What is laparoscopic surgery?

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It was George Kelling (seen here) who performed the first experimental laparoscopy in Berlin in 1901.  He called the procedure "celeiscopy". 

Kelling used a cystoscope to look inside a dogs abdominal cavity that he had distended with filtered air via a device that he called a trocar.   He used insufflation to create not only a pneumoperitoneum  to see what he was doing but also to prevent intra-abdominal bleeding.  Jacobeus performed the first human celioscopy in Sweden in 1910, advocating the technique for the evaluation of patients with ascites,

In 1923, Kelling reported his 22 years of experience with laparoscopy to the German Surgical Society. Kelling became one of the earliest advocates of minimally invasive surgery. He encouraged surgeons to use diagnostic laparoscopy in order to spare patients the prolonged and costly stay of a laparotomy.

In 1929, Kalk introduced the foroblique (135 degrees) lens system, and advocated the use of a separate pneumoperitoneum needle and a second puncture site. These refinements in technique, along with Kalk's descriptions of therapeutic laparoscopic interventions earned him the designation as the "Father of Modern Laparoscopy."  In 1938, Veress developed a needle with a spring-loaded obturator that allowed safe insertion and insufflation of the peritoneal cavity. Thereafter, pneumoperitoneum was established prior to instrumentation of the abdomen.

Despite such advances in laparoscopic imaging and technique, several troublesome problems persisted. Bowel and vascular injuries during trochar insertion continued to occur. No scientific knowledge existed regarding the dangers of increased intraabdominal pressure. And finally and most distressingly, unipolar cautery was associated with a high rate of thermal injury to the bowel. These dangers severely restricted the use of laparoscopy. Few surgeons judged that the advantages of laparoscopy outweighed the inherent risks of the technique.

In 1952, Fourestier, Gladu, and Valmiere developed a new imaging system which revolutionized endoscopy. The system utilized a quartz rod to transmit an intense light beam distally along a telescope. This development solved many of the aforementioned problems and additionally permitted the light intensity to be concentrated enough to photograph images. Closed-circuit television was added in 1959

Patrick Steptoe (seen below in a drawing by Peter Wardle) is best known for being  the Oldham gynaecologist who launched IVF with the worlds first "test tube baby" - Louise Brown in 1978.  Patrick Stepto was a man ahead of his time.  He was also the first UK surgeon to see the potential for laparoscopy and quickly set about using it in his day to day gynaecological surgical practice.  It was Stepto who also first developed laparoscopic tubal ligation/sterilisation.  In 1967 he published his classic surgical text book -  Laparoscopy in Gynaecology.  

Semm, a German gynaecologist performed the first laparoscopic appendicectomy in 1983.  

The first laparoscopic assisted cholecystectomy was performed by Eric Muhe in Boblinghen, Germany in 1985.  Following the development of the solid state image sensor in 1985 it was possible for the first time to transmit the pictures from the laparoscope to a television monitor to enable assistants to hold the camera and participate in the operation.  The first laparoscopic cholecystectomy as we would recognize it today was performed by Phillip Mouret  in Lyons in 1987 shortly followed in 1988 by McKernan and Saye in Georgia, and Reddick and Olsen in Nashville. The technique was introduced into the UK the following year.

Application of videolaparoscopic techniques to colorectal operations was initially limited by the lack of appropriate instruments. Consequently, the first laparoscopic colon resections were "laparoscopically-assisted" colectomies where mini-laparotomies were utilised for ligation of mesenteric vessels, extracorporeal anastomoses and specimen removal. The first laparoscopic colonic resection using this technique was a right hemicolectomy performed by Moises Jacobs in Miami, Florida, in June of 1990.

The introduction of a laparoscopic intestinal stapler, the Endo-GIAtm allowed the transection of the bowel to be accomplished intraperitoneally.

Using this instrument for ligation of the mesentery and transection of the colon, Dennis Fowler (see below) performed the first laparoscopic sigmoid resection in October of 1990. The anastomosis was contructed with a Premium CEEAtm stapling device.
The following month, using a similar technique, Patrick Leahy was able to resect a proximal rectal cancer and to construct a low anterior anastomosis. Several months later, on July 26, 1991, Joseph Uddo performed an entirely laparoscopic right hemicolectomy.

Laparoscopic surgery is performed using cameras and video monitors eg a right hemicolectomy (illustrated).

A small cut is made in the tummy button to introduce CO2 into the peritoneal (tummy) vacity and create a space in which to operate.

A telescope/camera and operating instruments are inserted (as shown) and the surgery begins.

Modern equipment produces bright, magnified images (see above) which allow all the internal organs to be examined and all surgical manoeuvres safely performed with minimal upset to the patient.  In our opinion the surgery is not only easier to perform it is more exact! 

The obvious benefit to patients lies in preserving the abdominal wall ie a large incision (seen below) can be confined to surgical history.  As a result, the surgery is less painful and the requirement for opiate analgesiia is considerably reduced.  This leads to a rapid postoperative recovery.

An increasing number of our patients are now discharged within 24hrs of their surgery! 

Although widely accepted (USA & many centres in Europe), laparoscopic surgery has been slow to gain acceptance in the UK.  The main reasons are (i) it takes time and effort to master (ii) evidence to convince UK surgeons to learn this technique is only just emerging. 

Even surgeons who are brilliant in open techniques need prolonged training to transfer their skills to the video monitor. Surgeons with relatively little experience take longer to complete the procedure and predictably are more likely to make mistakes. Laparoscopic surgeons leave the familiar three-dimensional operating field to work from a two-dimensional video display. It is difficult to judge depth. The visual field is smaller and the necessity to work with screen images demands mental effort. A trocar serves as both a fulcrum and steadying point; a small proximal movement gives a large distal movement. The normal axis is also inverted in that to go left the trocar is moved right and to go down it must be moved up; to turn it in circles one goes in the usual direction, but the instrument is 180 degrees from where one might suppose. The surgeon effectively operates in a mirror! This shift is critical and requires training.

Few UK centres offer more than laparoscopic cholcystectomy (gallbladder removal). Bristol Laparoscopic Associates undertake a large number of operations each year. These include operations for diseases of the stomach, bile duct, small and large bowel, appendix, hernias, spleen, kidneys, adrenals, prostate and bladder.  We also offer weight loss or bariatric surgery.

Since overall trauma is reduced, pain is less - patients mobilise sooner and have fewer unwanted effects from analgesia. The fine instruments are also less apt to cause tissue trauma and bleeding. Complication rates are lower e.g. infection and incisional hernias. This is because tissues are no longer exposed to the cooling and drying effect of the operating theatre air or excessive handling and retraction by the surgeon. These benefits also reduce adhesions and the later hazard of bowel obstruction.

Video magnification offers better exposure of diseased organs and surrounding vessels/nerves. Delicate manoeuvres can be performed to protect these structures during removal/repair of target organs. These benefits shorten the recovery period and reduce the risks of bone loss, muscle atrophy and urinary retention seen with bed rest and inactivity. Other benefits of early mobilisation are lower rates of chest infection and deep vein thrombosis. Finally, patients prefer small scars.

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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051