Nonetheless, the clinic where the operation was performed banned all laparoscopic procedures until independent experts could confirm that surgeons are qualified to perform the operations.

The reaction of the clinic underlines one of many concerns about keyhole surgery: the lack of training of surgeons. While the training and skills level of the surgeon involved in the inquest case was never in question, it is widely accepted that the general level of skill is low, sometimes dangerously so. In Britain, the government has set aside £4m to train surgeons specifically in keyhole techniques.

This came as the result of a report by a working party of surgeons headed by keyhole surgery pioneer Professor Alfred Cushieri. The British government has refused to publish the findings which can only lead to speculation that the findings are far more alarming than the currently known facts.

Those facts are bad enough. New York State has reported 158 "adverse incidents" involving keyhole surgery between August 1990 and May 1992. Twenty four of these were "permanent or life threatening", and more than two thirds required further surgery to repair injuries. In the first 26 kidney laparoscopic operations in Washington University, nearly a third suffered complications. Those with major complications had to be operated on again using open surgery (The Lancet, 4 December, 1993).

Serious complications arise in 15 out of every 1000 procedures in gynecological operations, a favoured area for laparoscopic surgery, according to figures from the American Association of Gynecologic Laparoscopists. Three out of every 100,000 patients die as a result of the surgery.

Gynecological surgeons performing laparoscopic procedures seem to fit in one of two camps; they are either "kamikaze surgeons who will push the bounds of this surgery to the outer limits", or they are "as maladroit as a beetle on its back" (J of Gynecol Surg 1989; 5:131-2).

Gall bladder operations (cholecystectomies) are another favourite for laparoscopic techniques. However, in a recent American survey of 77,604 of these operations, over half of the deaths due to the surgery were attributed to complications of the laparoscopic procedure (Amer J of Surg 1993; 165:9-14).

In Britain, the first damages of £22,500 have been awarded to a woman who may need a liver transplant after a routine gall bladder operation went wrong when the surgeon accidentally cut her bile duct, which leaked and caused jaundice.

Deaths and serious complications are only to be expected with a surgeon untrained in laparoscopic techniques. Instead of the usual "hands on" experience he is used to, he has to have the skills of a video game player. He has to judge three dimensions by using a scope, instead of being able to see the organ in front of him, and then has to manipulate instruments. In a way, he is operating without the sense of touch, and with a different way of seeing.

In one American study in 1991, the incidence of damage to the bile duct fell from 2.2 per cent in the first operations performed to just 0.1 per cent once the surgeon had gained experience (New Eng J Med, 1991; 302:30-1).

A common complication is the puncturing of organs with the microscopic equipment, which accounted for three out of 10,000 complications in gynecological surgery in the US, and occurred in 0.05 per cent of laparoscopic cholecystectomies. Of these, two died as a result of the injury.