1805
P. Bozzini
Inventor of “Lichtleiter”
Composed of Mirrors, a wax candle for illumination and an urethral cannula used to visualise GU tract
1853
A. J. Desormeaux
“Father of endoscopy”
First to use Bozzini’s “Lichtleiter” on a patient
Genital speculum, mirror and kerosene lamp used
1877
M. Nitze
Created first workable cystoscope
1901
G. Kelling
Performed first experimental laparoscopy using insufflation (dog)
Created pneumoperitoneum using filtered atmospheric air, to prevent intra-abdominal bleeding
1911
B. Bernheim; H.C. Jacobaeus
Performed first laparoscopic procedures
Bernheim: used a half-inch diameter protoscope and ordinary light to perform an “organoscopy”
Jacobaeus: performed procedure both on thorax and abdomen, introducing trocar without pneumoperitoneum
1920
R. Zollikofer
Determined benefits of using CO2 for insufflation
1929
H. Kalk
Developed 135° lens system and dual trocar
Performed diagnostic laparoscopy as diagnostic method – liver and gallbladder
1938
J. Veress
Developed spring-loaded needle
Used as a treatment for pneumothorax in TB patients
1944
R. Palmer
Performed gynaecological laparoscopic procedure
Placed patients in Trendelenberg position to allow air to fill pelvis
Advocated continuous intra-operative abdominal pressure monitoring
1953
H. Hopkins
Developed rigid rod lens system and videoscopic surgery
1972
H. C. Clarke
Developed laparoscopic suturing technique
1978
Hasson
Alternative open trocar placement
1983
Semm
First laparoscopic appendicectomy
1987
P. Mouret
First laparoscopic cholecystectomy using video technique
1989
H. Reich
Used bipolar diathermy in first laparoscopic hysterectomy
Demonstrated laparoscopic staples and sutures
1989
Reddick and Olsen
Reported that in laparoscopic cholecystectomy – CBD injury risk is 5 times higher than open procedure
US government: surgeons should do 15 under supervision
1990
Wickham and Davies
First surgical robot developed for transurethral ultrasound – “PROBOT”
Automated system performed in 30 patients
1994
AESOP Robotic arm developed for holding telescope
1996
First robotic telesurgery performed
2000
FDA approves US military funded Da Vinci device
2002
Menon
First robotic radical prostatectomy
Principles of MIS
Today, MIS is performed routinely across a wide range of specialities: from urology to cardiothoracic surgery. In particular, a high percentage of gastrointestinal and gynaecological procedures are carried out by MIS, especially gallbladder surgery: approximately 90 % of cholecystectomies are performed laparoscopically in the US [1].
Fundamentally, laparoscopic surgery is carried out via four sequential stages: patient positioning, port insertion and insufflation, specimen retrieval, and port removal. In the first stage, the patient is positioned appropriately on the operating table using gel pads and strapping to support the body. This ensures good weight distribution and prevents the development of pressure sores, neuropathies or rhabdomyolysis associated with poor positioning. Furthermore, patient positioning can be crucial to providing adequate intra-operative exposure. For example, in the Trendelenburg position, the patient is laid supine (flat on the back), with the table tilted in order to place the feet higher than the head. This provides better access to the pelvic organs, by allowing gravity to pull the mesentery and intestines away from the operative field. In the second stage, an initial port (trocar) is inserted into the abdomen. This trocar is used to establish pneumoperitoneum by insufflating the abdomen with CO2 gas. This distends the peritoneal cavity and allows for optimal visualisation. Additional ports can then be inserted safely under direct vision, and subsequently used for the camera and instruments. In the third stage, the surgical procedure is performed and the specimen retrieved. Finally, the trocars are removed and the incisions are closed. The fundamental requirements for laparoscopic surgery are summarised in Box 11.1 and discussed below.
Box 11.1 Required components
Trocar (access)
Insufflation (retraction)
Light source (visual input)
Camera (visual output)
Instruments
Trocar
Trocars act as ports, providing sealed entrances for the camera and instruments to be inserted into the abdomen in laparoscopic surgery. Modern trocars are derivatives of the ‘trochartor triose-quarts’ created in 1706: a three-faced instrument with a sharp, pointed perforator housed within a metal cannula. Today, modern trocars may be inserted via a closed or open technique.
Closed insertion is performed with a Veress needle, which is used to puncture the abdomen at the umbilicus. Developed by Janos Veress in 1938, the 12–15 cm long, 14 gauge needle has two elements. The first part is a cannula with a bevelled needle point, which functions to pierce the abdominal wall. Two ‘pops’ can be heard during insertion of the Veress needle: the first signalling perforation of the linea alba and the second, the peritoneum. Upon entering the peritoneal cavity, there is a sudden decrease in pressure against the needle. This draws forwards the second part of the instrument from within the cannula: a spring-loaded, blunt stylet, which covers the sharp needle. This is accompanied by an audible ‘click’. Though use of the Veress needle is fast, preferred by many doctors and is standard practice in the USA, blind insertion of the needle is associated with higher risk of various complications. When compared to open trocar insertion, the commonest complication is failed entry, and other risks include injury to the omenta and viscera, vascular injury and extraperitoneal insufflation [2]. This technique is not advocated by any of the UK Royal Colleges of Surgeons, however it is used by the Royal College of Obstetricians and Gynaecologists.
The alternative open method of trocar insertion is termed the Hasson technique, which can be thought of as a “mini-laparotomy”. In order to access the peritoneal cavity in this way, a small incision and split in the fascia is created at or near the umbilicus, approximately 1 cm in length. The abdominal wall layers are cut down, and after the peritoneum is incised, a Hasson trocar (a blunt tipped cannula with an olive shaped sleeve) is inserted through the incision. The cannula body is then securely fastened using stay sutures to the fascial edge. With regard to the comparative safety of these two access methods, currently the choice is subject to individual surgeon preference, as literature review found non-inferiority of Veress in contrast to the Hasson technique.
Insufflation
The process of inflating the abdomen, or ‘insufflation’, creates a domed gas-filled space within the peritoneal cavity (known as a pneumoperitoneum) that allows the surgeon to see the organs clearly. In order to create the pneumoperitoneum, a machine with an adjustable flow rate setting of between 0 and 35 L/min is used to supply a maximal pressure of 15–20 mmHg, limited to allow venous return. Working pressures of between 10 and 15 mmHg in adults, and 10 mmHg in children are generally used.
Insufflation results in an even distribution of pressure throughout the whole abdomen: as a consequence there is less local wound trauma than there would be when using retractors in open surgery. However, there are pathophysiological processes associated with the induction and maintenance of pneumoperitoneum, which must be considered. A raised intra-abdominal pressure above 20 cm H2O can precipitate a reduction in venous return; an increase in cardiac stress related to hypotension; a reduced forced respiratory capacity; and cerebral ischaemia. The pathophysiology is summarised in Fig. 11.1.
Fig. 11.1
Pathophysiological effects of pneumoperitoneum on the respiratory (a), cerebral (b) and cardiovascular (c) systems
Another important consideration in the induction of pneumoperitoneum is the insufflant used. Carbon dioxide is the gas of choice as it is readily available, cheap and non-flammable. CO2 is extremely soluble and removed from the circulation via the lungs. However, it has a very high diffusion rate in extraperitoneal cavities, which means that establishing and maintaining sufficient CO2 volumes in pelvic and particularly renal surgery can be difficult. Provided that oxygen levels are adequately maintained, hypercapnia is well tolerated temporarily, though high CO2 levels in the circulation increase the risk of pulmonary hypertension and aciduria. There is also a risk of venous gas embolism, which may travel up the inferior vena cava to the right heart. This may lead to a ‘gas lock effect’, preventing right ventricular ejection, and lead to circulatory collapse. Though this is rare with use of CO2 due to its high solubility, it may occur more frequently with other gases.
Alternatives to CO2 include nitrous oxide, helium and argon. Nitrous oxide is generally not recommended as it is combustible and causes bowel expansion from cross-peritoneal diffusion. Helium and argon provide biologically and chemically inert substitutes. Though argon is relatively inexpensive, there is a risk of prolonged subcutaneous emphysema which may cause respiratory complications.
Light and Camera
The choice of light source and camera type is dependent on surgical specialty and nature of the procedure. Rigid laparoscopes are most typically used in MIS procedures. The tip may be straight (zero degree telescope) or angled, commonly at 30 degrees, to improve the visual field, allowing the surgeon to look around and behind organs. At the tip there may be a video chip connected to a rigid cable, surrounded by optic fibres, which provides a light source. Scopes adapted for use in small spaces, such as the arthroscope, may have two other channels as well as the viewing channel: one for medical instruments and manipulators (the working channel); and one for suction and irrigation. Arthroscopes may also have a camera attached to the eyepiece instead of a video chip (Fig. 11.2).
