ENDOSCOPIC & LAPAROSCOPICSURGERYDr.Anil Haripriya In the nearly 150 years since the urinary bladder wasfirst inspected telescopically, technical progress &therapeutic alternatives have been limited until the lasttwo decades. Intervention using endoscopy includedonly a slightly more extended view of existing spaces,but alternatives in therapy were not a reality. With theadvent of Video-endoscope allowing co-operative &assisted procedures, high energy light sources & high-flow insufflation of distending gases, the stage was setto provide alternative access for complex abdominalsurgical procedures. Thereafter followed an enthusiasticexplosion of “new” endoscopic procedures, the limit ofwhich was now only the imagination.Perhaps the best legacy of minimal-access surgery notto imply that an epitaph is being written - is analternative way of thinking. Surgery at the beginning ofcentury maintained that “more is better”. Whether inradical mastectomies or regional colectomies, the moreresected the better the cure. We have seen theupheaval of this paradigm in the later part of this
century, for which minimal access surgery can beconsidered the logical extension. With the movementtoward “less is more”, the door is open to analternative school of surgery.DEFINITIONSENDOSCOPY : examining the in-accessible bodycavities with the use of instruments through naturalorifices.LAPAROSCOPY : viewing the internal organs, usingsome form of a telescope, through ports made surgically& not through the already existing body orifices.“A revolution is evolution in leaps”Evolution: can be classified asI. Evolution of Laparoscopy.II. Evolution of Instrumentation (a) Endovision (b) Insufflation (c) InstrumentsIII Evolution of Operative (Therapeutic) Laparoscopy
I. EVOLUTION OF LAPAROSCOPY (in chronological order):1805: Philipp Bozzini, Germany , visualised the urethral orifice with candle light & a simple tube called “lichtleiter”. The “ lichtleiter” was presented to the Faculty of Medicine in Vienna in 1805 for viewing the human urethra. Unfortunately, the intended use of the instrument was considered an unnatural act & Bozzini was censured by this scientific body despite no evidence that this device was ever used on humans.1843: Desormeaux coined the term “Endoscopy”. He developed first urethroscope & Cystoscope using mirrors to reflect light from a kerosene lamp. He was awarded for the achievement.1874: Stein, Germany developed photoendoscope.1874: Nitze, Germany added lens system to the tube allowing magnification of the area viewed. Nitze, compelled by the concept of an internal light source, stated “in order to light up a room, one must carry a lamp into it”. He made a cystoscope with electrically heated platinum wire light source placed behind a quartz shield.1880: Thomas Edison, USA invented incandescent bulb.1883: Newman, Scotland, developed cystoscope using
a small incandescent light bulb at distal end.1901: Ott, Russian gynaecologist introduced “ventroscopy” for the inspection of abdominal cavity. He described the use of head mirror to reflect light into the speculum introduced through a small abdominal wall incision.1901: George Kelling from Dresdon introduced Nitze cytoscope into a living dog & used room air for insufflation. He called it “Kolioskopie”1910: Hans Christian Jacobaeus of Stockholm coined the term “thoraco-laparoscopy” · First published report of 72 cases. · Identified syphilis, tuberculosis, cirrhosis & malignancy. · Used trocar & cannula.1911: Bertram M. Berheim, USA coined the term “Organoscopy”. · Used proctoscope with illumination by electric headlight.1920: Orndoff, Intern from Chicago, USA used the term “Peritoneoscopies”. · Designed pyramidal trocar point.
· Invented valve for trocars to prevent gas leakage.1927: Heinz Kalk, a German hepatologist “Father of modern Laparoscopy” devised system of lenses for better visualisation. Introduced dual trocar. He used laparoscopy as a diagnostic method for liver & Gall Bladder disease.1928: Bovie introduced technique for diathermy1933: C. Fervers reported adhesionolysis and peritoneal biopsies. While using “Cold Caurtery” - electro- surgery & insufflating the abdomen with oxygen, Fervers described an explosion inside the peritoneal cavity with multiple audible “Detonations” and “Flames” visible through the abdominal wall. Thereafter, patient recovered but Fervers wisely argued against the use of oxygen.1937: John C. Ruddock, USA Intern-physician · Reported 500 laparoscopies involving 39 biopsies. · Published in Surgical Journal, even then, general surgeons did not embrace laparoscopy. Around this time enthusiasm was so great for this new procedure that Short, an English surgeon, advocated performing laparoscopy in the patients’ home adding interests to it domicilliary visit.
1980: Patric Steptoe from England started to perform Laparoscopic procedures in the operating room under sterile conditions.1982: First solid state camera was introduced.1994: A robotic arm was designed to hold the laparoscopic camera & instruments with the goal of improving safety, reducing resource utilization & improving efficiency & versatility of surgeon.1996: First live broadcast of laparoscopic surgery via the internet.II. EVOLUTION OF ENDOVISIONBreakthrough Points:1870s: Invention of Incandescent Light by Thomas Elva Edison. Development of Lens systems for scopes1960s: Invention of Rod Lens System by Hopkins and development of fiber optic cold light transmission1980s: Introduction of Computer Chip, Video Camera in 1985 by Circon Corporation (a) Endoscope
(b) Fiberoptic Cable (c) Light Source(a) Endoscope:1879: Nitze developed the first scope using 3 lenses and air filled scope Glass lenses relayed light more effectively than the mirrors employed by Bozzini & Desormeaux. The cystoscope remained same till further improvement in Optics. 1950s: Fouresteir, Gladis, Valmiere of Optical Institute developed “Quartz Rod” for Light transportation and magnification.HAROLD H. HOPKINS: British physicist developed Rod Lens Systems and fiberoptics. Hopkins re-designed the Internal systems of the Nitze Air filled Endoscope,
producing a solid glass-rod scope with internal air spaces as lens interface. He, thereby, reverted the normal setup by using glass, instead of air, to conduct the image and air instead of glass to focus the image. The higher refractive index of glass and large apertures produced an image that was 80 times brighter than that produced by the classic Nitze scope. Hopkin’s inventions effectively took care of the problems of very poor transmission and very poor image & color quality.KARL STORZ of Germany picked up the Hopkins innovations and developed the modern scope.1957: Hopkins, Herschowatz et al developed Fiberoptic bundle.1963: “Cold Light System” to eliminate the risk of thermal injury to bowel and other abdominal organs caused by incandescent lighting. Light Sources developed
· Halogen · Metal Halide · Xenon III. Circon corporation developed solid state camera with a silicon chip which picked up the image from the laparoscope and transmitted it electronically through a cable to a video processor which then projected the image on television screen. With this visual “Opening” of the closed abdominal cavity to the entire surgical teams, more complex procedures could be undertaken with a aid of guided assistance.III. EVOLUTION OF INSUFFLATION: Although Kelling and others reported creation of a new pneumoperitoneum using a needle and filtered air, many laparoscopists introduced their trocars and laparoscopes (usually modified Cystoscopes) directly into the peritoneal cavity to avoid injury from the insufflation & the possible side effects associated with a pneumoperitoneum. Evolution of components of insufflation: § NEEDLE
§ GAS § INSUFFLATOR § “OPEN LAPAROSCOPY” § GASLESS1918: Otto Goetze of Germany was first to introduce needle for pneumoperitoneum.1930: Janus Veress of Hungary developed “spring loaded” needle for creation of pneumothoracis in the treatment of tuberculosis. It is now being the most frequently used device for creating pneumoperitoneum. It remains almost unchanged to the present day.1924: Zollikofer,Switzerland, used carbondioxide for insufflation instead of standard filtered air.1971: H.M.Hasson, gynaecologist introduced “open laparoscopy” or “Hasson`s technique”. Although the Veress’s needle was quite safe, still the injury to intra-abdominal organs was a great concern. Hasson introduced blunt trocar & the canula fitted with cone shaped sleeve that was movable along the shaft of the canula, to which stitches takenthrough the fascia could be tied, thus preventing leak of gases & slippage of canula.
III. INSUFFLATOR:upto 1960: Primitive affair using hand held bulb or foot bellows.1960: Kurt Semm from Germany developed automatic insufflator developed modern dissectors & coagulation instruments. Achievements of Kurt Semm 1935 : Monopolar coagulation 1960-66: Automatic insufflator 1968 : Hook Scissors 1971 : Bipolar coagulation 1976 : Endo loop applicator (Roeder loop) 1979 : Endoligation techniques : tissue morcellator 1982 : Myoma enucleator 1985 : PelvitrainerIII EVOLUTION OF OPERATIVE LAPAROSCOPY
1937: E. T. Anderson Laparoscopic tubal ligation1972: Hulka Chips for Ligation1977: Dekok reported Laparoscopic assisted appendicectomy1983: Semm First incidental laparoscopic appendicectomy1987: Schzeiber presented 70 laparoscopic appendicectomies1987: PHILLIP MOURET, Lyons, France performed first laparoscopic cholecystectomy in human. Within a year LAPAROSCOPIC EXPLOSION occurred and many surgeons reported laparoscopic cholecystectomy: Dubois (Paris) Perissat (Bordeaux) Alfred Cuschieri (Scotland) Mckernan and Saye (Georgia) Reddick and Olsen (Nashville) Petelin and Phillips: Laparoscopic CBD exploration1990: Jocobs et al First laparascopically assisted colectomy.
EVOLUTION OF DIFFERENT PROCEDURES:LAPAROSCOPIC HERNIA REPAIR:1982: Ger used prototype stapler1990: Shultz and Corbitt stuffed mesh plugs into the defects Arreguin developed pre-peritoneal mesh repair (TAPP) Fitzgibbons laid intra-peritoneal onlay mesh Philip and Dulucq developed totally extra peritoneal mesh repairLAPAROSCOPIC VAGOTOMY1990: Katkhouda – anterior seromyotomy Bailey and Zucker, USA – anterior highly selective vagotomy combined with posterior truncal vagotomy1991: Bernard Dallemagne, Belgium performed highly selective (anterior and posterior) performed first laparoscopic Nissen fundoplication.LAPAROSCOPIC UROLOGY1976: Cortesi- laparoscopy for bilateral abdominal testis in 18 yr old
1979: Wicken- performed laparoscopic ureterolithotomy by retro peritoneal approach1985: Eshghi- laparoscopic guided percutaneous trans peritoneal removal of staghorn calculi from a pelvic kidney1991: Clayman- Laparoscopic nephrectomy.LAPAROSCOPIC SURGERY IN INDIA1990: Prof. Tchemton E. Udwadia, Mumbai presented the first laparoscopic cholecystectomy in 10th world congress of digestive surgery at New Delhi.FUTURE OF LAPAROSCOPY3-D laparoscopy:The surgeon’s ability to operate in a 3 – dimensionalfield may increase the speed of surgery and decreasethe difficulty of the surgeons’ learning curve. At present,the 3-D pictures lack the clarity of high definition, 2-Dimensional video.