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 Table of Contents  
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 139-143

'Key-hole surgery' – A study on patient perceptions about laparoscopic surgery in Kerala

1 Department of Surgery, MOSC Medical College, Kolenchery, Cochin, India
2 Department of Surgery, Kerala Institute of Medical Sciences (KIMS), Trivandrum, India

Date of Submission29-Jul-2020
Date of Decision06-Aug-2020
Date of Acceptance13-Aug-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. Prof. Sanoop K Zachariah
Kerala Institute of Medical Sciences (KIMS), Thiruvananthapuram - 695 029, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ksj.ksj_5_20

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Background: Patients often demand laparoscopic procedures irrespective of the indications. There seems to be an increased awareness of laparoscopic procedures among the people of Kerala. To date, there is no published study about the patient's awareness, perceptions and understanding of laparoscopic surgery in India. Aims: The aim is to assess the knowledge and identify various factors associated with the patient's perception of laparoscopic surgery. Methodology: This is a prospective cross-sectional study, including 200 participants. Kuppuswamy's Scale was used to assess the educational and occupational status of the participants. Knowledge scoring was obtained utilising a structured questionnaire. An initial survey divided patients into two groups, namely, those who were aware of laparoscopy and those who were not. Patients who were aware completed the remaining questionnaire. Others were briefly educated about laparoscopy, using print and visual aids. They were then assessed for their preference for the surgical procedure. Results: Awareness about laparoscopic surgery was high (96.5%). Friends and family (62%) contributed a major source of information and the least by the media (11.5%). 30.5% did not know that laparoscopy required special equipment. Interestingly, 56.5% were unaware of the requisite of gas insufflation. Educated participants had significantly better awareness. 55% had a good knowledge score. About 81.5% claimed their preference for laparoscopic surgery even if it were to cost more. Conclusion: The local population are well informed about laparoscopic surgery. The disadvantages are less known. Awareness through mass media is less. Health-care providers should focus their attention on deficient areas of awareness.

Keywords: Key-hole surgery, laparoscopy; patient perception, minimal access surgery, patient awareness

How to cite this article:
George S, Zachariah SK. 'Key-hole surgery' – A study on patient perceptions about laparoscopic surgery in Kerala. Kerala Surg J 2020;26:139-43

How to cite this URL:
George S, Zachariah SK. 'Key-hole surgery' – A study on patient perceptions about laparoscopic surgery in Kerala. Kerala Surg J [serial online] 2020 [cited 2022 Jun 26];26:139-43. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/139/300243

  Introduction Top

Laparoscopic surgery, popularly referred to as 'keyhole surgery' has brought about a paradigm shift in the surgical procedures performed worldwide and has become the standard of care for a vast majority of operations across various specialities.[1] Today, patients also seem to be familiar with terms such as laparoscopy, key-hole surgery and minimally invasive surgery. The general public has access to a wide range of health-care information readily available at their fingertips made available through social media, television programmes, print media and online resources.[2],[3],[4] This phenomenon has been casually referred to as the emergence of the e-patient.[5]

Kerala, situated in southern India, has the highest literacy rate, quality health services, lowest maternal mortality rates and lowest infant mortality rate in India, which is comparable to that of developed countries.[6]

Very often, patients demand laparoscopic procedures irrespective of the indications. This is probably due to higher literacy rates in Kerala, coupled with the dissemination of health-care information through media. This may contribute to unrealistic expectations. No study has reported the patient's perceptions of laparoscopic surgery in Kerala. A literature search identified only four studies about the perception of laparoscopic surgery.[1],[4],[7],[8] There were none from India. The scope of the present study was to find out the patients' perception of laparoscopic surgery. The paper aims to evaluate the cognition of patients regarding laparoscopic surgery (key-hole surgery) and to identify the various factors that are associated with a patient's perception of this procedure.


A prospective cross-sectional study was performed over a period of 2 months involving patients between 18 and 85 years admitted to surgery and gynaecology wards. Immediate post-operative patients (<24 h following surgery) were excluded from the study. All data were maintained confidential. Informed consent was obtained. We calculated the sample size by using the formula n = Z21−α/2 P (1 − P)/(P€)2 as 200, [where, Z1−α/2 = 1.96 (5% α), P-proportion, €-error. here, P = 66% and € = 10% ].

We used a validated questionnaire and literature on laparoscopic techniques. There were demographic details, patient's familiarity with open and laparoscopic procedures and specific questions about laparoscopic surgery, including basic technical details. The patients were divided into two categories, those who have heard about laparoscopy and those who were not aware of laparoscopy. Those unfamiliar with laparoscopy were given literature on laparoscopic and open surgeries. This group was then asked about their preference for open or laparoscopic surgery and the causes behind their choice were recorded. The methodology flowchart is depicted in [Figure 1]. Categorical variables were summarised using frequency and percentage. Quantitative variables were summarised using median and inter-quartile range (IQR). Chi-square test was performed to identify the various factors that were associated with a patient's perception of laparoscopic surgery.
Figure 1: Flowchart of methodology

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  Results Top

Of 200 patients, 164 were female and 36 were male (male:female = 9:41). These patients were categorised into two groups; Group A had 193 (96.5%) patients who were aware of laparoscopic surgery and Group B had 7 (3.5%) patients who were unaware. Among Group A patients, the major source of information was friends and family (62%), followed by the referring physician (23%) and media (11.5%) [Table 1].
Table 1: Source of information

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To evaluate the cognition of patients regarding laparoscopic surgery, Group A [Table 2], participants were further categorised into three groups to assess their depth of knowledge. We have an estimated median and IQR of knowledge score regarding laparoscopic surgery, as data violate normality assumption. It was observed that the median score was around 16 with Q1 = 13 and Q3 = 18. We have categorised the knowledge score into poor, average and good based on the number of correct responses in the questionnaire.
Table 2: Knowledge score

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It was observed that 55% have good knowledge, 40.5% have average knowledge and only very few (4.5%) have poor knowledge. The breakdown of correct responses for 20 questions for assessing the knowledge of patients regarding laparoscopic surgery is shown in [Table 3].
Table 3: Frequency of correct response of the questionnaire

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Majority of the patients (>90%) were aware that laparoscopic surgery is performed through small incisions and therefore leaves only a small scar, requires less hospital stay, associated with less pain, and is associated with faster recovery. Only 69.5% of the patients were aware that special equipment was needed for the procedure, and only 62.5% were aware of the fact that the procedure was done under video guidance. Interestingly, the results also revealed some misconceptions associated with the patient's awareness of laparoscopic surgery. Only a few people were aware of the technical aspects associated with laparoscopic surgery. They were less aware of the disadvantages. About 81.5% of the patients (which included patients after the health education) showed their preference for laparoscopic surgery even if it costs higher.

Factors associated with a patient's perception of laparoscopic surgery, namely the educational and occupational status of the participants, are given in [Table 4] and [Table 5] (according to Kuppuswamy's Scale). The most educated patients professional/graduate/Higher Secondary school/High school) had a significantly better understanding about laparoscopic procedures (P < 0.05) than the least educated participants (primary school/read and write/illiterate).
Table 4: Educational status

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Table 5: Occupational status

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Chi-square test showed that in the association between knowledge score with variables such as age, gender, occupation, education and operative status, only education was significantly (P < 0.05) associated with knowledge score [Table 6].
Table 6: Association between knowledge score and different variables

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On analysing if patients would prefer laparoscopic surgery even if it costs higher, it was observed that 81.5% (163) of the patients would prefer laparoscopic surgery even if it costs higher. Moreover 59% of the population were willing to pay >50%, more for laparoscopic surgery [Table 7].
Table 7: Preference-based on cost

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  Discussion Top

As far as we know, this is the first survey done in India to evaluate the awareness of laparoscopic surgery among patients. Furthermore, this is the first study done in the state of Kerala, the population of which has the highest literacy rate in India.

Majority of patients (96.5%) were aware of laparoscopic surgery, was contrary to findings from similar studies.[1],[4],[7] This is attributed to the higher literacy rates and superior quality of health services provided to this population of Kerala. Regarding the various factors that were associated with the patients' perceptions, only education showed significant association (P < 0.05). This also was probably a reflection of the high literacy rate of the population of Kerala. Similar findings were observed in the studies from Ghana and the USA.[1],[4]

Mass media is a well-known effective tool for education and dissemination of health-care information to the public. However, we found that the primary source of awareness was friends and family members. The role of mass media was the least. This means that the health care information delivery by the media has less impact on the people of Kerala.

Smaller incision, less pain, faster recovery and shorter hospital stay are the advantages. Here, only a few were cognizant about the complications of laparoscopy. People, therefore, seem to be more aware of the positive outcome of these techniques. Hence, patients probably need to be counselled and educated about the pros and cons of laparoscopy before the surgery.

The awareness of certain basic technical aspects was less. A large percentage of patients who knew about laparoscopy were unaware that gas (like CO2) is insufflated into the abdomen during the procedure. Furthermore, many were unaware that procedure is video-guided, requires specialised instruments and about special training required by the surgeons. We, therefore, feel that it is important to inform and educate the people on these aspects before surgery. It would make sense if the patient knows that their surgeon has been specially trained to do the procedure.

This study was able to unravel certain misconceptions about patients' understanding of laparoscopic surgery. Many patients believed that laparoscopic surgeries were not or do not involve major surgical procedures since these operations use only small incisions. It could, therefore, be argued that the patients probably consider laparoscopy as easy to perform surgeries that are synonymous with minor procedures.

Patients' preferring laparoscopic surgery, even if it costs higher, suggests that people nowadays prefer high-quality health care irrespective of the cost. This is found to be similar in the study done in Ghana.[1] However in another similar study, the cost was reported to not affect the choice of method.[7] The key-points of the study are summarised in [Table 8].
Table 8: Key points

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  Conclusion Top

Although a significant percentage of the local population were aware of laparoscopic surgery, mainly in the light of the advantages that this form of surgery offered, many were unaware of the disadvantages, basic technical considerations and possible procedural complications. This suggests that more emphasis should be placed on pre-operative counselling and health-care information so that they are well informed and can make truly informed decisions to reduce misconceptions and unrealistic expectations.


Department of surgery for their encouragement, ICMR for granting STS Award and studentship and Department of Bio-statistics for statistical help and the Medical College Administration for permission for conducting the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Gyedu A, Fugar S, Price R, Bingener J. Patient perceptions about laparoscopy at Komfo Anokye Teaching Hospital, Ghana. Pan Afr Med J 2015;20:422.  Back to cited text no. 1
Ventola CL. Social media and health care professionals: Benefits, risks, and best practices. P T 2014;39:491-520.  Back to cited text no. 2
Davis WM, Ho K, Last J. Advancing social media in medical education. CMAJ 2015;187:549-50.  Back to cited text no. 3
rani M, Prabakar C, Nematian S, Julka N, Bhatt D, Bral P. “Patient Perceptions of Open, Laparoscopic, and Robotic Gynecological Surgeries”, BioMed Research International, vol. 2016, Article ID 4284093, 6 pages, 2016. https://doi.org/10.1155/2016/4284093  Back to cited text no. 4
Masters K. The e-patient and medical students. Med Teach 2016;38:314-6.  Back to cited text no. 5
Park K. Textbook of Preventive and Social Medicine. 24th ed. Bhanot Publishers, India 2017 p. 520-1, 594-604  Back to cited text no. 6
Khalil, Susan S. MD; Altinbas, Sadiman K. MD; Desai, Kaveta MD; Sirota, Ido MD; Silverman, Henry J. MD; Nezhat, Farr R. MD; Patient Understanding, Attitudes, and Perceptions of Laparoscopic and Robotic-Assisted Laparoscopic Gynecologic Procedures, Obstetrics & Gynecology: May 2015 - Volume 125 - Issue - p 91S [doi: 10.1097/AOG.0000000000000816].  Back to cited text no. 7
Joseph SP, Moore BT, Slayden G, Sorensen GB, Boettger C, Potter D, et al. Patient perception of single-incision laparoscopic cholecystectomy. JSLS 2013;17:585-95.  Back to cited text no. 8


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]


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