ENDOSCOPIC & LAPAROSCOPIC SURGERY

Dr.Anil Haripriya

  In the nearly 150 years since the urinary bladder was

first inspected telescopically, technical progress &

therapeutic alternatives have been limited until the last

two decades. Intervention using endoscopy included

only a slightly more extended view of existing spaces,

but alternatives in therapy were not a reality. With the

advent of Video-endoscope allowing co-operative &

assisted procedures, high energy light sources & high-

flow insufflation of distending gases, the stage was set

to provide alternative access for complex abdominal

surgical procedures. Thereafter followed an

enthusiastic explosion of “new” endoscopic procedures,

the limit of which was now only the imagination.

Perhaps the best legacy of minimal-access surgery not

to imply that an epitaph is being written - is an

alternative way of thinking. Surgery at the beginning

of century maintained that “more is better”. Whether in

radical mastectomies or regional colectomies, the more

resected the better the cure. We have seen the

upheaval of this paradigm in the later part of this

century, for which minimal access surgery can be

considered the logical extension. With the movement

toward “less is more”, the door is open to an

alternative school of surgery.

DEFINITIONS

ENDOSCOPY : examining the in-accessible body

cavities with the use of instruments through natural

orifices.

LAPAROSCOPY : viewing the internal organs, using

some 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 as

I.         Evolution of Laparoscopy.

II.        Evolution of Instrumentation

(a)     Endovision

(b)     Insufflation

(c)     Instruments

III 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 diathermy

1933: 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 ENDOVISION

Breakthrough Points:

1870s: Invention of Incandescent Light by Thomas

Elva Edison.

Development of Lens systems for scopes

1960s: Invention of Rod Lens System by Hopkins

and development of fiber optic cold light

transmission

1980s: 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”

§    GASLESS

1918: 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 : Pelvitrainer

III EVOLUTION OF OPERATIVE LAPAROSCOPY

1937: E. T. Anderson Laparoscopic tubal ligation

1972: Hulka Chips for Ligation

1977: Dekok reported Laparoscopic assisted

appendicectomy

1983: Semm First incidental

laparoscopic appendicectomy

1987: Schzeiber presented 70 laparoscopic

appendicectomies

1987: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

exploration

1990:Jocobs et al First laparascopically assisted

colectomy.

EVOLUTION OF DIFFERENT PROCEDURES:

LAPAROSCOPIC HERNIA REPAIR:

1982:Ger used prototype stapler

1990: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 repair

LAPAROSCOPIC VAGOTOMY

1990: Katkhouda – anterior seromyotomy

Bailey and Zucker, USA – anterior highly selective

vagotomy combined with posterior truncal

vagotomy

1991:Bernard Dallemagne, Belgium performed highly

selective (anterior and posterior) performed first

laparoscopic Nissen fundoplication.

LAPAROSCOPIC UROLOGY

1976:Cortesi- laparoscopy for bilateral abdominal

testis in 18 yr old

1979:Wicken- performed laparoscopic ureterolithotomy

by retro peritoneal approach

1985:Eshghi- laparoscopic guided percutaneous trans

peritoneal removal of staghorn calculi from a

pelvic kidney

1991:Clayman- Laparoscopic nephrectomy.

LAPAROSCOPIC SURGERY IN INDIA

1990:Prof. Tchemton E. Udwadia, Mumbai presented

the first laparoscopic cholecystectomy in 10th

world congress of digestive surgery at New Delhi.

FUTURE OF LAPAROSCOPY

3-D laparoscopy:

The surgeon’s ability to operate in a 3 – dimensional

field may increase the speed of surgery and decrease

the difficulty of the surgeons’ learning curve. At present,

the 3-D pictures lack the clarity of high definition, 2-

Dimensional video.