Abstract:

When we think of the pioneers of endoscopic surgery, we think of people like Wittmoser, Semm, Miihe, Wickham, Mouret, Perissat and Buess as well as industrialists like Karl Storz and Leon C. Hirsch . Despite differences in personalities, these pioneers had an impact on endoscopic surgery because of important, common denominators they shared, such as curiosity, eccentricity, and, according to De Bono and Bocher, "lateral thinking". Of course, these pioneers were ignored at the beginning and even called crazy. They saw controlled clinical trials as irrelevant to their work. They were open minded, innovative and recognized the revolutionary potential of seeing their ideas come to fruition. And it was from these risk-takers that endoscopic surgery-this fascinating alternative in general surgery-was born.

Authors:

Prof. Dr Med Hans Troidi, University of Cologne, Cologne, Germany.

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Abstract:

Laparoscopic surgery in the United States was revolutionized in 1989. Even though Semm had popularized laparoscopic surgery in the early nineteen eighties in Germany, it was the advent of Laparoscopic Cholecystectomy in 1989that triggered the explosive training and eredentialing issues in laparoscopic surgery. In a letter to the editor of the American Journal of Surgery, in June 1990,the author had recommended the following for training courses: 1) the operators should have extensive hands-on experience in diagnostic laparoscopy prior to embarking on laparoscopic surgery; 2) hands-on training to develop hand-eye coordination using Berci-Sackier trainers; 3) extensive explanation on the use and abuse of video laparoscope and accessory instrumentation; 4) a minimum experience as prime operator in at least 3 pigs, each weighing 90- tOOlbs., with experience as an assistant operator and camera operator in 6 more pigs, making a total of9 pigs per participant, This letter was written with an intent that proper training of surgeons would take place. We advocated a surgeon/co-surgeon team approach, to avoid adverse outcomes. In those days, weekend courses proliferated and surgeons came back and started doing procedures with minimal experience. This explosive growth was driven by patient demands for this procedure. As anticipated, untoward outcomes were reported.

Authors:

Mohan C. Airan, M.S., F.A.C.S., F.A.C.M.Q., Sung-Tao Ko, M.D. F.A.C.S., F.R.C.S., Mount Sinai Hospital Medical Center, Chicago, IL

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Abstract:

If surgical art can be defined as the operative relationship between the surgeon and the living tissue then it is easy to conclude that this relationship has changed. On the one hand, changed for the better as far as the end result is concerned, but on the other hand, for the worse, as far as it relates to the surgeon's effort, that is, the method by which this improved result is obtained. In essence, the surgeon will have to work a great deal harder to provide the added benefit for the patient.

Authors:

Zoltan Szabo, Ph.D., F.I.C.S., MOET Intitiute, San Francisco, Ca. John G. Hunter, M.D., Emory University, Atlanta GA, Demetrius E.M. Litwin, M.D., F.R.C.S., University of Toronto, Ontario, Canada, George Berci M.D., F.A.C.S., F.R.C.S., Ed. (Hon.), University of Southern California, Los Angeles, CA

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Abstract:

Video imaging technology has significantly enhanced the performance of minimally invasive surgical procedures. However, a major limiting factor for the endoscopic surgeon is to work in a 3-dimensional field while viewing a two-dimensional video image. Advances in electronic video imaging have resulted in satisfactory image quality yet the lack of depth perception with standard 2-dimensional video system results in the surgeon having to rely on indirect evidence to assess the third dimension. To gauge depth, one may have to rely on touching the tissues with endoscopic instruments or estimate the relative movement of the instruments in relation to the intra-abdominal organs. These maneuvers result in a reduction in the speed of surgery and may cause unnecessary tissue trauma. Recently a number of manufacturers have developed three-dimensional (3-D) video systems which significantly improve visualization and enhance the ability of the surgeon to perform delicate endoscopic dissection and suturing. These 3-D video systems may also improve the education of surgeons-in-training as they would have a better understanding of 3-dimensional anatomy during laparoscopic surgery.

Authors:

Asim F. Durrani, M.D., Glenn M. Preminger M.D., Duke University Medical Center, Durham, NC

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Abstract:

Since the new advances in video technology in the mid 1980's and the couplmg of the video camera to the laparoscope the surgeon no longer needs to control the laparoscope with his own hands. The advantage of this new development in laparoscopic surgery is that (1) it is not as tiring to perform (i.e., he no longer had to bend over the patient to look through the laparoscope's ocular), (2) the whole operating team could follow the progress of the surgery (for better or worse), and (3) that the surgeon is then enabled to operate with two hands, a new skill which must be learned since it is one of the keys to being more effective and efficient under the laparoscope. One of these advanced skills, intracorporeal suturing, is an especially demanding skill and requires a well-centered, and steady camera support for the technique to be performed efficiently. The disadvantage is that he must give oral commands to the individual who is now charged with guiding the laparoscope within the operative field and this disadvantage alone is sometimes thought the tip the balance in the wrong direction.

Authors:

Zoltan Szabo, Ph.D., F.I.C.S., MOET Institute, San Francisco, CA Johnathan M. Sakier, M.D., University of California School of Medicine, San Diego, CA

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Abstract:

The ideal energy form for use in laparoscopic surgery should provide controlled, hemostatic cutting. A good dissection technique should be further characterized by minimal thermal injury to surrounding tissue, no smoke obscuring the visual field, cutting ability equal to or superior to a conventional scalpel, coagulative ability equal to or greater than electrosurgery, lack of danger to the patient such as from stray energy, no toxins from exposure to smoke in the pneumoperitoneum elevating patient levels of methemoglobin or carboxyhemoglobin, no need for special preparation of the patient (grounding pad) or surgeon (glasses), and no need for special training. For a technology to replace that which is the current standard, this should all be provided at a cost similar to the cost associated with electrosurgery.

Authors:

Joseph F. Amaral, M.D., Brown University, Providence, RI

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Abstract:

Laparotomy is vision of the abdominal content by direct eyesight through an abdominal incision. Laparoscopy achieves the same or better result with an optic device placed into the abdomen through special introducers. Exploration, part or complete procedures, can be performed with much less postoperative morbidity; this has instilled a new sense of optimism in both the community and surgical ranks. Suddenly it appeared that the old "sacred" rules of traditional surgery had been buried under a thick layer of dust.

Authors:

Osvaldo Contarini, M.D., Jacksonville, FL

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Abstract:

The liver, with its multiple metabolic, detoxifying, and filtering functions plays a key role in the field of oncology, as it is the site of both metastatic and primary cancers. This phenomenon occurs because of two factors, namely the proximity of the liver to other intraabdominal organs as well as the extensive portal vein and lymphatic drainage systems. The lobular structure of the liver represents a barrier to cancer cells which ultimately flourish by producing either synchronous or metachronous hepatic lesions. The size of these metastasizes varies greatly and obeys the laws of expediential tumor growth, thus implying that some lesions will be too small to be detected by conventional methods.

Authors:

Namir Katkhouda, M.D., Sharrie Mills M.D., University of Southern California School of Medicine, Los Angeles, CA

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Abstract:

At the beginning of laparoscopic surgery, common bile duct (CBD) stones were thought to be a contraindication for laparoscopic cholecystectomy (LC) in the treatment of gallstones. At present, well-trained surgeons remove these stones in relation to LC. CBD stones are often present during laparoscopic cholecystectomy and when these stones are removed choledochoscopically a T-tube has to be inserted. This approach to remove the CBD stones has been documented. Insertion of a T-tube into the CBD is a subject open to discussion, because of one disadvantage when the T-tube is inserted into the CBD, patients stay in the hospital for more than 2 to 3 weeks postoperatively.

Authors:

Seigo Kitano M.D., Toshio Bandoh, M.D., Takanori Yoshida, M.D., Koichirou Shuto M.D., Oita Medical University, Oita, Japan.

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Abstract:

In the years since 1987,when Mouret introduced laparoscopic cholecystectomy in France, this approach has become the preferred method for management of symptomatic gallbladder disease. However, the treatment of calculous disease other than the gallbladder is not generally practiced by the laparoscopic approach. The treatment of common duct stones is largely managed by preoperative Endoscopic Retrograde Cholangio Pancreatography (ERCP)or choledochotomy and exploration through a laparotomy incision. The authors believe that this lack of acceptance of laparoscopic treatment of common duct stones is because of the ready availability of ERCP and sphincterotomy in most centers countenanced by the difficulty of laparoscopic treatment.

Authors:

Paul S. Strange M.D., St. Francis Hospital, Indianapolis, IN, Zoltan Szabo, Ph.D., F.I.C.S., MOET Intitute, San Francisco, CA

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Abstract:

Gasrro-esophageal reflux d.isease (GERD), with or without hiatal hernia, is the consequence of a functional disturbance of the -lower sphincter of the esophagus. This dysfunction is more and more often seen in populations with Western eating habits. According to recent reports, 10 percent of the patients suffer from constant heartburn, 30 percent from discontinuous heartburn demanding active treatment. Finally, a great number of non-digestive symptoms, either pulmonary, E.N.T.,or cardiac, are also connected with GERD. In the early 1970s, medical treatment was not very effective, hence the popularity of open surgery. Although the results were satisfactory, postoperative sequelae, in particular parietal ones, could not be avoided. The reason is that a large laparotomy is necessary to gain access to the esophageal hiatus, which always involves potential risks of postoperative incisional hernia.

Authors:

Jacques J. Perissat M.D., Denis Collet M.D., University Hospital of Bordeaux, Bordeaux, France.

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Abstract:

Afundal wrap of the abdominal segment of the esophagus, transposed from the Rossetti modification of the classic Nissen fundopfication. is the operation of choice for surgical treatment of gastroesophageal reflux refractory to medical therapy. Previously validated by open anti-reflux surgery, fundoplication has also proven reliable, effective, and reproducible when performed by laparoscopy, a technique the authors have used routinely since 1989 thanks to the experience gained in vagotomy by a trans hiatal approach.

Authors:

Jean Mouiel M.D., University of Nice, France, Namir Katkhouda M.D., Sharrie Mills, M.D., University of Southern California School of Medicine, Los Angeles, CA

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Abstract:

Peptic ulcer disease will eventually affect more than 3-4% of the Occidental population. The medical management of this disease, including H2 Blockers, proton pump inhibitors and antihelicobacter therapy, has been well defined and has been very successful. However, the treatment of chronic duodenal ulcer disease has been less successful, thus subjecting these patients to long term disability. It is with chronic duodenal ulcer disease as well as with its complications, such as bleeding, obstruction or perforation, where the surgeon can impact, using laparoscopic surgical techniques as an added therapeutic option.

Authors:

Sharrie Mills, M.D., Namir Katkhouda, M.D., University of Southern California, Los Angeles, CA, Jean Mouiel M.D., University of Nice, Nice, France

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Abstract:

Anew laparoscopic operation for the treatment of mucosal or submucosal gastric lesions has been designed and performed on 12 patients. In this procedure, all three trocars are placed in the gastric cavity, penetrating both the abdominal and gastric walls in order to perform a Iaparoscopic removal of gastric lesions. The operation is then carried out in the gastric cavity using currently available laparoscopic instruments and laparoscopic monitoring. The procedure is easy, safe and feasible for mucosal or submucosal lesion of the stomach that cannot be treated by gastrofiberscopic technique. In this series, we treated a total of 12 patients: 10 patients with early gastric cancer, 1 with a submucosal leiomyoma and 1 with giant polyps of the stomach- all of which were treated uneventfully. Since this technique is based on a new concept in laparoscopic surgery, the author has named this operation "Laparoscopic Intra-gastric Surgery"(L.I.G.S.).

Authors:

Shuichi Ohashi, M.D., Takarazuka, Japan

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Abstract:

The first successful totally intra-abdominal laparoscopic Billroth II gastrectomy was performed on February 10, 1992,by our group (4) in Singapore. The patient was a 76-year-old Chinese man with a 2- year history of gastric ulcer, which presented with bleeding. The operation took 4 hours and consumed 17 ENDO GIA* (Auto Suture, USSC, Norwalk, CT) staplers. The benefits of this minimally invasive approach were clearly evident. The patient was walking on the first postoperative day, taking liquids on the third, solids on the fourth, and was discharged on the fourth postoperative day. The operation was subsequently emulated by surgeons in about a dozen countries. The description in this chapter is a modification of the original technique, using the improved instrumentation that is now available.

Authors:

Peter M.Y. Goh, M.D., F.R.C.S., David J. Alexander, M.D., National University Hospital, Singapore

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