“The cleaner and gentler the act of operation, the less pain the patient suffers, the smoother and quicker the convalescence, the more exquisite his healed wound, the happier his memory of the whole incident”
—Lord Moynihar (1920)
INTRODUCTION
The rising popularity of laparoscopic surgery is one of the most spectacular events in modern surgical history putting an end to the era of ‘Big surgeons Big incisions’.
The history of laparoscopic revolution is quite intriguing and can be traced back to the tenth century AD. The Arabian physician Abulkasim (936-1013) is often credited with being the first to use reflected light to inspect an internal organ, the cervix.
Other investigators subsequently developed instruments to examine the nasal recesses and urinary bladder with artificial light and mirror. However, these interventions were associated with thermal tissue injury caused by the illuminating light source. This was probably the reason that cystoscopy which was developed in the nineteenth century preceded other forms of endoscopy, because of the coolant effect of water on the distal light source. The early pioneers introduced the trocars and cystoscopes directly into the peritoneal cavity.1 At the turn of the 20th Century, Georg Kelling of Dresden (Fig. 1.1) used a cystoscope to observe the abdominal organs of dogs. He realized that pneumoperitoneum was very important for exposure and therefore used room air for insufflation of the peritoneal cavity. He, then, coined the term “celioscopy” to describe this technique.
The importance of photography to record the endoscopic findings was also recognized early and by 1874 Steen had modified existing cameras to record images of bladder pathology.
The first report of using this procedure in man was by the Swedish physician Hans Christian Jacobaeus in 1910 (Fig. 1.2). He is also credited with coining the term “laparoscopy”.2
These early procedures were entirely diagnostic in nature; the exposure obtained and the instruments available then did not permit any operative intervention.
Goetz and later Veress developed a spring loaded insufflation needle for the safe introduction of gas into the abdomen (pneumoperitoneum), which is used till today.1
One of the most important aspects of laparoscopy is the use of an optimal insufflating gas. The ideal gas for pneumoperitoneum should be non-toxic, inexpensive, colourless, nonflammable, readily soluble in blood and easily ventilated through the lungs.
Air was the first gas to be used for pneumoperitoneum and for several decades it was the insufflating gas of choice. It was cheap and easily available. Later oxygen was also used for a long time. However, both these gases support combustion and have a potential for gas embolism because they have a poor Ostwald's blood gas solubility coefficient (0.006, 0.013).
In the 1970s, nitrous oxide (N2O) emerged as the gas preferred by gynaecologists because of its low cost and high turnover. However, it supports combustion, if mixed with methane (from the bowel).
In 1924, Richard Zollikofer of Switzerland promoted the use of CO2 as the insufflating gas for pneumoperitoneum rather than filtered air or nitrogen, and which has now become the standard gas for pneumoperitoneum. It is relatively inert, permitting the use of electrocoagulation, and is readily absorbed by the peritoneal membrane (blood/gas solubility 0.48) and is readily exhaled via the lung. Previously, industrial impure CO2 was employed, which led to arrhythmias. Nowadays with the availability of pure CO2, these problems have been overcome.
Other alternative gases like helium, argon and xenon are inert but expensive and have a very low blood gas solubility (0.00018), and therefore, have high chances of gas embolism if accidental injection in to a blood vessel occurs.
Raoul Palmer in Paris (1944) (Fig. 1.3) stressed the importance of monitoring intra-abdominal pressure. It was another 20 years, however, before Kurt Semm in Kiel, Germany, developed an automatic insufflation device that monitored intra-abdominal pressure and gas flow. Prior to this time air was introduced into the peritoneal cavity by means of a syringe.2
With the development of safer insufflation needles as well as instruments for controlling gas flow during pneumoperitoneum, complications such as bowel perforations and injuries to retroperitoneal vessels were significantly reduced. Nevertheless, because laparoscopy was considered a “blind” procedure with an inherent risk of injury to intraperitoneal structures, acceptance was slow throughout Europe and North America.
One of the most significant advances in rigid endoscopy was the development of the rod lens system in 1966 by the British optical physicist Hopkins. His design resulted in vastly improved image, brightness and clarity. These same principles are still utilized in laparoscopes today. The introduction of fiberoptic (cold) light sources in the early 1960s eliminated the risk of bowel burns caused by incandescent lighting.
Laparoscopic visualization of the abdominal cavity was once restricted to the individual directing the operative procedure and participation by other members of the surgical team was limited. Therefore, surgery was generally cumbersome and tedious because of the inability of the assistant(s) to effectively interact with the surgeon.
The development of a computer chip TV camera attached to the laparoscope in 1986 solved this problem and changed the face of surgery. It facilitated the extension of laparoscopic surgical techniques to more complicated procedures and also aided in training programmes. Easy documentation of the procedures became possible in videotapes.
Laparoscopic cholecystectomy for the purpose of removing gallstones in pigs was performed by Frimdberg in 1978 (personal communication, 1990).
Although in 1985, Erich Muhe of Germany (Fig. 1.4) described his technique of laparoscopic cholecystectomy in humans using the galloscope, it was in 1987 that the complete removal of a diseased gall bladder in a patient was performed by Mouret in Lyon, France. Interest in these procedures grew almost exponentially, largely fuelled by patient demands.2
Public awareness that endoscopic surgery is associated with diminished pain and cosmetic disfigurement as well as quicker resumption of normal activities accelerated its acceptance so much that all wanted the ‘pin hole’ surgery.3
Initially laparoscopic surgery was confined to short diagnostic gynaecological procedures, which were conducted on young healthy females. However, now they are conducted on older and high risk patients who were earlier considered unfit for laparotomy. Nowadays, more and more patients are being referred for surgery as soon as the diagnosis has been established, relegating medical treatment.
After the acceptance of laparoscopic procedures like cholecystectomy and appendicectomy, which are intraperitoneal procedures, there was a surge for extraperitoneal surgery which included inguinal hernia repair, adrenalectomy and nephrectomy including donor nephrectomy. These procedures necessitate extraperitoneal insufflation of gas with the attendant risk of increased CO2 absorption.
It has become the standard surgical approach for gastroesophageal reflux disease (GERD), donor nephrectomy, adrenal tumours and morbid obesity. In fact, nowadays, there is hardly any absolute contraindication for a procedure to be performed laparoscopically, since the postoperative benefits far exceed the stress of intraoperative pathophysiological changes.3
The rapid development in the field of laparoscopic surgery, its increasing list of procedures and the inclusion of high risk patients would not have been possible without concurrent advancements in anaesthetic techniques. The anaesthesiologist has constantly strived to provide safe anaesthesia for these “minimal access” surgeries where there is “maximal trespass” of normal homeostasis. Extremes of patient positioning, insufflation of exogenous gases and increased intra-abdominal pressure (IAP) pose a severe strain on the patient's physiology. The anaesthesiologist, should be aware of these changes and the possible complications during the various procedures, so that early detection and prompt treatment may be instituted. The initial learning curve for a new procedure may be quite long and anaesthesiologists have patiently cooperated and encouraged their surgical colleagues till the surgical technique could be mastered.
Robotic systems for videoscopic surgery were introduced in the late 1990s to enhance manoeuvrability, visualization and ergonomics for minimally invasive thoracoscopic and laparoscopic surgery (Figs 1.5A and B).
The robot can reproduce a surgeon's movements rapidly, precisely and without tremor of the human hand or fatigue. They may be useful teaching modalities and might offer potential benefits in decreasing learning curves and increasing safety in a teaching environment. It allows the tutor to take over at any desired moment or to literally take the resident by the hand to guide him in videoscopic manoeuvres.
CONCLUSION
To conclude, advances in laparoscopic surgery have been associated with parallel development in anaesthetic approaches and a team approach among the surgeon, anaesthesiologist and theatre staff has been pivotal in its development. It is a challenging anaesthesia speciality and the anaesthesiologist must constantly improvise and evolve his approach in the face of an ever expanding domain of laparoscopic surgery.
REFERENCES
- Grzegorz S. Litynski. Highlights in the History of Laparoscopy, 1996.
- Karl A. Zucker. Surgical Laparoscopy, 1991.
- Jayashree Sood, Lakshmi Jayaraman, V.P. Kumra. Endoscopic Surgery- Anaesthetic Challenges – A Historical Review. Indian J Anaesth 2006; 50(3): 178–82.