Summary

  • This report summarises the status of laparoscopic surgery in Australia in early 1994, reviewing developments with the most significant procedures.
  • Laparoscopic cholecystectomy has replaced most open cholecystectomies in Ali$tralia. The rate of diffusion of this technique has been very high; other laparoscopic methods are evolving more slowly. A higher rate of bile duct injury is of concern. Cost savings to the health care system have been eroded  by increased  cholecystectomy  rates since the introduction of laparoscopic cholecystectomy. The laparoscopic method has produced cost savings and other benefits to society.
  • Laparoscopically assisted  hysterectomy may not offer cost advantages to the health care system. Serious complications  are of concern. Limited numbers have been performed  in Australia  to date and endometrial ablation/ resection is an alternative for some cases.
  • Laparoscopic appendicectomy is safe and effective, but opinions differ as to its relative effectiyeness in comparison with open appendicectomy. It may not offer cost advantages to the health care system. It has been in use at some centres in Australia for a number  of years, with rates rising slowly.
  • The safety and effectiveness of laparoscopic vagotomy  have yet to be determined. It may replace some open vagotomy  and medical treatment.
  • Techniques  for laparoscopic repair of groin hernias are still developing. The relative safety in comparison with open alternatives is of concern, and long-term recurrence  rates are unknown. Cost advantages to the health care system may be small or non-existent.
  • Like laparoscopic vagotomy, laparoscopic fundoplication has not been proven safe and effective, but has the potential to impact on high-cost medical treatment as well as open surgery.
  • Laparoscopic bowel resection  requires considerable skill and training, and has not been proven more effective or safer than open surgery.
  • Laparoscopic techniques are diffusing more slowly in urology  than in general surgery, and their role is yet to be determined.
  • Laparoscopy has an emerging role in the diagnostic area complementary to conventional scanning techniques. Its comparative accuracy is not well established to date.
  • Thoracoscopic techniques have been developed  for a number  of open procedures. For procedures such as lung biopsies, excision of cysts and sympathectomy, the thoracoscopic  technique may become the preferred  approach, but its role has not been determined for other procedures.
  • Difficulty in performing procedures laparoscopically appears to have changed standard surgical practice in at least one instance.
  • Instrumentation and equipment are evolving rapidly, confronting  hospitals with issues of the timing and costs of upgrades. Relative overall costs of disposable  and reusable instruments are still uncertain.
  • The safety of laparoscopic techniques and training in their use remain important issues.
  • Other issues that have arisen include:
    • use of laparoscopic procedures in day surgery;
    • public demand and funding mechanisms driving diffusion of new procedures before their safety and cost-effectiveness are established;
    • changes to hospital infrastructure;
    • the cost of major complications.
  • Further  work is needed to determine:
    • safety and effectiveness of some laparoscopic procedures;
    • relative advantages and disadvantages of other laparoscopic procedures over open surgical alternatives;
    • long-term complication  and recurrence  rates.