Doctor, can you carry out keyhole circumcision for my son?

A parent once posed this question to a paediatric surgeon.

Perhaps, he meant doing the procedure with a laser – laser energy devices produce focused intense light that can be used to cut the skin, sealing blood vessels in the process, and thus, reducing the risk of bleeding.

This is very different from keyhole surgery. Such surgery, also called minimally invasive surgery, is performed within a body compartment, using a small telescope to visualise the targeted area and small surgical instruments to conduct the procedure.

The surgeon sees the video image on a TV screen captured via the small telescope, while the small instruments used are essentially tiny extensions of the surgeon’s hands through which small incisions are made.

Most surgical specialties make use of keyhole surgery.

For example, orthopaedic surgeons use them in joint surgeries, neurosurgeons use them in surgeries in the skull cavity, and ear, nose and throat surgeons use them for work in nasal passages or sinuses.

Keyhole surgery, also called minimally invasive surgery, is performed within a body compartment, using a small telescope to visualise the targeted area and small surgical instruments to conduct the procedure.

As a paediatric surgeon, the spaces I commonly perform keyhole surgeries are in the chest, the lungs, the oesophagus and the abdomen, on solid organs such as the liver, spleen and kidneys, or hollow structures like the intestines, urinary tract and bladder.

In short, keyhole surgery is used for operations on deep structures.

Keyhole surgery in children and babies has been around for many decades, but it wasn’t until the early 1990s that smaller instruments were made specifically for children.

The instruments and camera that we use for children are about 3mm in diameter, sometimes smaller.

Major paediatric surgical centres around the world preferentially perform keyhole surgery.

It is now a well-established technique, far from when it was labelled as experimental in the early 1990s.

There are a multitude of clinical trials showing that the keyhole method is superior to open techniques for certain operations (although not all procedures).

Cholecystectomy (removal of the gall bladder) is a very common operation in the adult population, and usually done by the keyhole method.

It’s unconceivable for this operation to be carried out primarily by the open method in this day and age, for both the adult and paediatric population.

The same goes with appendectomy, which is a very common emergency procedure.

The advantages of keyhole surgery over open procedures is mainly significantly faster recovery, less pain after the operation and better appearance of surgical scars.

Keyhole surgery generally takes an additional 10%-20% longer to perform, and costs at private hospitals are generally higher compared to an open surgery.

In some conditions, keyhole surgery may not offer much advantage over open surgery if such surgeries can done with a small incision.

However, for conditions like removing a part of an abnormal lung (congenital lung abnormality) in a baby who has yet to have symptoms, it is easier for parents to accept the prompt post-operative recovery and virtually scarless keyhole surgery over open surgery, which involves a big incision on the chest and a longer recovery.

So, how would you know if keyhole surgery is viable for your child’s surgical condition?

Sometimes, there is no choice in the matter, especially in an emergency situation. However for most operations in the chest and abdomen, keyhole surgery is possible.

In general, all surgeries involving child patients should be conducted by children’s surgeons (paediatric surgeons), especially if it is done through the keyhole technique.

The well-known quote “children are not little adults” has been paraphrased in these series of articles repeatedly. Children vary in their anatomy, physiology and psychology from adults. Adult surgeons are not trained to deal with these differences.

You need to do your research as to what is available locally and where your paediatric surgeons are based. Have a discussion with them as to the feasibility of keyhole surgery for your child’s condition and its benefits.

If needed, they may be able to point you to the right person to do the keyhole procedure if they don’t do it themselves.

This article is courtesy of the Malaysian Association of Paediatric Surgery. For further information, e-mail The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.