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CHAPTER 31

Key Principles of Laparoscopic Surgery

Joanne Johnson

The need for staff educated and trained specifically in minimal access surgery techniques and skills is well recognised and documented.

This chapter aims to provide an insight into the key principles of laparoscopic surgery to provide specific knowledge in relation to patient care and safety by understanding the technical aspects of the equipment and instrumentation required.

The development of laparoscopic surgery is inextricably linked with advances in the field of medical imaging, instrument development and with the skills of the surgeon and the theatre team.

In , when Philip Bozzini built an instrument which allowed him to look into the human body, lit by a candle, this was the start of the development of endoscopy, although he was years ahead of his time. Still relevant today in laparoscopic surgery is the use of carbon dioxide for insufflation discovered by Richard Zollikofer in and the rigid rod lens system developed by Harold Hopkins in , which revolutionised videoscopic surgery (Mishra ).

These developments have allowed patients to have surgery without the need for large abdominal wounds, which decreases postoperative pain and potentially disfiguring scars. The ability to offer a laparoscopic approach to a patient allows a shortened postoperative recovery in hospital and convalescent time at home. In conjunction with this the development of endoscopic stapling devices has advanced colorectal and bariatric laparoscopic surgery.

Preparing the Environment

Experience has shown that until the team is familiar with the extra equipment and checks required for laparoscopic surgery, additional staff may be required. For theatre practitioners there appears to be much more to do at the beginning and end of a session and less during each procedure There is always the possibility that conversion to open surgery may be necessary, and therefore any additional instruments should be readily available and a full-scale swab and instrument check initiated at the commencement of the laparoscopic procedure.

Although each team will determine its own set-up depending on personal preference and theatre size, some general principles can be identified. The use of specially designed stacking systems for equipment is strongly recommended as connections can be maintained between sessions, equipment is positioned at the appropriate height, access is eased and cabling from the unit to the power source is reduced. To maximise function of the stack and for all the team to get the best views of the screen, careful positioning of the equipment is essential.

All equipment must be functioning and positioned correctly prior to commencement.

The insufflator should be checked to ensure there is adequate CO2 in the cylinder, that it is correctly connected, has been turned on and that the insufflator performs a self-calibration test.

The monitors are positioned on either side of the patient such that the surgeon, assistant and scrub practitioner have a clear, unobstructed view. The surgeon will also need to see the insufflator display panel. Instrument trolleys and stacks, suction equipment, leads, cables and tubing need to be arranged to facilitate access by the theatre team, and to ensure that they do not become tangled or damaged during draping of the patient.

Attention to the placement of technical equipment and room preparation needs to be considered in conjunction with the usual preoperative preparation of the patient.

In minimal access surgery, the positioning of the patient is dependent upon the operation being undertaken. General principles identified include the use of an X-ray translucent table, and a secure patient position.

Medical Imaging

There are five main components to the imaging system:

• video camera and control unit
  
• scope
  
• light source, fibreoptic cable
  
• video monitors
  
• video recorder/printer.

Video camera and control unit

The video camera and control unit consist of a small lightweight camera head, cable and camera control unit with the following features:

• Lens
  
• Video imaging chips: These are one or three charged coupled devices (CCDs) covered in silicone cells (pixels) that are light-sensitive. They emit electronic signals via the camera cable to the camera control unit (CCU) that transforms information into a video signal, which is transmitted to the monitors. Colour, detail and image sharpness (resolution) are governed by the number of imaging chips. A three-chip camera provides greater resolution and a more accurate and natural colour, but is more expensive. Single-chip cameras, however, do now have improved resolution due to advanced electronics in CCDs and also in CCUs due to improved signal processing.
  
• Auto shutter: This controls the amount of light the camera detects at the surgical site. Shutter speed is changed automatically to reduce flare caused by metal reflective instruments passing through the field of view.
  
• Focus: This moves the lens elements in the camera relative to the CCD to sharpen the image (it can be manually controlled using a focus ring on the camera body).
  
• Light gain switch: This helps the camera compensate for low light situations by boosting the video signal amplitude. Unfortunately, the gain switch also boosts unwanted video signal ‘noise’.
  
• White balance: This creates a fixed point of reference for all the other colours viewed by the camera which compensates for the type and condition of light source being used.
  
• Orienting feature: This enables operators to keep the image in the correct plane on the monitor.

Scopes

Video endoscopes are designed to transmit the image to a monitor. Within the scope is a negative or objective lens which creates the image at the operative site. A delicate system of rod-shaped glass lenses which are positioned end to end (Hopkins rod lens system) transmit the image along the length of the scope to the ocular lens which magnifies the image. Wrapped around these delicate lenses are thousands of light-carrying fibres, transmitting light to the operative site.

Scopes have different diameters, 5 and 10 mm, and also different angles of view – 0, 30 and 45 degrees.

Warming the scope to body temperature before insertion will minimise fogging of the distal lens. Anti-fog chemicals can also be used or scope-warming devices. The objective lens needs to be cleaned during the procedure if it becomes soiled. Never use abrasives; warm saline and proprietary solutions may be used.

Continuous vision of the operative field is essential, it is particularly important to keep all instruments within sight to avoid accidental damage to tissue. This is particularly pertinent to port insertion and electrosurgery activation.

Light source and fibreoptic cable

The ideal light source emits a light with consistent intensity and balanced colour temperature. Other features include:

• auto and manual control of light output
  
• infrared filter (heat dissipation)
  
• standby mode to prolong lamp life
  
• hours meter for lamp life measurement.

There are two principal lamps used in laparoscopic light source units: metal halide and xenon. The light source and cable produce an intense light beam. The light should be on its lowest setting or switched off unless the laparoscope is in use (standby mode).

Careful handling of the hot end of the light cable reduces the chance of burns to staff or the patient. Retinal damage can be caused by looking directly at the light beam.

Video monitors

Signals are processed by the CCU and displayed via video cables on the monitor. Monitors should be high resolution, medical grade to maintain the quality of the video image and be fully compatible with the imaging devices in use. Most systems now have high definition (HD) monitors.

Note: It is important to be familiar with the sequence of the colour bars on a correctly connected RGB system; it is white, yellow, cyan, green, magenta, red and blue.

Video recording/documentation equipment

The procedure may be recorded by attachment of the appropriate cables to the CCU.

Video/Imaging Systems

Recent developments which have improved image and the integration of systems include the following (Leeds Institute for Minimally Invasive Therapy ):

• digital camera systems, giving improved image quality and the ability to enhance images while maintaining high quality
  
• interfaces with other digital equipment and larger images (panoramic view)
  
• ‘intelligent’ light sources
  
• scope recognition
  
• voice operation (control of light and camera properties without compromising sterile fields)
  
• digital video recorders (DVR)
  
• flat screen display devices using plasma technology
  
• digital printers that can be interfaced with computers
  
• laparoscopic ultrasound (LYNX) that can be mixed with camera image and ­displayed as a PIP (picture in picture).

Laparoscopic Instrumentation

Instruments may be described as either ‘access’ or ‘operating’ instruments, according to their use.

Most instruments are available as single patient use (spu) or reusable multiple patient use (mpu) (MHRA ). The majority of mpu instruments are ‘take-apart’, to help with the process of cleaning and decontamination. Prior to use, all instruments need to be checked to ensure correct assembly and that each one is functioning as designed. It is also essential to check that insulation is intact, to prevent inadvertent burns to the patient or surgeon.

Access

There are three main methods to gain access to the abdomen: open or closed techniques and under vision.

Veress needle

A Veress needle is used to introduce carbon dioxide gas into the abdomen prior to port insertion. It consists of a blunt inner tube with a spring-loaded outer sheath with bevelled sharp needle and a luer lock at the proximal end for attaching insufflation tubing. The standard diameter of the needle is 2 mm and they are available in different lengths for obese patients and as a spu or mpu.

Instruments

Laparoscopic instruments need to do much the same as open instruments but have to be designed for tissue handling at depth, and through the ports.

There is a wide range of forceps and graspers, some with generic uses and others designed for a specific purpose. Instruments can be either single action, where only one side of the instrument jaw moves, or double action, where both sides move. A choice of handle for most grasping forceps is available – pistol grip or in-line – with the option of a ratchet mechanism which locks the handle, exerting a constant pressure on the tissue being held. The handle may well be a mpu and the instrument spu; this type of instrument is termed a reposable instrument. Any instrument that is to be used with ­diathermy needs to be insulated. The ergonomics of the instrument need to be designed for ease of use and operator comfort.

Scissors should be checked for blade alignment and that they are sharp if mpu. Needle holders need to be able to grasp and firmly hold a metal needle. They are designed with jaws made of tungsten carbide to prevent the needle rotating.

Care and Handling

The costs associated with the purchase of laparoscopic instrumentation are high and most purchasers have a limited budget. Therefore it is essential that the users are aware of the manufacturer’s recommendations for cleaning and sterilisation.

The complexity of laparoscopic instrumentation and the way it is used can make it very difficult to clean thoroughly. All theatre personnel involved in laparoscopic surgery should be aware of the instruments in use in their department and understand the assembly, disassembly and sterilisation method required.

Perioperative staff should be familiar with all technical equipment, products and instruments used. Laparoscopic instrumentation is constantly changing and improving. Perioperative staff need educational resources and product information with instructions that are concise, clear and easy to follow.

The decontamination of reusable instrumentation for laparoscopic surgery needs well-trained staff. Instrument design should allow easy dismantling and rinsing of internal parts. Correct handling and maintenance processes need to avoid damage to the instruments. Protective transport and effective containment reduces the potential for damage to fragile laparoscopic instruments.

Reusable instruments are an economical option, however disposable parts on reusable tubes and handles offer an alternative to complicated or easily damaged working tips (e.g. scissors blades that easily blunt).

Instrument Handles

With instruments that ‘take-apart’ there are various handles available. Non-ergonomic positioning of the hand and fingers can lead to pressure areas, nerve irritation and rapid fatigue for the surgeon over a period of time.

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Ports

A port is a tubular device (cannula) providing access to the internal surgical site, facilitating instrument access via the lumen. Common features include; a stopcock/tap to allow insufflations, a tubing attachment, a seal or valve preventing loss of pneumoperitoneum. Ports are available in a variety of diameters and lengths. Selection is dependent on the surgery being undertaken and individual body dynamics.

Disposable, reposable and reusable versions are available. A variety of trocars are available to enable safe insertion of the port. Trocar selection is dependent on the chosen method of access and on surgeon preference.

Initiating and Maintaining the Pneumoperitoneum

In order to expand actual or potential body spaces to facilitate surgery, carbon dioxide is used because it is cheap, does not support combustion, does not distort the image and is readily soluble and excreted via the lungs.

When initiating closed pneumoperitoneum, using the Veress needle method, it is important to ensure that the scrub practitioner is familiar with the assembly and safety checks necessary on the Veress needle. The procedure is as follows:

Minimally invasive operation within the abdominal or pelvic cavities Medical intervention LaparoscopyICD-9-CM54.21MeSHOPS-301 code1-694

Laparoscopy (from Ancient Greek λαπάρα (lapára) 'flank, side' and σκοπέω (skopéō) 'to see') is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.[1]

Laparoscopic surgery, also called minimally invasive procedure, bandaid surgery, or keyhole surgery, is a modern surgical technique. There are a number of advantages to the patient with laparoscopic surgery versus an exploratory laparotomy. These include reduced pain due to smaller incisions, reduced hemorrhaging, and shorter recovery time. The key element is the use of a laparoscope, a long fiber optic cable system that allows viewing of the affected area by snaking the cable from a more distant, but more easily accessible location.

Laparoscopic surgery includes operations within the abdominal or pelvic cavities, whereas keyhole surgery performed on the thoracic or chest cavity is called thoracoscopic surgery. Specific surgical instruments used in laparoscopic surgery include obstetrical forceps, scissors, probes, dissectors, hooks, and retractors. Laparoscopic and thoracoscopic surgery belong to the broader field of endoscopy. The first laparoscopic procedure was performed by German surgeon Georg Kelling in .

Types of laparoscopes

[edit]

There are two types of laparoscope:[2]

1. A telescopic rod lens system, usually connected to a video camera (single-chip CCD or three-chip CCD)
2. A digital laparoscope where a miniature digital video camera is placed at the end of the laparoscope, eliminating the rod lens system

The mechanism mentioned in the second type is mainly used to improve the image quality of flexible endoscopes, replacing conventional fiberscopes. Nevertheless, laparoscopes are rigid endoscopes. Rigidity is required in clinical practice. The rod-lens-based laparoscopes dominate overwhelmingly in practice, due to their fine optical resolution (50 μm typically, dependent on the aperture size used in the objective lens), and the image quality can be better than that of the digital camera if necessary. The second type of laparoscope is very rare in the laparoscope market and in hospitals.[citation needed]

Also attached is a fiber optic cable system connected to a "cold" light source (halogen or xenon) to illuminate the operative field, which is inserted through a 5 mm or 10 mm cannula or trocar. The abdomen is usually insufflated with carbon dioxide gas as the safety, harms, and benefits of other gasses (e.g., helium, argon, nitrogen, nitrous oxide, and room air) is uncertain.[3] This elevates the abdominal wall above the internal organs to create a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.[4]

Procedures

[edit]

Patient position

[edit]

During the laparoscopic procedure, the position of the patient is either in Trendelenburg position or in reverse Trendelenburg. These positions have an effect on cardiopulmonary function. In Trendelenburg's position, there is an increased preload due to an increase in the venous return from lower extremities. This position results in cephalic shifting of the viscera, which accentuates the pressure on the diaphragm. In the case of reverse Trendelenburg position, pulmonary function tends to improve as there is a caudal shifting of viscera, which improves tidal volume by a decrease in the pressure on the diaphragm. This position also decreases the preload on the heart and causes a decrease in the venous return leading to hypotension. The pooling of blood in the lower extremities increases the stasis and predisposes the patient to develop deep vein thrombosis (DVT).[5]

Gallbladder

[edit]

Rather than a minimum 20 cm incision as in traditional (open) cholecystectomy, four incisions of 0.5–1.0 cm, or, beginning in the second decade of the 21st century, a single incision of 1.5–2.0 cm,[6] will be sufficient to perform a laparoscopic removal of a gallbladder. Since the gallbladder is similar to a small balloon that stores and releases bile, it can usually be removed from the abdomen by suctioning out the bile and then removing the deflated gallbladder through the 1 cm incision at the patient's navel. The length of postoperative stay in the hospital is minimal, and most patients can be safely discharged from the hospital the same day.[7]

Colon and kidney

[edit]

In certain advanced laparoscopic procedures, where the specimen removed is too large to pull through a trocar site (as is done with gallbladders), an incision larger than 10 mm must be made. The most common of these procedures are removal of all or part of the colon (colectomy), or removal of the kidney (nephrectomy). Some surgeons perform these procedures completely laparoscopically, making the larger incision toward the end of the procedure for specimen removal, or, in the case of a colectomy, to also prepare the remaining healthy bowel to be reconnected (create an anastomosis). Many other surgeons feel that since they will have to make a larger incision for specimen removal anyway, they might as well use this incision to have their hand in the operative field during the procedure to aid as a retractor, dissector, and to be able to feel differing tissue densities (palpate), as they would in open surgery. This technique is called hand-assist laparoscopy. Since they will still be working with scopes and other laparoscopic instruments, CO2 will have to be maintained in the patient's abdomen, so a device known as a hand access port (a sleeve with a seal that allows passage of the hand) must be used. Surgeons who choose this hand-assist technique feel it reduces operative time significantly versus the straight laparoscopic approach. It also gives them more options in dealing with unexpected adverse events (e.g., uncontrolled bleeding) that may otherwise require creating a much larger incision and converting to a fully open surgical procedure.[8]

Conceptually, the laparoscopic approach is intended to minimise post-operative pain and speed up recovery times, while maintaining an enhanced visual field for surgeons. Due to improved patient outcomes in the early 21st century, laparoscopic surgery has been adopted by various surgical sub-specialties, including gastrointestinal surgery (including bariatric procedures for morbid obesity), gynecologic surgery, and urology. Based on numerous prospective randomized controlled trials, the approach has proven to be beneficial in reducing post-operative morbidities such as wound infections and incisional hernias (especially in morbidly obese patients), and is now deemed safe when applied to surgery for cancers such as cancer of colon.[9][10]

The restricted vision, the difficulty in handling of the instruments (new hand-eye coordination skills are needed), the lack of tactile perception, and the limited working area are factors adding to the technical complexity of this surgical approach. For these reasons, minimally invasive surgery has emerged as a highly competitive new sub-specialty within various fields of surgery. Surgical residents who wish to focus on this area of surgery gain additional laparoscopic surgery training during one or two years of fellowship after completing their basic surgical residency. In OB-GYN residency programs, the average laparoscopy-to-laparotomy quotient (LPQ) is 0.55.[11]

In veterinary medicine

[edit]

Laparoscopic techniques have also been developed in the field of veterinary medicine. Due to the relatively high cost of the equipment required, it has not become commonplace in most traditional practices today but rather limited to specialty practices. Many of the same surgeries performed in humans can be applied to animal cases – everything from an egg-bound tortoise to a German Shepherd can benefit from MIS. A paper published in JAVMA (Journal of the American Veterinary Medical Association) in showed that dogs spayed laparoscopically experienced significantly less pain (65%) than those that were spayed with traditional "open" methods.[12] Arthroscopy, thoracoscopy, and cystoscopy are all performed in veterinary medicine today.

Advantages

[edit]

There are a number of advantages to the patient with laparoscopic surgery versus an open procedure. These include:

• Reduced hemorrhaging, which reduces the chance of needing a blood transfusion.[13][14]
• Smaller incision, which reduces pain and shortens recovery time, as well as resulting in less post-operative scarring.[14][15][16]
• Less pain, leading to less pain medication needed.[17][16]
• Use of regional anesthesia (with the recommendation of using a combined spinal and epidural anaesthesia) for laparoscopic surgery, as opposed to general anesthesia required for many non-laparoscopic procedures, can produce fewer complications and quicker recovery.[18]
• Although procedure times are usually slightly longer, hospital stay is less, and often with a same day discharge which leads to a faster return to everyday living.[15][19]
• Reduced exposure of internal organs to possible external contaminants, thereby reduced risk of acquiring infections.[9]

Although laparoscopy in adults is widely accepted, its advantages in children are questioned.[20][21] Benefits of laparoscopy appear to recede with younger age. Efficacy of laparoscopy is inferior to open surgery in certain conditions such as pyloromyotomy for infantile hypertrophic pyloric stenosis. Although laparoscopic appendectomy has less wound problems than open surgery, the former is associated with more intra-abdominal abscesses.[22]

Disadvantages

[edit]

While laparoscopic surgery is clearly advantageous in terms of patient outcomes, the procedure is more difficult from the surgeon's perspective when compared to conventional, open surgery:

• Laparoscopic surgery requires pneumoperitoneum for adequate visualization and operative manipulation.[5]
• The surgeon has a limited range of motion at the surgical site, resulting in a loss of dexterity.[23]
• Poor depth perception.[23]
• Surgeons must use tools to interact with tissue rather than manipulate it directly with their hands. This results in an inability to accurately judge how much force is applied to tissue and higher risk of damaging tissue by applying more force than necessary. This limitation also reduces tactile sensation, making it more difficult for the surgeon to feel tissue (sometimes an important diagnostic tool, such as when palpating for tumors) and making delicate operations such as tying sutures more difficult.[24]
• The tool endpoints move in the opposite direction to the surgeon's hands due to the pivot point, making laparoscopic surgery a non-intuitive motor skill that is difficult to learn. This is called the fulcrum effect.[25]
• Some surgeries (carpal tunnel for instance) generally turn out better for the patient when the area can be opened up, allowing the surgeon to see the surrounding physiology, to better address the issue at hand. In this regard, keyhole surgery can be a disadvantage.[26]

Risks

[edit]

Some of the risks are briefly described below:

• The major problems during laparoscopic surgery are related to the cardiopulmonary effect of pneumoperitoneum, systemic carbon dioxide absorption, venous gas embolism, unintentional injuries to intra-abdominal structures and patient positioning.[5]
• The most significant risks are from trocar injuries during insertion into the abdominal cavity, as the trocar is typically inserted blindly. Injuries include abdominal wall hematoma, umbilical hernias, umbilical wound infection, and penetration of blood vessels or small or large bowel.[27] The risk of such injuries is increased in patients who have a low body mass index[28] or have a history of prior abdominal surgery. While these injuries are rare, significant complications can occur, and they are primarily related to the umbilical insertion site. Vascular injuries can result in hemorrhage that may be life-threatening. Injuries to the bowel can cause a delayed peritonitis. It is very important that these injuries be recognized as early as possible.[29]
• In oncologic laparoscopic procedures there is a risk of port site metastases, especially in patients with peritoneal carcinomatosis. This incidence of iatrogenic dissemination of cancer might be reduced with special measures as trocar site protection and midline placement of trocars.[30]
• Some patients have sustained electrical burns unseen by surgeons who are working with electrodes that leak current into surrounding tissue. The resulting injuries can result in perforated organs and can also lead to peritonitis.[31]
• About 20% of patients undergo hypothermia during surgery and peritoneal trauma due to increased exposure to cold, dry gases during insufflation. The use of surgical humidification therapy, which is the use of heated and humidified CO2 for insufflation, has been shown to reduce this risk.[32]
• Not all of the CO
  2 introduced into the abdominal cavity is removed through the incisions during surgery. Gas tends to rise, and when a pocket of CO2 rises in the abdomen, it pushes against the diaphragm (the muscle that separates the abdominal from the thoracic cavities and facilitates breathing), and can exert pressure on the phrenic nerve. This produces a sensation of pain that may extend to the patient's shoulders in about 80% of women for example. In all cases, the pain is transient, as the body tissues will absorb the CO2 and eliminate it through respiration.[33]
• Coagulation disorders and dense adhesions (scar tissue) from previous abdominal surgery may pose added risk for laparoscopic surgery and are considered relative contra-indications for this approach.
• Intra-abdominal adhesion formation is a risk associated with both laparoscopic and open surgery and remains a significant, unresolved problem.[34] Adhesions are fibrous deposits that connect tissue to organ post surgery. Generally, they occur in 50-100% of all abdominal surgeries,[34] with the risk of developing adhesions the same for both procedures.[35][36] Complications of adhesions include chronic pelvic pain, bowel obstruction, and female infertility. In particular, small bowel obstruction poses the most significant problem.[35] The use of surgical humidification therapy during laparoscopic surgery may minimise the incidence of adhesion formation.[37] Other techniques to reduce adhesion formation include the use of physical barriers such as films or gels, or broad-coverage fluid agents to separate tissues during healing following surgery.[35]
• The gas used to make space and the smoke generated during surgical procedures can leak into the operating room through or around access devices as well as instruments. The gas plume can pollute the airspace shared by the operating team and patient with particles and potentially pathogens, including viral particles.[38][39]

Robotic laparoscopic surgery

[edit] Main article: Robotic surgery

In recent years, electronic tools have been developed to aid surgeons. Some of the features include:

• Visual magnification — use of a large viewing screen improves visibility
• Stabilization — Electromechanical damping of vibrations, due to machinery or shaky human hands
• Simulators — use of specialized virtual reality training tools to improve physicians' proficiency in surgery[40]
• Reduced number of incisions[41]

Robotic surgery has been touted as a solution to underdeveloped nations, whereby a single central hospital can operate several remote machines at distant locations. The potential for robotic surgery has had a strong military interest as well, with the intention of providing mobile medical care while keeping trained doctors safe from battle. [citation needed]

In January , a robot performed the first ever successful laparoscopic surgery without the help of a human. The robot performed the surgery on the soft tissue of a pig. It succeeded at intestinal anastomosis, a procedure that involves connecting two ends of an intestine. The robot, named the Smart Tissue Autonomous Robot (STAR), was designed by a team of Johns Hopkins University researchers.[42]

Non-robotic hand-guided assistance systems

[edit]

There are also user-friendly nonrobotic assistance systems that are single-hand guided devices with a high potential to save time and money. These assistance devices are not bound by the restrictions of common medical robotic systems. The systems enhance the manual possibilities of the surgeon and his/her team, regarding the need of replacing static holding force during the intervention.[43]

With laparoscopy providing tissue diagnosis and helping to achieve the final diagnosis without any significant complication and less operative time, it can be safely concluded that diagnostic laparoscopy is a safe, quick, and effective adjunct to non‑surgical diagnostic modalities, for establishing a conclusive diagnosis, but whether it will replace imaging studies as a primary modality for diagnosis needs more evidence.[44]

History

[edit]

It is difficult to credit one individual with the pioneering of the laparoscopic approach. In , Georg Kelling of Dresden, Germany, performed the first laparoscopic procedure in dogs, and, in , Hans Christian Jacobaeus of Sweden performed the first laparoscopic operation in humans.[45]

In the ensuing several decades, numerous individuals refined and popularized the approach further for laparoscopy. The advent of computer chip-based television cameras was a seminal event in the field of laparoscopy. This technological innovation provided the means to project a magnified view of the operative field onto a monitor and, at the same time, freed both the operating surgeon's hands, thereby facilitating performance of complex laparoscopic procedures.

The first publication on modern diagnostic laparoscopy by Raoul Palmer appeared in ,[46] followed by the publication of Hans Frangenheim and Kurt Semm, who both practised CO
2 hysteroscopy from the mid-s.[47]

Patrick Steptoe, one of the pioneers of IVF, was important in popularizing laparoscopy in the UK. He published a textbook, Laparoscopy in Gynaecology, in .[48]

In , H. Courtenay Clarke invented, published, patented, presented, and recorded on film laparoscopic surgery, with instruments he invented and were marketed by the Ven Instrument Company of Buffalo, New York.[49] He was the first to perform a surgical laparoscopic process with standard sutures[50] and simple instruments. This was meant to facilitate the application of laparoscopic surgery to all economic sectors by avoiding expensive materials and devices.[51]

In , Tarasconi, from the Department of Ob-Gyn of the University of Passo Fundo Medical School (Passo Fundo, RS, Brazil), started his experience with organ resection by laparoscopy (Salpingectomy), first reported in the Third AAGL Meeting, Hyatt Regency Atlanta, November and later published in The Journal of Reproductive Medicine in .[52] This laparoscopic surgical procedure was the first laparoscopic organ resection reported in medical literature.

In , Semm, from the gynecological clinic of Kiel University, Germany, performed the first laparoscopic appendectomy. Following his lecture on laparoscopic appendectomy, the president of the German Surgical Society wrote to the Board of Directors of the German Gynecological Society suggesting suspension of Semm from medical practice. Subsequently, Semm submitted a paper on laparoscopic appendectomy to the American Journal of Obstetrics and Gynecology, at first rejected as unacceptable for publication on the grounds that the technique reported on was "unethical," but finally published in the journal Endoscopy. The abstract of his paper on endoscopic appendectomy can be found at the journal site.[47][53]

Semm established several standard procedures that were regularly performed, such as ovarian cyst enucleation, myomectomy, treatment of ectopic pregnancy and finally laparoscopic-assisted vaginal hysterectomy (also termed cervical intra-fascial Semm hysterectomy). He also developed a medical instrument company Wisap in Munich, Germany, which still produces various endoscopic instruments. In , he constructed the pelvi-trainer = laparo-trainer, a practical surgical model whereby colleagues could practice laparoscopic techniques. Semm published over papers in various journals. He also produced over 30 endoscopic films and more than 20,000 colored slides to teach and inform interested colleagues about his technique. His first atlas, More Details on Pelviscopy and Hysteroscopy was published in , a slide atlas on pelviscopy, hysteroscopy, and fetoscopy in , and his books on gynecological endoscopic surgery in German, English, and many other languages in , , and .[47]

In , Erich Mühe, professor of surgery in Germany, performed the first laparoscopic cholecystectomy.[54] Afterward, laparoscopy gained rapid acceptance for non-gynecologic applications. The first video-assisted laparoscopic surgery was performed in , a laparoscopic cholecystectomy.[55] Before this time, the operating field was visualised by surgeons directly via a laparoscope.

In , Alfred Cuschieri performed the first minimally invasive surgery in the UK with his team at Ninewells Hospital after working with multiple researchers from across the world, including Patrick Steptoe. Cuschieri took advantage of smaller cameras to perform operations with smaller cuts and shorter recovery times. After some controversy and patient deaths, new laparoscopic training centres were set up as most surgeons lacked the necessary specialised training to perform laparoscopic surgery. The first opened in Dundee in and became the Cuschieri Skills Centre at Ninewells Hospital in . As of , 40 specialist centres around the world base their laparoscopic training on the Cuschieri Skills Centre.[56]

Prior to Mühe, the only specialty performing laparoscopy on a widespread basis was gynecology, mostly for relatively short, simple procedures such as a diagnostic laparoscopy or tubal ligation. The introduction in of a laparoscopic clip applier with twenty automatically advancing clips (rather than a single load clip applier that would have to be taken out, reloaded and reintroduced for each clip application) made general surgeons more comfortable with making the leap to laparoscopic cholecystectomies ( gall bladder removal). On the other hand, some surgeons continue to use the single clip appliers as they save as much as $200 per case for the patient, detract nothing from the quality of the clip ligation, and add only seconds to case lengths. Both laparoscopy tubal ligations and cholecystectomies may be performed using suturing and tying, thus further reducing the expensive cost of single and multiclips (when compared to suture). Once again this may increase case lengths but costs are greatly reduced (ideal for developing countries) and widespread accidents of loose clips are eliminated.[citation needed]

The first transatlantic surgery performed was a laparoscopic gallbladder removal in . The first robotic advanced pediatric surgery series were performed overseas in Egypt at Cairo University.[57][58] Remote surgeries and robotic surgeries have since become more common and are typically laparoscopic procedures.

Surgical associations

[edit]

There are many International and American Surgical Associations involved in surgical education and training for laparoscopy, thoracoscopy and many minimally invasive procedures for both adults and pediatrics. These societies include:

For adults

[edit]

• Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
• Society of Laparoscopic & Robotic Surgeons[59]
• World Association of Laparoscopic Surgeons

For pediatric surgery

[edit]

• International Pediatric Endosurgery Group (IPEG)[60]
• European Society of Paediatric Endoscopic Surgeons (ESPES)
• British Association Of Paediatric Endoscopic Surgeons (BAPES)

Gynecological diagnosis

[edit] Further information: Fertiloscope

In gynecology, diagnostic laparoscopy may be used to inspect the outside of the uterus, ovaries, and fallopian tubes, as, for example, in the diagnosis of female infertility.[61] Usually, one incision is placed near the navel and a second near the pubic hairline. A special type of laparoscope called a fertiloscope, which is modified for transvaginal application, can be used. A dye test may be performed to detect any blockage in the reproductive tract, wherein a dark blue dye is passed up through the cervix and is followed with the laparoscope through its passage out into the fallopian tubes to the ovaries.[1]

See also

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• Arthroscopic surgery – Examination of a joint via small surgical incisionPages displaying short descriptions of redirect targets
• Invasiveness of surgical procedures – Surgical technique that limits size of surgical incisions neededPages displaying short descriptions of redirect targets
• Laparotomy – Surgical procedure to open the abdominal cavity
• Minimally invasive procedure
• Natural orifice translumenal endoscopic surgery
• Percutaneous – Type of surgical procedure
• Revision weight loss surgery
• Single port laparoscopy

References

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