Keyhole Surgery

Keyhole surgery, or minimally invasive surgery, is a surgical method used to access the interior of the body through a small incision, removing the need for open surgery. 1 2

Keyhole surgery is most commonly used to access the abdomen and the female pelvic organs in a procedure known as a laparoscopy. 2 When used to access the thorax, the medical name for the chest, the procedure is known as video-assisted thoracoscopic surgery. 3 Keyhole surgery on a joint, such as the knee, is called an arthroscopy. 4

During keyhole surgery, a thin rod, fitted with a telescopic lens, light source and a camera is passed through a small incision in the skin, giving doctors a magnified view of the inside of the body. 1 The rod is called an endoscope. Surgical instruments can also be passed through the incision, allowing surgeons to operate.

Keyhole surgery may be used to diagnose certain medical conditions, as well as perform a variety of surgical procedures, such as the removal of damaged or diseased organs, or parts of organs.

Keyhole surgery is a commonly performed procedure with a number of advantages over traditional open surgery. These include reduced recovery times after the surgery and reduced levels of pain, scarring and hemorrhaging. The procedure is generally safe, though possible complications do exist.

This resource is primarily about laparoscopy, but includes a section on other types of keyhole surgery too.

A laparoscopy can be used to diagnose and treat a range of conditions. 1 2

It is most commonly used in:

• Gastroenterology. To diagnose and treat conditions related to the digestive system
• Gynecology. To diagnose and treat conditions related to the female reproductive system
• Urology. To diagnose and treat conditions affecting the urinary system

If non-invasive diagnostic methods like ultrasound or CT scans prove ineffective or produce no conclusive results, keyhole surgery may be necessary. Keyhole surgery may be used to help diagnose conditions including: 1 2 5 6

• Appendicitis
• Inflammation of the gallbladder/gallstones
• Pelvic inflammatory disease
• Endometriosis
• Ectopic pregnancy
• Ovarian cyst
• Fibroids
• Female infertility
• Unexplained abdominal or pelvic pain

Keyhole surgery may also be used to obtain a tissue sample in a procedure called a biopsy. This involves extracting a small amount of tissue from the relevant area, before sending it to a laboratory for analysis. The information collected by performing a biopsy can help diagnose and differentiate between various types of tumors, which may be cancerous or non-cancerous growths.

Feeling unwell? Get a free symptom assessment with the Ada app.

Keyhole surgery can also be used as a treatment option. It is commonly used to: 1 2 7 6

• Remove the appendix in cases of appendicitis
• Remove the gallbladder
• Remove sections of the intestine
• Treat hernias, which is when an organ or part of an organ protrudes through a weak spot in the abdominal wall
• Treat problematic stomach ulcers
• Remove or partially remove organs affected by cancer, including the ovaries, kidneys, colon, liver, prostate and bladder
• Treat ectopic pregnancy
• Remove fibroids, which are non-cancerous tumors that can develop in the womb
• Remove the womb, for example in cases of pelvic inflammatory disease or endometriosis

Laparoscopy is normally performed under general anesthesia. This means that the person undergoing surgery is put to sleep and woken up once the procedure is complete. 1 2

Once under general anesthesia, the person’s skin will first be cleaned, before a number of small incisions are made through the skin. If the laparoscopy is only for diagnosis rather than to treat a specific illness, generally only one incision needs to be made. Otherwise, multiple incisions will usually be necessary in order to allow different surgical instruments to be used during the procedure. A more modern technique called a single-port laparoscopy allows doctors to perform treatment operations using a single incision. 1

Gas, usually carbon dioxide or, more rarely, nitrous oxide, is inserted through one of the incisions, inflating the abdomen and allowing doctors to see more clearly. 1 2 8 9 The laparoscope will then be inserted through an incision so doctors can use the attached camera to see images from inside the cavity.

After the procedure is complete, all instruments will be removed, and the incision will be stitched up and dressed. 1 8

Before going under general anesthesia, a period of fasting will generally be necessary. This means no food or drink can be consumed for six to 12 hours beforehand, as well as refraining from chewing gum and smoking. Doctors will give specific instructions on how to go about this, and these will need to be followed closely. 1 2

After the procedure, people who have undergone keyhole surgery will be observed in hospital for a number of hours while having their vital signs monitored. A person will generally be able to go home on the day of the laparoscopy, but this will depend on a number of factors, such as the condition of the person and the reasons for the operation. For example, a hysterectomy to remove all or part of the womb will generally require an overnight stay at the hospital. 1 2 10

In the hours and days following laparoscopy, a person may experience the following symptoms: 10 11

• Mild to moderate pain in the area where the incision was made, e.g. the lower abdomen
• Sometimes pain in the shoulder area due to the gas
• Bloating, also due to the gas
• Nausea, due to the anesthesia and gas
• Sore throat, because of the tube used to assist with breathing during the surgery
• A small amount of vaginal bleeding

Painkillers may be prescribed by doctors for the stomach and shoulder pain. Lozenges or gargling salt water may help with a sore throat. These symptoms should all wear off in a few days. Contact a doctor for advice if they persist any longer. 10 11

It is common for a person to feel more tired than they usually would in the weeks following the operation. This is largely because the body is using up extra energy to heal itself. Regularly taking naps may help with the tiredness. 2

If keyhole surgery has been used to diagnose a condition, regular activities can normally be resumed in under a week. 1 10 If used to treat a condition, recovery times can range between two and 12 weeks, depending upon what kind of surgery has been undertaken. 2

Laparoscopic surgery has a number of advantages over traditional open surgery, as it generally causes less pain and has fewer risks. However, as with any surgical procedure, complications can arise, albeit rarely. Minor complications are more common than major complications and can often be dealt with quickly by doctors.

Possible minor complications include: 12 13 14

• Nausea or vomiting
• Bruising or bleeding around the incision
• Infection of the incision area
• A hernia
• Trapped air underneath the skin and joints causing popping or cracking sounds, known as crepitus

Possible major complications include: 12 13 14

• Doctors being forced to convert the operation into traditional open surgery, i.e. make a larger incision through which to operate
• Deep vein thrombosis, which is when a blood clot forms in a vein deep in the body and can lead to pulmonary embolism
• Damaged organs, which could lead to organ failure
• Injured blood vessels/artery damage
• Injured urinary tract
• Injured nerves
• Complications associated with the use of carbon dioxide during the procedure, e.g. gas bubbles entering the bloodstream
• Infection of deeper areas beyond the incision, involving the entire abdominal wall or the lining of the abdominal cavity
• Increased pressure on the heart, which may cause problems for those affected by heart disease and other cardiac issues
• The development of cancerous lesions inside the abdominal wall after keyhole surgery to remove other tumors, known as port-site metastasis.
• A collapsed lung, also known as pneumothorax

A doctor should be called if any of the following symptoms are experienced following a laparoscopy: 1 10

• Fever or a temperature of 38 C / 100 F
• Severe pain that keeps getting worse
• Any pain, redness, swelling, discharge or bleeding around the incision area
• Intense vomiting, e.g. repeatedly and with little time between vomits
• Feeling very cold with no explanation
• A burning sensation when urinating
• The feeling that the bladder is still full after urination
• A significant amount of vaginal bleeding or unusual vaginal discharge
• Pain or swelling in one of the legs

Feeling unwell? Get a free symptom assessment with the Ada app.

There are a number of advantages of keyhole surgery over traditional open surgery. 1 10 15

Reduced physical impact: Operating through small incisions rather than large open wounds typically reduces the amount of blood that is lost, as well as the pain and discomfort that is felt by the patient after surgery. Due to the small size of the instruments used during the procedure, tissue damage is also reduced. On the outside of the body, this can result in smaller scars, giving improved cosmetic outcomes compared to open surgery.

Reduced risk of complications: After the procedure, the risk of complications such as infection, hernia and cellulitis, a bacterial infection of the skin and tissues beneath the skin, is also lessened.

Reduced recovery time: The necessary recovery time after keyhole surgery is also shorter than that following open surgery, reducing the risk of conditions associated with extended periods of bed rest such as muscle atrophy, bone loss and pneumonia. Given the small size of the incision, scarring is also significantly reduced.

Good to know: There are, however, disadvantages of keyhole surgery. The primary drawback is that, due to its complex nature, keyhole surgery can often take longer to perform than open surgery, therefore also requiring a longer period under general anesthesia. 3

Keyhole surgery on a joint, such as the knee, is known as an arthroscopy, and keyhole surgery on the chest is known as video-assisted thoracoscopic surgery.

Just like a laparoscopy, an arthroscopy can be used for both helping doctors with a diagnosis and treating certain conditions. Some of the common reasons for an arthroscopy include: 16 17

• Chronic inflammation
• Cartilage and tendon tears
• When small bits of bone become loose from the joint
• Arthritis

The following parts of the body are where arthroscopies are most commonly used: 16 17

• Knee, e.g. for meniscal cartilage tears and anterior cruciate ligament tears
• Ankle
• Shoulder, e.g. for rotator cuff tendon tears and repeated dislocations
• Elbow
• Wrist, e.g. for carpal tunnel syndrome
• Hips

A person will usually be able to resume normal activities a few days after an arthroscopy. However, a longer break from any sporting or high impact activities will likely be required.

VATS is used to operate on conditions that affect the chest and lungs. When the operation is purely for diagnostic reasons, it is sometimes known as a pleuroscopy.

VATS works in much the same way as a laparoscopy, with a general anesthetic used during the operation and small incisions being made through which to guide an endoscope. Some of the reasons doctors may use VATS include: 18 19 20

• Removing small samples of the lung or its lining for laboratory testing
• Removing lymph nodes
• Removing tumors or growths and checking if they are cancerous
• Removing an entire organ, such as the lung
• Treating chest trauma
• Treating various lung conditions, such as pleural effusion, also known as water on the lungs

A person is generally kept in hospital for a few days after this type of surgery, but this depends on a number of factors, including the specific reason for the operation.

• Laparoscopy
• Arthroscopy
• Thoracoscopy
• Video-assisted thoracoscopic surgery
• Pleuroscopy

Q: What is the recovery time for keyhole surgery?
A: The recovery time for keyhole surgery differs from case to case, depending largely on the reason why the procedure has been carried out. If keyhole surgery has been used to diagnose a condition, a person will normally be able to recover within five to seven days. If keyhole surgery has been used to treat a condition, recovery can take between two and 12 weeks, depending on whether the surgery was minor or major. 1 2

Q: What is robotic keyhole surgery?
A: Robotic keyhole surgery is when mechanical arms, controlled by surgeons from an operating console, are used for keyhole surgery. This is theoretically more precise than a surgeon using tools alone and thus lowers the risk of complications. The number of these machines in hospitals worldwide is increasing, but they remain expensive, and doctors using them require specialist training. 21

Q: How long does keyhole surgery last?
A: Anywhere between 30 minutes and four hours, potentially longer if there are complications. The time it takes largely depends on the reason for the surgery, as well as a number of other factors. 20