Most shoulder operations can now be done through keyhole, but not all should be. A London shoulder surgeon explains the real differences and how the decision is made.
If you have been told you may need shoulder surgery, one of the first questions you will probably ask is whether it can be done through keyhole. It is a sensible question. Keyhole surgery usually means smaller scars and an easier first few weeks.
The short answer: most common shoulder operations, including rotator cuff repair, surgery for frozen shoulder and stabilisation for repeated dislocations, are now usually done as keyhole procedures. A smaller number, most notably shoulder replacement, still need an open approach, and for good reasons.
This guide explains what each approach actually involves, where the differences genuinely matter, where they matter less than you might think, and how a specialist decides which is right for your shoulder.
Keyhole surgery on a joint is known medically as arthroscopy, so if your GP or physiotherapist has mentioned a shoulder arthroscopy or an arthroscopic repair, they mean the same thing.
Instead of opening the shoulder through one large incision, the surgeon makes two to four small cuts, each usually under a centimetre. Through one of these, a thin rigid telescope called an arthroscope is passed into the joint. It carries a high-definition camera, and the joint is filled with sterile fluid under some pressure to create a clear view. The surgeon operates while watching a magnified image on a screen, using slender instruments passed through the other small incisions.
That magnified view is worth dwelling on for a moment. Inside a shoulder, an arthroscope can often show the surgeon more detail than the naked eye would see in open surgery, because the camera can be moved right up to the cartilage, tendons and ligaments and around corners that are difficult to expose through an incision. This is especially useful for diagnosing more subtle problems.
Most keyhole shoulder operations are done as day-case procedures. You will usually have a general anaesthetic together with a nerve block in the neck that numbs the shoulder and arm, which keeps you comfortable when you wake and often for the first 12-18 hours afterwards.
Open surgery uses a single larger incision, commonly five to ten centimetres depending on the operation, to expose the joint directly. Muscle is usually parted or detached and repaired rather than simply pushed aside, which is part of why the early recovery tends to be sorer and slower.
That may sound like the outdated option, but it is not. Open surgery remains the right choice, and sometimes the only safe choice, for certain operations:
Two of these differences deserve a closer look, because they are the ones patients ask about most.
Pain and the first few weeks. Keyhole surgery disturbs far less muscle.. Most patients need less pain relief, get moving earlier and find the early weeks more manageable than after an equivalent open procedure.
Infection. Infection is uncommon after either approach, and it is less likely after keyhole surgery because the wounds are small and therefore more difficult for bacteria to enter the operative field. Open surgery carries a somewhat higher risk for the same reason in reverse. Neither approach is risk-free.
The risks that apply either way. No shoulder operation is without risk. Alongside infection, both approaches carry a small chance of stiffness, ongoing pain, temporary numbness or weakness from the nerve block, blood clots, anaesthetic complications, and a repair that does not heal as intended and needs further surgery. Mr Baring will go through the risks that apply specifically to your operation and your health before you decide anything.
This is the point most websites skate over, and it is the single most useful thing to understand before your consultation.
The size of the incision determines how sore the journey in and out was. It does not change the biology of what was repaired. A rotator cuff tendon stitched back to bone needs roughly the same three to four months to heal securely whether the surgeon reached it through a one centimetre portal or a six centimetre incision. If you need a sling for four to six weeks after a keyhole cuff repair, that is not the surgery being slow. That is the tendon healing at the speed tendons heal.
So when you compare recovery times, be precise about what is being compared:
Keyhole surgery makes the early weeks kinder and lets rehabilitation start sooner. It does not let anyone skip the healing. A surgeon who promises otherwise is worth being wary of. If you want the detail of what those weeks look like, recovery after keyhole shoulder surgery sets it out week by week.
Most of the conditions we see week in, week out can be treated arthroscopically:
If your diagnosis is on that list, there is a good chance your operation can be done through keyhole. Whether it should be is a judgement that depends on your scan, your history and what you need your shoulder to do, which is exactly what a consultation is for. You can book an appointment with Mr Baring here.
It would be easy to write a page that says keyhole is modern and open is old fashioned. It would also be wrong, and any experienced shoulder surgeon will tell you so.
Open surgery is the better choice when the operation itself demands it: replacing the joint, fixing certain fractures, or revising previous surgery where scar tissue and altered anatomy make direct vision the safer route. In these situations the larger incision is not a compromise. It is what allows the surgeon to do the definitive job properly, once.
The question to ask is not can this be done through keyhole? but which approach gives my shoulder the best long-term result? Sometimes those answers are the same. Sometimes they are not.
In my experience: Mr Toby Baring
Prompt question: what do you say to patients who come in specifically asking for keyhole surgery?
Patients quite often arrive having decided they want keyhole surgery before we have looked at the scan together. I understand why, and most of the time that is exactly what they will have. But I always make the same point: the approach is chosen to fit the problem, not the other way round. My practice is arthroscopic or keyhole wherever it gives an equal or better result. Where an open operation will give a more reliable repair, I will say so plainly and explain why. The goal is to do the best operation for you, not what operation is going to give the smallest scar.
At a consultation, the choice between keyhole and open surgery, and indeed whether you need surgery at all, comes down to a few concrete things:
It is worth saying that a good proportion of the people we see do not need an operation at all. Injections, targeted physiotherapy and time resolve many shoulder problems. A consultation is an assessment, not a commitment to surgery.
For some shoulder problems, waiting costs you more than comfort. Rotator cuff tears can enlarge over time and the muscle can waste, which makes a repair harder and the result less predictable. A frozen shoulder left to run its own course can mean a long stretch of disturbed sleep and restricted movement.
None of that is a reason to rush into an operation. It is a reason to find out what you are dealing with while every option is still open to you, including the option of not operating at all.
Mr Baring sees patients in London, usually within days rather than months. Consultations are covered by all major private medical insurers, including Bupa, AXA Health, Aviva and Vitality, and self-paying patients are welcome.
Book an appointment or call 07561 812 682 to arrange a consultation.
Is keyhole shoulder surgery done under general anaesthetic? Usually, yes. Most patients have a general anaesthetic plus a nerve block that numbs the shoulder and arm, so you wake comfortable. The block often provides pain relief well into the next day.
How long does keyhole shoulder surgery take? Most procedures take between thirty minutes and an hour and a half, depending on what is being done. You will normally arrive and go home on the same day.
Will I have scars? Keyhole surgery leaves a few marks under a centimetre long, which usually fade to faint dots. Open surgery leaves a single scar, typically down the front or side of the shoulder, which softens and fades over a year or so.
When can I drive again? After minor keyhole procedures, often within one to two weeks, once you are out of the sling and can control the car confidently. After a rotator cuff repair, driving usually waits until after the sling comes off, commonly six to eight weeks in total. Mr Baring will give you guidance specific to your operation, and you should check your insurer's position.
Is keyhole surgery safer than open surgery? Neither is risk-free, and both have a good record in experienced hands. Keyhole surgery carries a lower risk of infection and less early pain. Open surgery is sometimes the sounder way to achieve a reliable repair. The right operation is the one that fits your problem.
How long will I be off work? Desk-based work: often one to two weeks after minor keyhole procedures, and two to four weeks after a cuff repair, once pain and the sling allow. Manual work takes longer, commonly three months or more after a repair, whichever approach is used.
Mr Toby Baring is a consultant orthopaedic surgeon specialising in shoulder and elbow surgery, with a particular interest in arthroscopic rotator cuff repair, shoulder instability surgery and shoulder replacement. Read more about Mr Baring or book an appointment.
