12 reasons why surgery by laparoscopy in gynecology is not popular in Malaysia

I have been performing surgery by laparoscopy surgery for more than 25 years. Unfortunately, the progress made in surgery by laparoscopy in gynaecology in Malaysia is very slow. These are the reasons I think why gynaecologists in Malaysia perform so few surgeries are performed by laparoscopy.

  1. You don’t get paid extra for performing Surgery by Laparoscopy
    Malaysian Private Health Care Act 1998 states that the fees that can be charged for a procedure is the same whether it is performed by laparoscopy or laparotomy. This means that if I were to perform a hysterectomy by an open laparotomy, vaginally or by laparoscopy, the doctor’s fees is the same. Surgery by Laparoscopy in gynaecology requires extra skills. It takes a long time to acquire these skills and the surgery takes a longer time to perform. Off course the benefits to a patient when undergoing surgery by laparoscopy compared to laparotomy are enormous. When the remuneration is the same, most gynaecologist do not have the incentive to learn and perform surgery by laparoscopy.
  2. Obstetricians in private practice are too busy delivering babies.
    Most OBGYN in the private practice are busy obstetricians. Obstetrics is a tough profession and time consuming. It will be difficult for some one who is doing a lot of obstetrics to spend time learning and practicing surgery by laparoscopy. Patients come in labour at any time of the day and sometimes when surgery by laparoscopy is being performed. As such a busy obstetrician will prefer to perform a quick laparotomy and attend to their patients in labour than to spend time performing surgery by laparoscopy.
  3. Patients trust their obstetrician and gynaecologists and do not question them
    Most patients have their own obstetricians who delivered their babies. They trust them immensely. So when they or their family members have a gynaecological problem that required surgery, their obstetrician who does not perform laparoscopy will suggest a laparotomy. They will not question their trusted obstetrician and ask whether if the surgery can be done by laparoscopy.
  4. Private Gynaecologist do not like to refer their patients out of their practice
    Most private gynaecologist who do not have the skills to perform surgery by laparoscopy will not refer their patients to their colleagues who perform this type of surgery. It is more common to tell the patient that surgery by laparoscopy is dangerous and has a lot of complications then to say that they cannot perform this type of surgery and a colleague can do so. As such the naïve patient will listen to their trusted obstetrician and undergo the surgery by laparotomy.
  5. Too many complications give laparoscopic surgery a bad name
    Most gynaecologists in private sector are keen to learn surgery by laparoscopy. Unfortunately they have had no opportunity to learn it while they were in the public or teaching hospitals. When they move to the private sector, they don’t have the time to go and learn surgery by laparoscopy because it takes a long time to acquire these skills. Most of them attend short workshops lasting a few days and then try to perform surgery by laparoscopy on their patients. These not so well trained gynaecologists, have a higher chance of having complications thus giving surgery by laparoscopy a bad name.
  6. No credentialing of laparoscopic surgeons in Malaysia
    There is no proper credentialing for laparoscopy surgery in Malaysia. Every gynaecologist whether trained of not can call themselves a laparoscopy surgeon and perform surgery by laparoscopy. More ever, in Malaysia it is a taboo to ask a doctor how many cases of a particular procedure he has done. As such Malaysian do not question their doctors skills.
  7. The public is not well informed about surgery by laparoscopy
    Unlike in most other countries in this region, some how women in Malaysia is not well informed about the benefits of surgery by laparoscopy. The media is not proactive to promote this type of surgery and so there is no demand from the public for surgery by laparoscopy. Since there is no demand from the public, there is no push for gynaecologists to learn the skills required to perform the surgery by laparoscopy.
  8. Strict advertising laws make it difficult for the public to look for good laparoscopy surgeons.
    If a patient is keen to get her surgery done by laparoscopy, it is difficult for her to find someone who is good at it. Malaysia has strict laws that do not allow doctors to advertise their skills. As such it will be difficult for the public to find the correct doctor to perform their surgery by laparoscopy.
  9. You don’t get good assistants when performing surgery by laparoscopy
    In most hospitals, nurses assist in all types of surgeries. It is difficult to train a nurse to be a good assistant in surgery by laparoscopy. This is because surgery by laparoscopy is performed by looking at a monitor. It requires the assistant to learn “hand eye coordination”. It takes a long time to train them. Many of them after being trained move to other hospitals or overseas where the pay is better. In private hospitals, most gynaecologists are solo practitioners even when they work in a big private hospital. They are dependen on nurses to assist them. As such many gynaecologist give up performing surgery by laparoscopy because of poor support from staff.
  10. No good equipment to perform laparoscopic surgery
    Surgery by laparoscopy requires good instruments. Most hospitals do not provide all the necessary equipment to perform surgery by laparoscopy.
  11. Public and University Hospitals are too busy to perform surgery by laparoscopy.
    Most gynaecologists are trained in the public or university hospitals. In the public hospitals, service is of utmost importance. There are too many patients and too little time. As such surgeries need to be done promptly. Laparotomy can be easily taught to junior doctors and they can perform the surgeries easily. When it comes to surgery by laparoscopy requires more time, more equipment and more training. So there is no incentive in the public hospitals to perform surgery by laparoscopy.
  12. There are not many teachers in surgery by laparoscopy in the Public Hospitals.
    As so few laparoscopic surgeries are performed in the public hospitals, there are too few specialist in the public hospitals who are skilled to teach surgery by laparoscopy. So most trainees are not exposed to surgery by laparoscopy When they become specialist they do not have the skill or the opportunity to perform surgery by laparoscopy. So they are not able to teach surgery by laparoscopy to their juniors. The cycle is repeated.



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Dr. Selva

Dr S. Selva (Sevellaraja Supermaniam) is a Consultant Obstetrician and Gynaecologist and a subspecialist in Reproductive Medicine at a private hospital in Melaka, Malaysia. He heads the O&G unit and the IVF Centre at the hospital.

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