- Diagnostic laparoscopy or a short procedure: usually home the same day, with a week or so before you feel yourself again.
- Keyhole hysterectomy or myomectomy: usually one night in hospital. Most women are walking comfortably within a few days. I usually advise about four weeks before returning to work, or light desk work from home after about two weeks if you need it, and no heavy lifting for around six weeks.
- Surgery for deep endometriosis: usually a few nights in hospital and around four to six weeks or more before you feel back to normal.
Shoulder-tip pain from the gas used during surgery is common for a day or two and settles on its own. All surgery carries risks, including bleeding, infection, injury to nearby organs and blood clots. Occasionally it is safer to convert a keyhole operation to an open one. I will explain how these apply to you, and you will have full written information well before your operation.
Training other surgeons
I have been on the faculty of the Royal College of Surgeons, the Royal College of Obstetricians and Gynaecologists and the Minimal Access Therapy Training Unit (MATTU), and I now train other surgeons in robotic (da Vinci) and laparoscopic surgery. In 2018 my colleagues and I received the Kurt Semm Laparoscopic Video Award at the Global Congress of the American Association of Gynecologic Laparoscopists (AAGL). In 2023 we presented our work on training surgeons with augmented reality to close the top of the vagina at keyhole hysterectomy [5].
