C. Hospital Facility Factors

1. Lack of adequate operating facility and instruments

The set up of an operating room for laparoscopic surgery can be costly. Basic laparoscopic equipment allows basic laparoscopic surgery. Therefore for more advance laparoscopic cases, the hospital must be willing to invest on good laparoscopic equipment for patient safety.


2. Lack of training supportive personnel.

This is especially truth when caring for patient with morbid obesity.

Pictures of Incisions used for traditional open versus laparoscopic surgery

The incisions here are represented by th red dotted lines.

The picture of the left represent a classical midline incision and a left subcostal insicion.

The picture on the right represent a incisions used by laparoscopic approach. Usually it has three or more small ( less than 10 to 12 mm each) incision.

Some argue that the combination of these small incisions in lenght may be approximate the a large open incisions. Therefore, outcome should be quite similar. This statement is NOT TRUTH. As mentioned, post operative pain is less, complications is less, patients ambulate earlier, start oral intake ealier and likely to be dismissed from the hospital earlier.

B. Physician Factors

1. Lack of Adequate Training

The minimally invasive surgical technique started in 1991-1992 with laparoscopic gallbladder removal. Since the success of that operation, more than 90% of the gallbladder is now removed via minimally invasive technique. A more structural training for general surgery resident was not available until very recently. In fact for more advanced laparoscopic surgery (i.e laparoscopic esophageal surgery, laparoscopic liver and pancreas surgery etc), many general surgery resident has undertake an extra 1 or 2 years of training or so called the “ fellowship”. During the fellowship, they are properly supervised and taught by the respective authority in the field.

Therefore, it is possible that some of the general surgeons may not have the exposure to the minimally invasive surgery to allow to them to gain experience. Certain general surgeons, however, do engage in active learning and has acquired the necessary skill to perform these operations.

2. Lack of data to support the outcome of minimally invasive surgery.

This statement could have been truth 4 or 5 years ago. Many excellent surgical centers who had engaged in clinical study have subsequently answered the safety questions. Studies showed not only this minimally invasive technique are safe but is in fact more beneficial to the patients (as mentioned in previous page).

Laparoscopic surgery or minimally invasive surgery is SAFE in experienced hand.

3. Do not have the time.

No doubt that laparoscopic operation can be very time consuming, especially when they are at their learning curve. An open colectomy that usually take 1 to 2 hours to perform can takes up to 3 to 4 hours to perform. Despite the longer operating time, the recovery time for patient after the operation is certain much shorter and the risk of post operative complications is equally lowered as well

A. Patients Factors

1. Patient can not tolerate general anesthesia
It is essential that a patient is under general anesthesia for laparoscopic operations.

2. Patient body habitus
In many cases, patients that is has morbid obesity, laparoscopic operation is quite technically challenging to perform. Except when the laparoscopic operation is performed for weight lost. For example: Laparoscopic insertion of adjustable gastric banding system, laparoscopic sleeve Gastrectomy and laparoscopic RNY gastric by pass)

3. Patient had many previous abdominal operations
Many previous operations may have generated significant amount of scarring or so called adhesions. These increase the challenge of creating a “working space” within the abdominal cavity. These certainly will make the operation longer and perhaps increase the risk of iatrogenic injury to the internal organ. Some experience laparoscopic training surgeons are still willing to offer the minimally invasive approach to the patient knowing that should he/she encounter difficulty, the conduct of the operation will be changed to a traditional open approach.