Before this time, operations had mainly been done under general anaesthetic using large incisions. Incisions had to be large for surgeons to get their hands and instruments into the relevant area to perform the surgery.

For instance, in the gallbladder surgery (cholecystectomy) an incision in some 10 to 20 cm long was generally made on the right side of the abdomen under the ribs through which the liver was retracted and the gallbladder removed. In the 1980s, laparoscopic cholecystectomy was introduced which allowed the same operation to be performed through a one to 2 cm incision at the bellybutton (umbilicus) and one or two other incision is usually about 5 mm long on the abdomen where other instruments were introduced. These very small incisions gave rise to the term keyhole surgery.

The reason that such keyhole surgery could be performed was the development of very clear cameras, allowing surgeons to see inside the body using the laparoscope. This is a 1 cm wide instrument through which light is passed to illuminate the inside of the body, and fibre optics are used to give an image back up the laparoscope. A camera then placed over the end of the laparoscope is connected to a video monitor, allowing surgeon and all assistants in theatre a magnified view of the surgery.

Not only this, but also an additional channel in the laparoscope allows instruments to be passed down the laparoscope to perform parts of the surgery. Companies and surgeons then developed other instruments that could be used to perform surgery through tiny 5 mm incisions, being guided by the laparoscope.

The excellent illumination provided by the laparoscope and the magnification obtained by using the system, allows fantastic views of certain difficult areas of the body and allows the surgeon to have access and good visualisation in areas that with open surgery cannot be reached. Even in areas that can be reached by open surgery, a magnified views and allow for much finer surgery to be performed.

The advantages of keyhole surgery or laparoscopic surgery are many including reduced postoperative pain, leading to reduced postoperative complications and earlier return to normal activity. In addition the scars are far at smaller at giving a better cosmetic result and on the inside, the reduction in scars means a reduction in the risk of adhesions (internal scarring) and the reduction in risk of bowel obstruction or internal pain in the future.

Operations that are now regularly performed with keyhole surgery are gallbladder surgery (laparoscopic cholecystectomy), appendix (laparoscopic appendicectomy), gynaecological operations such as hysterectomy or oophorectomy, hiatus hernia repair. Advocates of the keyhole surgery approach are now also performing bowel surgery and bowel cancer surgery using keyhole techniques, prostate operations, kidney operations, suprarenal or adrenal gland operations, and lung surgery and now even cardiac surgery.

Although keyhole surgery has been a major way forward in surgical practice, it does require a whole new set of skills for the surgeon to learn. In addition, certain operations such as varicose vein operations are now performed by pinhole surgery - surgical techniques performed through even smaller incisions and using imaging such as x-rays or ultrasound rather than the cameras to guide the surgeon.

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