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MAIN MENU INTRODUCTION TO LAPAROSCOPIC COLECTOMY HISTORY OF LAPAROSCOPIC COLECTOMY CARDIOVASCULAR CHANGES DURING
LAPAROSCOPIC COLECTOMY
LAPAROSCOPIC COLECTOMY FOR
COLONIC VOLVULUS
LAPAROSCOPIC COLECTOMY AT A
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REVIEW OF 752 LAPAROSCOPIC COLECTOMIES LAPAROSCOPIC COLECTOMY:
AN UPDATE

MINIMALLY INVASIVE SURGERY FOR
DISEASES OF THE COLON & RECTUM:
THE LEGACY OF AN ANCIENT TRADITION

(SA Sgambati & GH Ballantyne.
In:Rama M. Jager, M.D. , Ph.D. & Steven Wexner, M.D.
LAPAROSCOPIC COLECTOMY, Churchill & Livingstone. New York. 1995. Pp 13-23)


GARTH H. BALLANTYNE, M.D., M.B.A.
F.A.C.S., F.A.S.C.R.S.

BOARD CERTIFIED IN:
GENERAL SURGERY & COLON AND RECTAL SURGERY

OFFICE: 4 SHAW'S COVE, SUITE #201, NEW LONDON, CT 06320

SURGEON IN CHIEF
LAWRENCE & MEMORIAL HOSPITAL
NEW LONDON, CT 06320

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MORE ABOUT LAPAROSCOPIC COLORECTAL SURGERY

MAIN MENUINTRODUCTION TO LAPAROSCOPIC COLECTOMYHISTORY OF LAPAROSCOPIC COLECTOMYCARDIOVASCULAR CHANGES DURING
LAP. COLECTOMY
LAPAROSCOPIC COLECTOMY FOR
COLONIC VOLVULUS
LAPAROSCOPIC COLECTOMY AT A
VA HOSPITAL
REVIEW OF 752 LAPAROSCOPIC COLECTOMIESLAPAROSCOPIC COLECTOMY:
AN UPDATE

 

INTRODUCTION

Surgical procedures that treat diseases of the colon and rectum have been plagued by high rates of morbidity and mortality throughout history. Undoubtedly, this resulted from the high bacterial counts within the colon. In fact, during the classical period, surgeons rarely operated upon the abdominal cavity. Rather, classical physicians confined their intervention to indirect methods such as diet changes, cathartics, and purgatives. When confronted with diseases requiring more invasive therapy, surgeons attempted to develop minimally invasive techniques that not only treated the disease process but also minimized patient morbidity. Minimally invasive surgery thus has a rich history spanning over thousands of years.

In the modern era, surgeons continued to develop minimally invasive techniques, particularly to treat colorectal diseases. Perineal approaches to rectal prolapse allowed treatment of elderly patients prior to the advent of modern anesthesia. The use of the rigid sigmoidoscope for non-operative decompression of sigmoid volvulus dramatically decreased the mortality from this form of colonic obstruction. The flexible endoscope provided intraluminal access to the colon and permitted the development of polypectomy techniques. Through minimally invasive techniques, surgeons could safely and effectively treat a larger patient population.

The introduction of laparoscopic cholecystectomy in 1987 clearly illustrates the potential benefits of minimally invasive approaches to gastrointestinal diseases. Patients suffer less postoperative pain, develop fewer infections, resum oral intake and are discharged sooner than after cholecystectomy performed through a standard Kocher incision. Laparoscopic cholecystectomy's tremendous success, along with the flood of new technology into general surgery, stimulated surgeons to apply laparoscopic techniques to treat other gastrointestinal diseases.

Within two years of the first successful videolaparoscopic cholecystectomy, the first laparoscopic-assisted colectomy was accomplished. Preliminary reports suggested that many of the same benefits accrued by patients following laparoscopic cholecystectomy were reaped by patients with colorectal diseases. As such, the current efforts in the development of videolaparoscopic techniques represent the continuation of an ancient tradition: surgeons' attempt to treat colorectal diseases with minimally invasive techniques in order to decrease the morbidity associated with colorectal procedures. Nonetheless, innovative efforts to develop minimally invasive techniques for colorectal operations have been met with a groundswell of controversy. Many surgeons have questioned whether the expense of this new technology and the required retraining of practicing surgeons can be justified by the improved results reported in early series.

Surgeons have traditionally attempted to find new methods to treat their patients' afflictions which would concomitantly reduce the injury caused by the treatment. The application of minimally invasive techniques to operations for colorectal diseases follows in this tradition. Consequently, the purpose of this review is to trace the evolution of minimally invasive techniques for gastrointestinal diseases over the last three thousand years and to highlight recent successes in the application of these techniques to diseases of the colon and rectum. These efforts will demonstrate that videolaparoscopic colorectal surgery represents the arrowhead of an ancient tradition, which is pointing the direction towards surgery of the Third Millennium.


 

MINIMALLY INVASIVE THERAPEUTICS
IN THE CLASSICAL PERIOD

Classical physicians were limited in their invasive therapeutic options. Religious prohibitions prevented cadaveric dissections which resulted in a limited knowledge of human anatomy. Surgical procedures on anything but superficial structures carried high rates of infection and death. Consequently, classical physicians directed their efforts towards the stimulation of the patient's own economy to fight off the disease. The classical physician believed that thesymptoms of disease were produced by the response of the patient's natural faculties to the disease. He believed that disease resulted from the putrefaction of humors within the body. The principle role of the physician, therefore, was to moderate symptoms and to assist in the neutralization and disposal of malevolent humors.

The classical physician attentively studied the progression of symptoms in both acute and chronic illnesses. In particular, he focused on the divergence of symptoms between patients that recovered and those that succumbed to the disease. It was the role of the physician to promote symptoms such as vomiting and diarrhea when the response of the patient was judged inadequate and to temper symptoms when they became too extreme. The role of the physician, then, was to assist Nature in the fight against disease. 1-3

The importance of Nature in the battle against disease explicitly remained the central postulate of therapeutics until the 19th Century. This doctrine was deemed the Vis Medicatrix Naturae. William Cullen, Professor of Medicine at the University of Edinburgh in the late 18th and early 19th Century, defined this important concept. Cullen wrote while addressing the Phaenomena of Fevers:

How the state of debility produces some of the symptoms of the cold stage, we cannot particularly explain, but refer it to a general law of the animal oeconomy, whereby it happens, that powers, which have a tendency to hurt and destroy the system, often excite such motions as are suited to obviate the effects of the noxious power. This is the VIS MEDICATRIX NATURAE, so famous in the school of physic; and it is probable, that many of the motions excited in fever are the effects of this power.4

Thus, the classical physician did not believe that he could directly treat a disease. Instead, his role was to support and to assist the natural response of his patient to his illness. The physician guided the powers of Nature in the struggle against disease. In other words, he strived to use minimally invasive therapies so as to avoid compromising the patient's response to disease.


 

THE USE OF THE GASTROINTESTINAL TRACT
IN CLASSICAL THERAPEUTICS

The gastrointestinal tract played a central role in the classical medical therapeutics. The classical physician recognized that alterations in gastrointestinal activity produced important effects on the natural history of acute and chronic illnesses. Hippocrates (460 B.C.- 375 B.C.) wrote in Aphorism LXVIII of Section VII that in acute diseases,

"and with respect to the alvine [alimentary] evacuations..it is then necessary to purge; but if instead of this nutritive liquids be administered the disease will be proportionally increased."5

Thus, stimulation of the colon ameliorated the disease while stimulation of the proximal gastrointestinal tract worsened it. The classical Greeks did not identify the mechanisms by which the colon might produce these beneficial actions, but did attempt to treat patients by affecting gastrointestinal function. This minimally invasive approach avoided the very real dangers of more invasive approaches.

The interest of Galen (133 -199 A.D.), physician and surgeon to Emperor Marcus Aurelius, was directed toward the lower gut, as he believed that it played an important role in health. The production and elimination of excrements was a fundamental requirement for the preservation of health. Galen emphasized in De Sanitate Tuenda:

Now our discussion has shown these two objectives of wholesome living, one the replacement of wastes, the other the elimination of excrements. And the third, that the animal should not age prematurely, follows of necessity those aforesaid. For if there were no failure, either in replacing the wastes or in the excrements remaining within, the animal would be healthy and would flourish for a long time.6

In Book I of this treatise, Galen devoted Chapter XIII to "Causes and Prevention of Excrementary Retardation"6 and Chapter XIV to "Evacuation of Retained Excrements".6 Difficulties with retention or evacuation of excrement could be avoided by careful management of diet and exercise. By careful regulation of the evacuation process, the patient could help preserve his own health.

Function of the lower gut not only played an important role in the preservation of health, but also in the diagnosis and treatment of disease. In illness, for example, the normal process of concoction becomes unbalanced. The normal sources of nutrition are not fully separated from the excrement and this can lead to retention of yellow bile and the suppression of the excretion of black bile and excrement.6 The physician could obtain insight into the cause of his patient's disease by another non-invasive technique: examination of the stool. Stool color and thickness was indicative of the specific imbalance in the process of concoction.

Galen taught that "nature itself at the first onset [of sickness] often expels bile or pituita through vomit and through the bowel; therefore it might be harmful not to imitate the actions of nature".7 It was thus the physician's responsibility to restore normal concoction, thereby re-establishing health. The physician accomplished this through the administration of syrups. Galen's non-invasive therapeutics used syrups: 1) to concoct, 2) to alter the disease by a contrary quality, 3) to extenuate and to comminute, 4) as a diuretic, 5) to control the bowels, 6) to bind the bowels, and 7) to strengthen the patient.7 The physician carefully timed the administration of syrups so as to accomplish these different goals at different times in the natural history of the disease.


 

MINIMALLY INVASIVE SURGERY IN THE CLASSICAL PERIOD

Some diseases, however, failed to respond to non-invasive modalities. When patients were afflicted with intestinal obstruction, more direct means of treatment were required. The Greeks used the term "ileus" for intestinal obstruction. Hippocrates detailed one fatal case of ileus in a woman in whom no remedy would work.8 Hippocrates did not specifically discuss the anatomic basis of ileus, but his writings suggest several etiologies. In his Affections, Hippocrates wrote that this malady supervened when a great quantity of fecal material accumulated within the intestines. In the Third Book of Diseases, he explained that ileus might occur when the upper abdomen was heated and the lower cooled.

Some of the treatments which Hippocrates practiced also lend insight into the possible etiologies of ileus. In the Affections, he advised injecting a large quantity of air into the intestines through the anus.8 In the Diseases, Hippocrates advocated the insertion of a suppository 10 digits long (@ 22 cm). Modern experience has demonstrated the efficacy of reducing an intussusception with insufflation and reducing a volvulus with a proctoscope which is 25 cm long. These descriptions suggest that Hippocrates equated ileus with intestinal obstruction and thought that there were several possible etiologies, including fecal impaction, intussusception, and sigmoid volvulus. Moreover, Hippocrates treated these life-threatening conditions with minimally invasive approaches.

Hippocrates' treatment of another colorectal disease further illustrates his minimally invasive surgical technique. The Hippocratic corpus suggested several remedies for the treatment of rectal prolapse. The most dramatic calls for suspending the patient in the air:

If procidentia ani [1] takes place, having fomented the part with a soft sponge, and annointed it with a snail, bind the man's hands together, and suspend him for a short time, and the gut will return.8

Hippocrates also describes a technique for maintaining permanent reduction of the prolapse. A caustic potass is applied to the rectal mucosa and after reduction of the prolapse the thighs are bound together for three days. The inflammation and scarring serve to fix the rectum in place.6 A similar remedy is also suggested for children. Other methods are advocated if the major symptom is bleeding while yet another if the patient complains mostly of pain. The Greek physicians developed several different minimally invasive therapeutic modalities to treat the specific clinical presentations of rectal prolapse.


 

EARLY ATTEMPTS AT MINIMALLY INVASIVE ACCESS:
THE DEVELOPMENT OF ENDOSCOPY

Physicians have always attempted to gain additional information about the afflictions of their patients through careful physical examination. Direct visualization of accessible internal organs such as the mouth or rectum often provided important supplemental insight into the etiology of various symptoms. The descriptions of minimally invasive techniques date to ancient times and include endoscopic examination of internal structures such as the anus and rectum. Innovative physicians, frustrated with the intrinsic limitations of endoscopy, introduced the endoscope directly into the peritoneal cavity, naming the procedure "organoscopy." This gained access to additional organs and the serosal surface of the gut, providing important diagnostic information.

The earliest recorded references to endoscopy date to ancient times with Hippocrates' description of examination of the rectum with a speculum. Hippocrates wrote in Section 5 of On Hemorrhoids:

But if the condyloma be higher up, you must examine it with the speculum, and you should take care not to be deceived by the speculum; for when expanded, it renders the condyloma level with the surrounding parts, but when contracted, it shows the tumor right again.8 Classical physicians used speculums for examination but did not describe their use in operations.

The transfer of Greek teachings of medicine to the Arabs included the use of speculums. The Arabian Abulkasim (936 -1013 A.D.) improved upon Hippocrates' method by using reflected light to examine the cervix (Figure 1).9 The next evolutionary step was fostered by Tulio Caesare Aranzi in 1585. Aranzi was the first to use a light source for an endoscopic procedure, focusing sunlight through a flask of water and projecting the light into the nasal cavity.10-13 Throughout the historical era, surgeons have utilized endoscopes to gain access to cavities of the human body. The industrial revolution provided the means to improve these instruments.

The modern era of endoscopy began in the early 18th Century. In 1806, Bozzini used an aluminum tube to visualize the genitourinary tract. The tube, illuminated by a wax candle, had fitted mirrors to reflect images. Unfortunately, Bazzini's invention was poorly received, and the idea of "a magic lantern in the human body" was ridiculed.14

In 1867, Desormeaux, "the father of cystoscopy," used an open tube to examine the genitourinary tract, combining alcohol and turpentine with a flame in order to generate a brighter, more condensable beam of light. In Dublin, Francis Cruise improved on Desmoreaux's model by enhancing illumination through a paraffin lamp, essentially making cystoscopy a practical technique. Cruise's instrument had attachments for examination of the rectum, uterus, auditory meatus, pharynx, and larynx. Also, Cruise envisioned that it might be adapted for investigation of the esophagus and stomach (Figure 2).14, 15

In 1869, Commander Pantaleoni used a modified cystoscope to cauterize a hemorrhagic uterine growth. Pantaleoni thus performed the first diagnostic and therapeutic hysteroscopy. Nitze, in 1877, developed a cystoscope with a distal light source and designed the first modern-type endoscope.11, 14, 15

In 1868, Kussmaul performed the first esophagogastroscopy on a professional sword swallower, initiating efforts at instrumentation of the gastrointestinal tract. Mikulicz and Schindler, however, are credited with the advancement of gastroscopy, having designed gastroscopes equipped with both an optical system and a means to insufflate air (Figure 3).16

The use of rigid endoscopic instruments severely limited access to the gastrointestinal tract. A flexible instrument was required to gain entrance into the duodenum or the colon proximal to the rectosigmoid junction. The necessary technology took over 100 years to be developed. In 1870, the British physicist John Tyndall demonstrated that light would follow a curved path. J.L. Baird of England and C.W. Hansell of the United States proposed using flexible glass fibers to propagate light in 1927 and 1930, respectively. It was not until 1954, however, that Lawrence Curtiss, an undergraduate physics student at the University of Michigan invented the process by which fine glass fibers could be coherently bundled in order to convey an entire image. The prototype fiberscope, initially adapted as a gastroscope, was introduced at the University of Michigan by Basil Hirshowitz in 1957.16

The tortuosity of the rectosigmoid colon limited the application of the fiberscope to the distal gastrointestinal tract. Advances in fiberoptics along with the persistence of Bergein F. Overholt led to the introduction of the first fiberoptic sigmoidoscope in 1963 (Figure 4).16 It was not until 1967, however, when Overholdt presented his experience to a skeptical American Society of Gastrointestinal Endoscopists, that colonoscopy was officially embraced. Technical refinements eventually led to advanced endoscopic surgical techniques, consistent with the goal of minimally invasive surgery.


 

THE DEVELOPMENT OF LAPAROSCOPY

The earliest reference to laparoscopy dates to Biblical history, where Ezekiel wrote,

"For the king of Babylon stood at the parting of the way, at the head of the two ways, to use divination: He made his arrows bright, he consulted with images, he looked in the liver (Ezekiel 21:21)."

During ancient times, the peritoneal cavity was a central focus, with the umbilicus symbolizing the connection to life and the liver representing the "cradle of the Soul."12

As previously discussed, classical Galenic medical tradition was based on the concept of maintaining balanced production and excretion of bodily waste, as imbalances led to disease states. Classical medical therapy aimed to restore normal balance through purgatives and cathartics. Alternatively, balance could be restored through surgery, by inserting a trochar into the abdominal cavity and draining the bad humors. Celsus (25 B.C.-50 A.D.) detailed the procedure:

"Some perform it below the navel at the distance of about four digits to the left; some perforate the navel itself; some cauterize the integument and make their opening into the abdomen by incision..."

A leaden or copper cannula with its lips curved outwards, or one that has a circular rim at its middle to prevent its slipping into the cavity is then introduced through the aperture. When the latter is used, that part of the instrument which is introduced should be no longer than that which remains external to the aperture, in order that it may proceed beyond the peritoneum.17

Instruments closely resembling laparoscopic trocars have been recovered from Roman ruins (Figure 5). Similarly, Albukasim described an "exploring needle with a groove" mounted on a handle. The term "trochar," however, was not coined until 1706, and is thought to be derived from trochartor troise-quarts, a three-faced instrument consisting of a perforator enclosed in a metal cannula (Figure 6).18

The first endoscopic examinations of the peritoneal cavity were accomplished early in the 20th Century. In 1901, Dimitri Ott, a German gynecologist described "ventroscopy," a technique in which a speculum was introduced through an incision in the posterior vaginal fornix. Ott wore head mirrors to reflect light and augment visualization. Also in 1901, George Kelling, a German surgeon, reported using a cystoscope to examine the intra-abdominal viscera of a dog after insufflating the peritoneal cavity with air, and coined the term "celioscopy." Jacobeus performed the first human celioscopy in Sweden in 1910, advocating the technique for the evaluation of patients with ascites. In 1911 in the United States, Bernheim published his laparoscopic experiences entitled, "Organoscopy," in the Annals of Surgery (Figures 7 - 8).10-14,16,19,

World War I interrupted technological advances, and it was not until the mid-1920's that enthusiasm for "organoscopy" was renewed and photographic documentation attempted. 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. 11,19, 20


 

TECHNICAL ADVANCES

The pioneers of laparoscopy believed that the technique was an important adjunct to surgical practice. Nonetheless, inadequate technology limited their vision, both literally and figuratively. Light sources in the first laparoscopes consisted of a distal light bulb with a rheostat to control intensity. The danger of thermal burns to intraabdominal contents from these primitive devices significantly limited their use. The laparoscope was introduced directly into the peritoneal cavity and pneumoperitoneum established by instilling air through the scope. Understandably, bowel perforations and vascular injuries posed very real risks in these early procedures.13,16,20

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."11 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.13

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.


 

MODERN LAPAROSCOPY

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 1959.11, 13, 14

Another decade was required, however, before the dangers of insufflation of the abdomen were overcome. In 1966, Kurt Semm introduced an automatic insufflation device capable of monitoring intraabdominal pressures. This allowed for safer laparoscopy, and bowel perforations and retroperitoneal vascular injuries subsequently declined. Semm developed thermocoagulation, revolutionizing laparoscopic surgery by virtually eliminating thermal injuries. Semm also designed a high-volume irrigation/aspiration system and perfected the EndoLoop applicator as well as intra-and extra-corporeal knot-tying techniques and instruments.11,13, 22 These technical advances elevated laparoscopy to a safe procedure which could be utilized in common clinical settings.

Therapeutic uses of laparoscopy were rapidly developed. Along with the technical advances, Semm adapted numerous surgical procedures to laparoscopic techniques, including tubal sterilization, salpingostomy, oophorectomy, salpingolysis, and tumor reduction therapy. Beyond the realm of gynecologic surgery, Semm popularized laparoscopic procedures such as omental adhesiolysis, bowel suturing, tumor biopsy and staging, and notably, incidental appendectomy.13, 22 Although interest was piqued, general surgeons still considered laparoscopy a "blind" procedure, fraught with risks of intraabdominal injuries, and thus did not incorporate the technique into the practice of general surgery.


 

LAPAROSCOPY IN GENERAL SURGERY

By the late 1970's, gynecologic surgeons had embraced laparoscopy and thoroughly incorporated the technique into their practice. General surgeons, despite their exposure to laparoscopy in consultation with gynecologic colleagues, remained skeptical and staunchly supported traditional open surgery. In 1978, Hasson introduced an alternative method of trochar placement which permitted direct visualization of trochar entrance into the peritoneal cavity. Subsequent to the development of the Hasson technique, general surgeons became more receptive to laparoscopic surgery, as the open technique allayed fears of bowel and vascular injuries.22

Liver biopsies were the first laparoscopic procedures attempted by general surgeons in 1982.23 Laparoscopy was applied to the staging of pancreatic cancer by Warshaw, Tepper, and Shipley in 1986, who reported 93% accuracy rate.24 In 1987, Mouret performed the first human laparoscopic cholecystectomy in France.25 McKernam and Saye performed the first laparoscopic cholecystectomy in the United States in 1988, but the technique was refined and popularized by Reddick and Olsen, who also developed the technique of laparoscopic cholangiography.26,27


 

MINIMALLY INVASIVE SURGERY OF THE COLON

Despite the advances in other areas of the gastrointestinal tract, many surgeons have remained reluctant to apply videolaparoscopy to colorectal surgery. It must be kept in mind, however, that efforts to develop minimally invasive techniques in colorectal surgery are merely a continuation of an ancient tradition. A striking example of the continuous effort towards minimally invasive colon surgery is seen in the history of the treatment of rectal procidentia. The vast majority of patients affected with rectal prolapse are elderly with associated medical problems which make them poor surgical candidates. In addition to the method offered by Hippocrates (see above), modern surgeons have struggled to find better means of treating these patients. Since the 1890's, over 100 procedures have been proposed to treat rectal prolapse, all aimed at definitive treatment through the least invasive means possible.

Several perineal procedures were designed in order to avoid laparotomy, namely the Thiersch Procedure in 1891, the Delorme Procedure (mucosal sleeve resection) in 1900, and the perineal rectosigmoidectomy. The latter procedure, originally advocated by Miles in 1933 and Gabriel in 1948, was popularized by Altemeier in 1952. Altemeier's success with the technique resulted in the association of his name with perineal rectosigmoidectomy, i.e., the Altemeier Procedure.28-30

Colonoscopy further illustrates recent efforts to develop minimally invasive modalities for the treatment of colorectal diseases. Colonoscopy became a vital component of colon and rectal surgery in the late 1970's, and improvements in technique and instrumentation permitted aggressive endoscopic treatment of colonic neoplasms. In many cases, formal laparotomy could be avoided, as polyps could be resected both safely and effectively through the colonoscope. Christopher Williams, Hiromi Shinya, and Jerome Way led the world in the development and promotion of colonoscopy as a minimally invasive surgical technique.16 The application of laparoscopy to colorectal diseases follows naturally in this same tradition.


 

LAPAROSCOPIC APPENDECTOMY

The first laparoscopic appendectomy was performed by DeKok in 1977. This was a laparoscopically-assisted procedure, with a mini-laparotomy performed to remove the non-inflamed appendix.31 Semm performed the first complete laparoscopic appendectomy in 1983. His technique, recommended only for non-acute cases, consisted of an extracorporeal ligation of the mesoappendix with endoscopic ligation of the appendix with a pretied loop. The appendix was transected across its base with electrocautery.32 Laparoscopy subsequently became a practical and popular technique for the evaluation and treatment of right lower quadrant pain in females, utilized by general and gynecologic surgeons alike.33,34


 

LAPAROSCOPIC COLON SURGERY

Patients who require colorectal surgery are often elderly and debilitated by chronic diseases. The abdominal wound has always been a source of major morbidity for these patients. The high concentration of bacteria within stool contributes to the high rate of wound infections, dehiscences and eviscerations associated with colorectal surgery. In addition, the pain from the abdominal wound often compromises pulmonary function and may limit the mobility of these patients in the immediate postoperative period as well as after hospital discharge. As a result, minimally invasive techniques, which limit the size of the abdominal wound, theoratically offer distinct advantages to patients requiring colorectal operations.

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, i.e., mini-laparotomies were utilized for ligation of mesenteric vasculature, extracorporeal anastomoses, and specimen removal. The first laparoscopic colonic resection using this technique was a right hemicolectomy, which was accomplished Moises Jacobs in Miami, Florida, in June of 1990. Similarly, closure of a colostomy required few specialized laparoscopic instruments. Joseph Uddo performed a laparoscopic colostomy closure on Novemnber 14, 1990. The anastomosis was constructed with a circular stapling device.

The introduction of a laparoscopic intestinal stapler, the Endo-GIAtm (United States Surgical Corporation, Norwalk, CT) 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 performed the first laparoscopic sigmoid resection in October of 1990. The anastomosis was contructed with a Premium CEEAtm (United States Surgical Corporation, Norwalk, CT) 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: the ileocolic anastomosis was constructed intracorporally. In a rapid succession, virtually all types of colorectal procedures were accomplished using minimally invasive techniques (Table 1).

The natural extension of minimally invasive techniques beyond colonoscopic polypectomy was the development of laparoscopic-assisted polypectomy. In 1991, Saclarides reported the laparoscopic removal of a colonic lipoma.35 Saclarides accomplishment added a technique to the growing armamentarium of minimally invasive surgery, as lesions not resectable colonoscopically heretofore required a laparotomy for removal. A lesion deemed non-resectable through the colonoscope could now be resected laparoscopically, extending the benefits of minimally invasive surgery to a larger patient population.


 

LAPAROSCOPIC COLECTOMY:
ADVANTAGES AND DISADVANTAGES

Initial reports indicate that laparoscopic colectomy can be performed safely with significant patient benefits. Advantages of laparoscopic colectomy include decreased postoperative ileus, pain, and disability; fewer pulmonary complications; improved cosmesis; shorter hospitalization; and reduced costs of care.36-38

Several controversial issues surround the application of laparoscopic techniques to colonic surgery. The biggest and potentially most severe issue concerns the propriety of laparoscopic colectomy for malignancy. The present standard of care dictates that generous mesenteric lymphadenectomy be performed when resecting for carcinoma. Resection through the laparoscope is thought to entail a less extensive lymphadenectomy, and thus concerns arise regarding the adequacy of laparoscopic colon resection for carcinoma.39-40

The issue is further complicated by institutional differences in reporting the lymph node content of pathology specimens. The small sample groups with large standard deviations of existing studies adds to the problem. Clearly, long-term clinical studies, including stage-specific survival data, are required. The American College of Colon and Rectal Surgeons established a laparoscopic colectomy registry in order to gather and analyze data from surgeons performing laparoscopic colorectal procedures. This body of data should provide the information needed to evaluate the therapeutic value and cost effectiveness of laparoscopic colorectal procedures.40

A second issue concerns the granting of privileges for surgeons to perform these operations in individual hospitals. Laparoscopic colectomy is significantly more complicated than laparoscopic cholecystectomy and has a very steep learning curve. Adequate instruction, animal model experience, and proctoring by individuals skilled in advanced laparoscopic techniques are required to minimize complications and optimize patient outcome. This complex issue also encompasses economic concerns such as restraint of trade. Several peer groups, most notably the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), have issue policy statements regarding privileging. Presently, however, privileging decisions remain with institutional credentialling boards.41-43


 

CONCLUSION

This historical overview has traced the evolution of minimally invasive surgery from ancient times through the present. Minimally invasive approaches to diseases of the colon and rectum were developed because of the high rates of septic complications associated with invasive bowel procedures. Similarly, endoscopes were developed to gain minimally invasive access to to the gastrointestinal tract. Throughout the 20th Century, surgeons have struggled to design surgical procedures, which minimally injured their patients, yet adequately treated their gastrointestinal afflictions. Perineal approaches to rectal prolapse and endoscopic reduction of sigmoid volvulus exemplify this strategy. More recently, laparoscopy evolved out of endoscopic principles gainning minmially invasive access to the abdominal cavity, and technological refinements led to the birth of laparoscopic intestinal surgery. These technological advances allowed the accomplishment of traditional gastrointestinal operations through small incisions. This approach produced a significant recuction in the injury inflicted upon the patient decreasing pain, decreasing rates of wound infection and shortening length of hospitalization. As these advantages became evident, surgeons naturally directed videolaparoscopic techn iques toward the performance of colorectal operations. These attempts at the development of minimally invasive colorectal procedures represent only the most recent endeavors in a truely ancient tradition. Nonetheless, laparoscopic colectomy is currently in its infancy, and will inevitably undergo many evolutionary stages. Each of these stages, however, will serve to improve results of treatment and strive to decrease patient morbidity. The chapters that follow will illustrate just how far minimally invasive colorectal surgery has progressed.


 

REFERENCES

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2. Kutumbiah P. The Evolution of Scientific Medicine. Madras, India: Orient Longman, 1971; 111.

3. Stubbs SGB, Bligh EW. Sixty Centuries of Health and Physick. London: Sampson, Low, Marston & Co, Ltd., ND; 58.

4. Cullen W. First Lines of the Practice of Physic. Edinburgh: William Creech, 1777; #XXXVII: 28.

5. Hippocrates (Coar T, trans). The Aphorisms of Hippocrates: with a Translation into Latin and English. London: AJ Valpy, 1822; 223-24.

6. Galen (Green RM, trans). A Translation of Galen's Hygiene (De Sanitate Tuenda). Springfield, Illinois: Charles C. Thomas, 1951; Book I, Chap. III,:9-10.

7. Michael Servetus (O'Malley CD, trans). Christianismi Restitutio and Other Writings. Birmingham: The Classics of Medicine Library, 1989; 115.

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Footnotes

     [1] Until the 18th Century, rectal prolapse was universally deemed "prolapsus ani" or "procidentia ani"


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  • GARTH H. BALLANTYNE, M.D. - BACKGROUND AND TRAINING Dr. Ballantyne's background, training, academic career and clinical experience are outlined. In addition a full list of his PUBLICATIONS and LECTURES are inluded on linked web pages. Finally, the INSURANCE PLANS in which Dr. Ballantyne participates are indicated on another linked page.
  • LAPAROSCOPIC SURGERY - A new type of surgery that decreases the size of incisions used by surgeons that causes less pain and speeds recovery compared to traditionsl surgical techniques. It is also called Keyhole Surgery, Band Aid Surgery and Minimally Invasive Surgery
  • LAPAROSCOPIC COLECTOMY - Laparoscopic removal of a part of the colon for diverticulitis, colon cancer, rectal cancer, colorectal cancer, Crohn's Disease, Chronic Ulcerative Colitis, rectal prolapse, volvulus, sigmoid volvulus, cecal volvulus or constipation.
  • LAPAROSCOPIC CHOLECYSTECTOMY - Surgical removal of the gallbladder for gallstones, cholelithiasis, acute cholecystitis, chronic cholecystitis, choledocholithiasis, biliary colic or common bile duct stones.
  • LAPAROSCOPIC INGUINAL HERNIA REPAIR - Surgical repair of inguinal hernia, femoral hernia, double hernia, recurrent hernia, groin hernia, indirect hernia or direct hernia.
  • GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD) - Hiatal hernia, heartburn, acid reflux, Barrett's esophagus, reflux esophagitis, or esophageal stricture.
  • THERAPY OF GASTRO-ESOPHAGEAL REFLUX DISEASE - Treatment of hiatal hernia, heartburn, acid reflux, reflux esophagitis, Barrett's esophagus or esophageal stricture.
  • SURGICAL TREATMENT OF GASTRO-ESOPHAGEAL REFLUX DISEASE - Selection of patients and selection of a surgeon for Laparocopic Nissen Fundoplication.
  • LAPAROSCOPIC NISSEN FUNDOPLICATION - Surgical repair of a hiatal hernia, acid reflux or heartburn.
  • WHICH IS ALTERNATIVE MEDICINE? TRADITIONAL WESTERN MEDICINE, MODERN EXPERIMETAL MEDICINE or LAPAROSCOPIC SURGERY.
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