Laparoscopy, also known as keyhole or minimally invasive surgery, is a technique carried out under anesthesia that allows surgeons to access the inner abdomen and pelvis without making large incisions. The intent of laparoscopic surgery is to produce less perioperative pain, postoperative bleeding, and scarring for patients undergoing gynecological, urological, or gastroenterological surgical procedures as compared to open surgery [1]. While it certainly seems logical that a laparoscopic procedure would involve less perioperative pain for the patient than an open surgery, it is nonetheless critical to investigate the reported pain and complications associated with both types of procedures across different types of surgeries and with different patient groups, especially considering unique complications associated with laparoscopy (which include vascular injury and bowel perforation) [2]. Various studies over the past few decades have allowed doctors to better understand when laparoscopic procedures are preferred over open surgery to prevent perioperative pain and negative postoperative outcomes for patients.
An early study comparing patient experiences and outcomes during laparoscopic and open surgery was conducted in 2000 by Dr. Vic Velanovich, then a general surgeon from the Henry Ford Hospital in Detroit, Michigan. In his article, Dr. Velanovich discussed the purported advantages of laparoscopic procedures over open surgery—less pain and faster return to normal functional status—and the relative lack of studies which included validated measures of quality of life that could support this claim. The study itself aimed to bolster medical literature: patients who underwent one of four procedures (elective inguinal hernioplasty, esophageal surgery, cholecystectomy, and splenectomy), all of which could be conducted laparoscopically or through open surgery, were asked to complete an SF-36 survey of patient health outcomes (a well-tested and validated health status instrument) and were reassessed after six or more weeks post-operation [3].
The results supported the idea that laparoscopic procedures provided better quality of life post-operation than the same procedures conducted through open surgery for cholecystectomy, splenectomy, and esophageal surgery. However, survey results suggested that open hernioplasty produced equally good, if not better, postoperative quality of life results when compared with the results of its laparoscopic counterparts [3]. This last assertion was recently supported in a study by Bruce et al. (2021) in which the researchers found that laparoscopic hernioplasty in pediatric patients was associated with greater postoperative pain (measured through the postoperative use of analgesia) than that associated with open hernioplasty—and, in fact, the authors recommended that caudal and intraperitoneal anesthesia be considered for suitable patients who must undergo the procedure [4].
This early study provided a clear indication that it is necessary to examine the benefits and drawbacks of laparoscopic and open surgical procedures thoroughly for different types of surgeries and that a blanket assumption about the superiority of laparoscopic methods concerning perioperative patient health and comfort should not be made. Nonetheless, it remains true that, for many procedures, a laparoscopic surgery is preferred to minimize perioperative pain: a 2011 study by Enes et al. conducted at the Cantonal Hospital Zenica in Bosnia and Herzegovina reaffirmed the finding that laparoscopic cholecystectomy was preferable to open cholecystectomy with respect to reducing the intensity of postoperative pain, especially when patients were also treated with a local anesthetic [5].
Of course, changes in the surgical field mean that some research findings must be reassessed over time. In 2016, Allvin et al. of the Örebro University Hospital in Sweden conducted a study using an international registry of patients (PAIN OUT) to concretely measure the postoperative pain outcomes of patients undergoing an open versus laparoscopic colonic surgery. While patients who underwent the laparoscopic surgeries scored minimum pain at a higher rate than those who underwent the open surgeries, there was otherwise no significant difference in reported patient postoperative pain. This result, may suggest an improvement in the technology or technique surrounding open procedures and highlights the necessity of taking the continued development and improvement of surgical procedures and technologies into consideration when predicting patient outcome. Furthermore, as Allvin et al. conclude in this article, regardless of the technique used, it is critical to provide adequate analgesia to patients to ensure successful pain management after any invasive surgical procedure [6].
References
1. Laparoscopy (keyhole surgery) – NHS. https://www.nhs.uk/conditions/laparoscopy/ .
2. Complications of laparoscopic surgery – UpToDate. https://www.uptodate.com/contents/complications-of-laparoscopic-surgery.
3. Velanovich, V. Laparoscopic vs Open Surgery: A Preliminary Comparison of Quality-of-Life Outcomes. Surg Endosc 2000, 14 (1), 16–21. https://doi.org/10.1007/s004649900003.
4. Bruce, E. S.; Hotonu, S. A.; McHoney, M. Comparison of Postoperative Pain and Analgesic Requirements Between Laparoscopic and Open Hernia Repair in Children. World J Surg 2021, 45 (12), 3609–3615. https://doi.org/10.1007/s00268-021-06295-x.
5. Enes, H.; Semir, I.; Sefik, H.; Husnija, M.; Goran, I. Postoperative Pain in Open vs. Laparoscopic Cholecystectomy with and without Local Application of Anaesthetic. Med Glas (Zenica) 2011, 8 (2), 243–248.
6. Allvin, R.; Rawal, N.; Johanzon, E.; Bäckström, R. Open versus Laparoscopic Surgery: Does the Surgical Technique Influence Pain Outcome? Results from an International Registry. Pain Research and Treatment 2016, 2016, 1–5. https://doi.org/10.1155/2016/4087325.