Evolution of laparoscopic surgery and laparoscopic instruments

1. Dr Aashish R. Chavan
Fellow In MAS
Dept. of Surgery
GMC,Nagpur
Evolution Of
Laparoscopic Surgery
And
Laparoscopic Instruments

2.  Early pioneers of endoscopy who planted the seed
 Finally the modern pioneers who pushed and expanded
these frontiers to give rise the birth of modern
laparoscopy.

3.  The innate human curiosity to peer inside the body
cavities can be traced back to ancient times.
 However, due to primitive technology and crude
instruments, many of these ambitions were not realized.

4.  The first description dates to Hippocrates in Greece, for
use of a speculum to visualize the rectum (460–375
BC).

5.  1806: Philip Bozzini
(German)
 Developed an instrument
“Lichtleiter “
 Looked inside urinary
bladder.
 A candIe as a light
source and consisted
of a light container,
mirrors, and tubes
through which the
light passed

6.  1853: Antoine Jean
Desormeaux used
Bozzini’s Lichtleiter
 1867: Desormeaux used
an open tube to examine
the genitourinary tract

7.  In 1867, a German dentist named Bruek
 described the first internal light source.
 He examined the mouth using illumination provided by a loop of
platinum wire
 connected to an electrical current.
 Because the wire generated intense heat, the loop was
cumbersome and dangerous to use;

8. Maximilian Nitze (1848 – 1906)
 1St cystoscope
(Nitze-Leiter
cystoscope)
 using an electrically
heated platinum wire
for illumination
cooled it by using a
continuous stream of
water through the
cystoscope.

9.  During the 19th century, lenses, light sources, and
endoscopes evolved, and surgeons and internists
performed cystoscopy, proctoscopy, laryngoscopy,
and esophagogastroscopy.
 In 19th century because internal visualization
remained relatively poor.

10.  1901 -Von Ott
 - First inspection of abdominal cavity using a speculum
and candlelight.
 In 1902, George Kelling (Germany)
 visualized peritoneal cavity insufflated the abdomen of a
dog with filtered air.
 used a Nitze cystoscope to look inside calling it
‘Celioscopy’.

11. Hans Christian Jacobaeus (1879 – 1937)
 1910: Swedish internist; first thoracoscopic diagnosis with
a cystoscope in a human subject.
 Jacobaeus in 1910, coined the term “ laparoscopy”
 Treatment of a patient with tubercular intra-thoracic
adhesions.
 The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities. Münchner
Medizinischen Wochenschrift, 1911

12.  The word laparoscopy is derived from a Greek word
 lapara- “the soft part of the body between ribs and hip, flank, loin”
 Skopein-“to look at or survey”.
 Jacobaeus in 1910, coined the term “ laparoscopy

13.  1920: Zollikofer discovered the benefit of CO2 gas for insufflation
 1938: Janos Veress developed a spring loaded needle for the induction
of pneumoperitoneum.
 After World War II, the development of fiberoptics represented an
important step forward for endoscopy

14. Duration Of Complications And Rejection
 During the mid-1950s to 1970s,
 increase in complication rates due to bowel injuries
 and cautery injuries for women undergoing laparoscopic sterilization.
 Laparoscopic surgery was effectively banned in Germany from
1956 to 1961.
 In the 1970s, similar concerns were raised in the United States,
 large part related to the limitations of technology for good
vision.

15. British Physicist, Harold Hopkins in 1952
Made most crucial invention in operative
laparoscopy
Who developed the idea of the rod lens system.

17. 1966: Hopkins rod lens scope & cold light

18. British Physicist, Harold Hopkins in 1952
Conventional endoscopes In Hopkins system
were constructed on an optical system that
comprised relay and field lenses made from
glass with long intervening air spaces.
the roles of glass and air are interchanged
such that the optical system consists of air
lenses and long glass air spaces.
Disadvantage
1. Low refractive index and less capacity of
transmission of light
2. Small radius of aperture at viewing optic
so smaller image
Advantages
1. As the refractive index is now
predominantly that of glass, the light
transmission capacity of the endoscopes
is doubled.
2. “larger radius of clear aperture”
available at the viewing optic so larger
and broader image

19.  1974: Dr Harrith M Hasson,
 MD working in Chicago, proposed a blunt mini-laparotomy which
permitted direct visualization of the trocar entrance into the peritoneal
cavity. It is popularly known today as Hasson‘s technique.

20.  The 1970s and early 1980s were not the season for
change.

21. Kurt Semm (1927-2003)
 To his struggle to establish the foundation of
minimally invasive surgery amongst his
contemporary surgeons
 In 3o may 1980, Semm performed the first
laparoscopic appendectomy.
 ‘father of gynaecological laparoscopy’
 He preferred the term ‘pelviscopy’ for operative
laparoscopy
 Bhattacharya K. Kurt Semm: A laparoscopic crusader. Journal of Minimal Access
Surgery. 2007;3(1):35-36. doi:10.4103/0972-9941.30686.

22. Kurt Semm (1927-2003)
 Semm's technique, however, was often criticized
 Once, while making a slide presentation on ovarian cysts; suddenly the projector was
unplugged - with the explanation that “such unethical surgery should not be presented”
 In 1970, after becoming the chairman of Ob/Gyn at the University of Kiel, his co-workers
demanded that he undergo a brain scan because, they said,
“only a person with brain damage would perform laparoscopic surgery”
 In 1972, following Semm's presentation on laparoscopic ovarian cyst enucleation, a German
gynaecology professor remarked - ‘My young colleague, if you wish to advance in the
German academic world, do not pay any attention to Semm's non-sense.’
 Between 1975 and 1980, his idea to perform laparoscopic cholecystectomy was rejected by
the general surgeons. The surgeons told him that they had enough work to do repairing the
intestinal damage, which occurred during extensive laparoscopic adhesinolysis

23. Kurt Semm (1927-2003)
 In 3o may 1980, Semm 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, which was rejected as unacceptable for publication
on the ground that the technique reported on was ‘unethical.’

24. Kurt Semm (1927-2003)
 In 1981, Professor Jon Beerman, President of the
American Society of Reproductive Medicine, from Detroit,
Michigan, visited Kurt Semm to see the ‘magic surgery.’ In
the operation theatre, Beerman observed laparoscopic
adnexectomy.
 He later commented ‘All I wanted to see was the reality of
this surgery. Now, I am ready to go on my planned hunting
trip.’
 These comment in the US helped to make laparoscopic
surgery acceptable in that part of the globe.

25. Kurt Semm (1927-2003)
 80 Inventions
 his first inventions were to develop an
electronic CO2insufflator, a uterine
manipulator and a tubal patency
testing device.
 In the 1970s, Semm developed
thermocoagulation, adapted the
Roeder loop, and further invented
extra- and intra-corporeal
endoscopic knotting to achieve
endoscopic hemostasis.
 Brother and father owned a medical
instrument company which rapidly
produced instruments for him
 He also developed a medical
instrument company Wisap in
Munich, Germany, which still
produces various endoscopic
instruments of high quality.
 In 1985, he constructed the
pelvi-trainer = laparo-
trainer, a practical surgical
model whereby colleagues
could practice laparoscopic
techniques

26. Kurt Semm (1927-2003)
 Finally in 2002, Semm received the ‘Pioneer in endoscopy’
award from the Board of Governors of the Society of
American Gastrointestinal Endoscopic Surgeons (SAGES).
 Semm Displayed an ability to push his ideas through despite
skepticism and suspicion Without Semm, the laparoscopic
revolution may have been postponed by many years
 At the age of 76, he died due to Parkinson's disease in 2003

27. Eric Muhe (In 1985)
 Eric Muhe, of German origin, is interested in the gallbladder surgery,
laparoscopy designs where the tube is of greater caliber and indirect vision
and equipped with valves that prevent loss of pneumoperitoneum.
 This author in 1985 performed the first laparoscopic cholecystectomy in
the world,
 He presented his work at the 1986 Congress of the German Surgical
Society.
 He, too, suffered skepticism and criticism and was ultimately
censored by the courts.
 The season for change had not yet arrived

28.  The single most important technological
advancement for complex laparoscopic surgery
would be the advent of video laparoscopy.

29. Biography of Camran Nezhat
Iran (Persia)
 “an overnight surgical sensation that was 75 years in the making.”
 founder “father” of operative video-laparoscopy.
 During internship and residency at the State University of New York
 Visualization difficulties from peering crouched over through the
endoscope with only one eye seemed the most crucial impediment
to overcome.

30.  At the forefront and important
juncture of the discovery of the
advantages of operating on the
images (videolaparoscopy),
 Camran performed endoscopic
surgery off the monitor starting in
1980s, using very heavy and
awkward video camera equipment
that had been produced for other
uses and which instead he
customized— rigged actually—for
use with the laparoscope

31.  During the early to mid-1980s, videoscopic images were
applied to endoscopy and ultimately to the laparoscope.
 The technology was now in place to support multiple
people working in concert by laparoscopy.

32.  In 1987, French surgeon Phillip Mouret
performed the first videolaparoscopic
cholecystectomy
 like Muhe, Semm, and Nezhat, was strongly
criticized.
 In 1988,Francois Dubois, another Frenchman,
was the second surgeon to perform
videolaparoscopic cholecystectomy and was the first
to publish his early experience

33. American College of Surgeons annual
meeting in October 1989.
 Laparoscopic cholecystectomy was introduced to the
general surgery world in the exhibit hall.
 Patients were demanding the new surgery, and
instrument companies were supporting courses and
even paying tuitions for surgeons to be trained to use
their products.

34.  Due to the poor intensity of light sources,
 at times he used an extra laparoscope connected to the light source
only to bring “more light to the subject.”

35. Sensor is charged coupled device (CCD)
solid state chip sensor.
The foundation of the laparoscopic camera is the solid state chip sensor.
The CCD is composed of
 small pieces of silicone called pixels, which are arranged in rows and columns
and are sensitive to light.
 When light strikes a pixel, the silicon emits electricity, which is transmitted to
the monitor.
 The electronic signals are then reconstructed on the monitor to give the video
image.
 The resolution of the CCD is determined by number of the pixels on the sensor.

37. Triple chip camera
 Each chip devoted to only one color of the spectrum.
 Since the major spectrum is derived from three colors i.e.
red, green and blue,
 Modern three chip camera is able to reconstruct the image
consisted of these three primary colors.
 Provide excellent resolution and color but they are
significantly more expensive.

38. Four types of lamp are used more
recently.
1. Quartz halogen.
2. Incandescent bulbs
3. Metal halide vapor arc lamp
4. Xenon.
5. LED Light
 Fiber optic cables,
Light source & transmission

39.  A normal light source (a light bulb) uses approximately
2 % in light and 98 % in heat.
 This heat is mainly due to the infrared spectrum of light
and due to obstruction in the pathway of light.
 A heat filter is introduced to filter this infrared to
travel in fiber optic cable.
 A cool light source lowers this ratio by creating more
light, but does not reduce the heat produced to zero.

40. Halogen bulb.
Most common type of light source.
The electrodes are made up of Tungsten.
They utilize halogen gas that allows the bulb to burn
more intensely.
They have average life of 2000 hours.
These lamps are cheap
However, they lack in providing the natural white light
color.

41. Xenon lamp
 The light emitted by xenon lamp is slightly bluish
 More natural compared to halogen lamp.
 A proper white balancing before start of the operation is a very good
practice for obtaining a natural color.
 The white light is composed of the equal proportion of Red, Blue and Green
Color
 At the time of white balancing the camera sets its digital coding for these
primary colours to equal proportion assuming that the target is white.
 And if at the time of white balancing the telescope is not seeing a perfectly
white object then the setup of the camera will be very bad and the colour
perception will be very poor.

42. Laparoscopy in India – a personal
perspective
 Father of laparoscopy in India.
 A forceful, innovative and renowned teacher and surgeon,
 Dr Udwadia was the first surgeon in India to start
Laparoscopy in surgery,
 First to perform Laparoscopic Cholecystectomy in the
developing world in 1990.
 Padma Shri National Award, New Delhi (2006)
Udwadia TE. Laparoscopy in India - A personal perspective.
J Min Access Surg 2005;1:51-2
Tehemton E. Udwadia
Emeritus Professor, Department of
Surgery,
Grant Medical College and JJ Hospital,
Consultant Surgeon, Head, Department
of Minimal Access Surgery, P.D.
Hinduja National Hospital, Consultant
Surgeon, Parsee General Hospital Breach
Candy Hospital, Mumbai, India

43.  Dr. F.P. Antia, then Professor at the KEM Hospital/Nair Hospital, Mumbai
performed a diagnostic laparoscopy on a patient with cirrhosis using a
Nitze-type telescope and a feeble filament light bulb and atmospheric air
instilled with the help of a sigmoidoscope pump for induction of
pneumoperitoneum.
 Dr Udwadia realised the importance of diagnostic laparoscopy for
surgeons.
 In 1971 saw Dr. N.D. Motashaw, the Honorary Gynaecologist at the KEM
Hospital perform a diagnostic laparoscopy using a Storz laparoscope.
 The first laparoscopic cholecystectomy in India was performed in 1990 at
the JJ Hospital, Mumbai, followed a few months later in Pune by Dr.
Jyotsna Kulkarni

44. FUTURE
 Robotic Surgery,
 Virtual Reality training
 TeleSurgery are the areas to watch out.
 Natural orifices transluminal endoscopic surgery
[NOTES]
 Single incision laparoscopic surgery.[SILS]
 The latter would make it possible for surgeons to
transmit their training, sense of touch, and
experience to injured patients on battlefields, at
disaster sites, perhaps even in outer space.

45.  Thank you