Keyhole Surgery

Introduction

Keyhole surgery is also known as minimally invasive surgery, or arthroscopy. Traditional open surgery involves making incisions big enough to allow adequate visualisation and access. Keyhole surgery, on the other hand, involves inserting a small camera mounted on a long “tube” into the area where surgery is meant to be performed. The camera allows the surgeon to adequately see what he/ she needs to and safely perform the surgery.

What is the benefit of keyhole surgery?

Many patients think the benefit of keyhole surgery is cosmesis – scar will be smaller. But to a surgeon, while of course I understand cosmesis is important, it is of secondary importance. The advantages of keyhole surgery are:

There is little “collateral damage”.

What I mean by this is, some structures that need repairing are deep in the joint or the body. In order to access these areas adequately via open surgery, not only will the wound have to be rather large, many structures that lie superficial to the target area will need to be cut or injured. The shoulder is a classic example. Sometimes the injury to be repaired lies at the back of the shoulder joint. To access the area from the back will mean having to go through many muscles and risk injuring nerves and blood vessels in that area. To access the area from the front will necessitate dividing a large tendon that sits in front of the joint. With keyhole surgery, an otherwise formidable surgery which would have otherwise taken 2-3 hours accompanied with a lot of stress now may take less than an hour!

Superior visualization

Sometimes, surgical access to certain areas cannot be safely enlarged. There might be important nerves or blood vessels that will be jeopardized otherwise. Previously, surgeons would then have to make small incisions and “peek” through the small openings in order to see what they are doing. And if the damaged structure is deep, the surgeon would then have to struggle with sufficient lighting in order to illuminate the deep recesses sufficiently to allow him to see what he is doing. That makes for rather dangerous surgery. After all, I’m sure most patients would turn and run for the door if they found out their surgeon was half blind! With keyhole surgery, the tube camera has a bright light that illuminates the cavity extremely well. Not only that, the view on the camera can be zoomed so small structures can be easily seen. The live video feed can then be viewed real time on a high-definition television.

Ease of work

The long instrumentation designed for keyhole surgery has made surgical repair a lot easier as well. Certainly, there is a fairly steep learning curve and it takes years to become proficient with keyhole surgery. But once the skill is acquired, the surgeries become way more efficient than having to perform them via open surgery.

Less pain

Patients tend to experience less pain with keyhole surgery because there is less disruption to the surrounding tissue. Recovery is also faster because the surrounding tissues have less surgical trauma to recover from.

Less blood loss

This point is related to the points above. With less damage to surrounding tissue, less blood loss is encountered.

Another diagnostic option

In some patients, their problem cannot be reliably diagnosed, even with sophisticated scans like an MRI. In these patients, a diagnostic arthroscopy is made possible by modern keyhole surgery technology and techniques. Please read the section on “Investigations” to learn more.

Wow, keyhole surgery is awesome. Does anyone still do open surgery?

Absolutely. There are many incidences when keyhole surgery cannot be performed. Many surgeries such as bone fixation and joint replacement cannot be performed via keyhole surgery! Open surgeries are not “inferior” or older techniques. Your orthopaedic doctor will be able to discuss your condition in greater detail and recommend the best technique to get you fixed up.

How is keyhole surgery performed?

Keyhole surgery in orthopaedic surgery is often performed under general anaesthesia. Please refer to the section on general anaesthesia to learn more.

A small incision measuring 4-5 mm is made and a long tube is inserted into the area where surgery is to be performed. The tube has an inflow port that allows a continuous flow of saline in and a hollow where a camera lens tube can be inserted. The lens is then connected to a light source and a camera unit. A live, real-time video feed can then viewed on a high-definition television.

Other small incisions throughout which long instruments are inserted will need to be made. The number of incisions required depends on the nature and extent of the surgery.The attached images show a typical ultrasound image seen in a patient with tennis elbow and a small bone spur. It also shows how an ultrasound examination of a knee is performed.

What kinds of surgery can be done via keyhole surgery?

A wide variety of different surgeries in different joints can be treated via keyhole surgery. You should speak with your orthopaedic surgeon to enquire if the surgery you require can be performed via keyhole surgery.

Shoulder arthroscopy (keyhole surgery)
Image seen by the surgeon during arthroscopy (surgeon inset)
Surgeon's view with surgeon inset. Note: Image seen here is not as sharp as that seen by the surgeon during surgery!

Summary

Keyhole (or minimally invasive surgery) is a major advance in the field of orthopaedic surgery. Although the learning curve for surgeons is high, once mastered, many procedures can be performed much more quickly with comparable and often superior results compared to open surgeries. Not all procedures, however, can be performed via keyhole surgery. Not all surgeons have the experience or expertise to perform keyhole surgery as well. Speak to your doctor about keyhole surgery, if an operation is something you think you might require.

Disclaimer:

The above information is meant to be used as a guide and for patient education purposes. This article is not meant to be a used for self diagnosis or a substitute for professional medical evaluation or advice. As patients may be differing symptoms, please see your family doctor or orthopaedic specialist if you have any symptoms or worries.

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