How safe is laparoscopic surgery

The gentle surgery

Even complex operations are now possible with "keyhole surgery"

by Carsten Gutt

The age of minimally invasive surgery began 25 years ago. It dispenses with large surgical access and is gentle on the patient. Surgical robots and computers have now optimized the process and allow complex interventions to be carried out. However, the surgeon's experience is still decisive for the success of the operation.

"Keyhole surgery" has revolutionized medicine. Since it was introduced into the surgical clinic, a new way of thinking has established itself, which found its expression in the term "minimally invasive surgery". The term “laparoscopy” has established itself for minimally invasive interventions in the abdominal cavity: the abdominal cavity is inspected with a rigid lens, the laparoscope. The prerequisite for this is a space, a so-called pneumoperitoneum, that is created with the help of carbon dioxide that is introduced into the abdominal cavity. The laparoscope can then be inserted and an attached camera transmits the image from inside the body to a monitor. Initially, laparoscopy was only used to assess organs; At the same time, it made it possible to take tissue samples (diagnostic laparoscopy). Today, even complex surgical interventions in the abdominal cavity are carried out with laparoscopic surgery.

Instruments that allow the inside of the human body to be inspected are known from antiquity. Natural body openings but also smaller cuts were used as access points. The Frankfurt doctor Philipp Bozzini (1773-1808) took the first step towards modern endoscopy. In 1805 he developed the “light guide”: a split concave mirror guided the light of a wax candle into the body and made it possible to illuminate and view body cavities at the same time. The “cystoscope” comes from Maximilian Nitze (1848-1906): The Dresden doctor used it in 1879 to mirror the urinary bladder. The cytoscope was combined with an incandescent lamp, and a lens system made it possible for the first time to transmit the image from the tip of the endoscope to the examiner's eyes.

At the beginning of the 20th century, a targeted attempt was made to inspect the abdominal cavity without a large abdominal incision. Georg Kelling (1866-1945), a surgeon in Dresden, developed the "air tamponade": By blowing air into the abdominal cavity and the resulting pressure, he was able to stop bleeding in the abdomen. In 1901 he achieved the first laparoscopy in an animal experiment with the aid of the cystoscope after the closed abdominal cavity had been filled with air.

In 1910 the work of the Swede Christian Jacobaeus became known. He used the technique of laparoscopy to diagnose liver diseases, coined the term “pneumoperitoneum” for the first time and invented the “trocar”, a small tube with a valve that allows endoscopes and instruments to be changed without air escaping from the abdomen. With this method Jacobaeus diagnosed numerous diseases in the abdominal cavity. In the middle of the 20th century, optics and light sources were significantly improved. That was the basis for the development of modern laparoscopy.

Initially, laparoscopy was used exclusively by gynecologists. The first laparoscopic removal of the appendix was achieved by the gynecologist Kurt Semm in 1980. Surgery was not yet interested in the method at that time. Erich Mühe is considered the actual surgical pioneer of operative laparoscopy, who laparoscopically removed the first gallbladder on September 12, 1985. Trouble was ahead of his time - his procedure did not get the attention it deserved in Germany. In France, Philippe Mouret from Lyon removed a gallbladder laparoscopically in 1987 for the first time. Francois Dubois from Paris followed a year later. His enthusiastic account of the first 36 laparoscopic operations on the gallbladder attracted worldwide attention. The age of minimally invasive surgery, "keyhole surgery", began.

Today, the laparoscopic removal of the gallbladder is the "gold standard" in the surgical treatment of gallstones. Acutely inflamed gall bladders have also been removed laparoscopically for a number of years. Today there is hardly any reason to make a major incision in the abdomen to remove a gallbladder. Surgical treatment of reflux disease - due to a defective sphincter muscle, acidic stomach contents flow into the esophagus - is now also basically minimally invasive. Even rarer diseases of the esophagus are now mainly performed laparoscopically due to the excellent visibility in this region of the body. New methods are currently being clinically tested that use tension-free plastic nets to strengthen the diaphragm (mesh-augmented hiatal plastic).

Laparoscopic removal of the acutely inflamed appendix is ​​also standard in many clinics. Research has shown that overweight patients developed fewer wound infections after laparoscopic removal of the appendix than patients in whom the conventional technique with the typical abdominal incision was used. If the pain is unclear, especially in young women, it is also possible to use diagnostic laparoscopy to rule out other causes. If the appendix ruptures, however, there may be more abscesses in the abdomen after the laparoscopic operation. In these cases, extensive rinsing of the abdominal cavity during the operation and, if necessary, switching to the open technique is recommended. Laparoscopic removal of an adrenal gland in benign tumors should be minimally invasive if the tumor is small. Both the path through the anterior abdominal wall and the path over the flank can be selected. Which of the two techniques is beneficial will depend on individual patient factors and the surgeon's experience. If a malignant tumor is suspected, an open approach is strongly recommended in order to avoid possible spread of tumor cells.

Morbid obesity surgery has become the most common laparoscopic surgery in the United States. Extensive studies have shown that surgical measures aimed at restricting food intake (restrictive procedures) and / or obstructing digestion (malabsorptive procedures) can achieve significantly better treatment results for obesity than conventional exercise and nutrition therapy. Surgical interventions have a firm place in the treatment of morbid obesity, especially when conservative therapy attempts have repeatedly been unsuccessful. The best known procedures in obesity surgery are gastric banding (restrictive) and gastric bypass (restrictive / malabsorptive). Both are done laparoscopically. With these procedures, obesity can be reduced by 50 (gastric band) to 70 percent (gastric bypass) in the medium to long term. Another very promising procedure that is currently being clinically tested is laparoscopic gastric sleeve formation. It is particularly interesting that diseases such as diabetes and high blood pressure can be cured with these surgical measures (“metabolic surgery”).

Surgery of the inguinal hernia, but also the hernia of the abdominal wall, can be carried out effectively and gently laparoscopically. In the laparoscopic treatment of the inguinal hernia, the abdominal wall is reinforced with a plastic mesh. Compared to open procedures, in which access is made through an incision in the groin, the laparoscopic technique is less painful for the patient; experienced centers also report excellent long-term results.

The laparoscopic removal of part of the large intestine in "diverticular disease", a disease in which there are sac-shaped protuberances (diverticula) of the intestinal wall, is now standard in many centers. Nevertheless, despite the excellent results in Germany, only around 50 percent of those affected have so far undergone minimally invasive surgery. This is primarily because diverticulum surgery is more complicated compared to removing a gallbladder or treating an inguinal hernia. It requires an experienced surgeon and an experienced surgical team.

The complete removal of the colon and rectum, for example in the case of inflammatory diseases or genetic malformations, is one of the most complicated laparoscopic operations. As a replacement organ for the missing rectum, a so-called small intestinal reservoir must be created during the procedure. These operations are reserved for specialized centers.

Laparoscopic removal of the spleen in certain immunological diseases is useful if the spleen does not exceed a certain size. The so-called hand-assisted procedure has also proven itself in many centers: In addition to the instruments, the surgeon's hand is inserted into the abdomen via a small incision. To a limited extent, operations on the liver, stomach and pancreas can also be performed in a minimally invasive manner. However, these are rare and demanding operations, the significance of which has not yet been clearly clarified.

Larger interventions are also increasingly performed laparoscopically, for example with malignant tumors of the abdominal cavity. In addition to colon carcinoma, in which the effectiveness of laparoscopic surgery has already been proven, it also seems to make sense to operate on rectal and esophageal tumors laparoscopically. Due to the considerable complexity, however, less than ten percent of these operations are currently performed laparoscopically. Many surgeons are also still suspicious of whether the laparoscopic technique can be as radical as open surgery. However, studies have shown that the special oncological requirements can also be met laparoscopically. The three-year results of a large study have shown that the laparoscopic technique for malignant colon tumors is at least equivalent to open surgery.

Basically, the more demanding a laparoscopic operation, the less often it is used across the board in surgery. The laparoscopic removal of a deep rectal tumor, for example, is one of the demanding interventions that have so far not found widespread use. The reason for this is the complex anatomy in the small pelvis, the narrowness and therefore only limited mobility of the laparoscopic instruments. However, the results of individual centers demonstrate that good results can be achieved with the appropriate expertise. The use of so-called surgical robots appears particularly promising in the future in the small pelvis.

Many different strategies and procedures are used today for minimally invasive surgery of the esophagus. The removal of the esophagus can be done entirely through the abdomen or combined with a reflection of the chest cavity. From the large number of techniques used, it can already be seen that none of the approaches has so far proven to be particularly advantageous. What they all have in common is an extremely high degree of complexity, which places the highest demands on the surgeon and his team. That is probably the main reason for the low prevalence to date. However, minimally invasive surgery certainly has the potential to make lasting changes to the therapy of diseases of the esophagus in the near future. The use of surgical robots is also of interest here; the surgical robots are already clinically evaluated in individual centers.

Before minimally invasive surgery is introduced into the treatment of malignant diseases across the board, it should be ensured that the oncological principles - just as in open surgery - are consistently observed. This requires extensive training, not only for the surgeon, but also for the surgical team; The consistent implementation of multimodal oncological treatment concepts and meaningful quality assurance are also included.

To improve the freedom of movement of the instruments during laparoscopic operations, a telemanipulator system (DaVinvi, Intuitive Surgical) was developed a few years ago. It allows the surgeon to operate on the patient from a console. The advantages of the system are the enormous mobility of the instruments, the high-resolution three-dimensional view, the ergonomic position of the surgeon and the intuitive operation. Many different laparoscopic interventions have already been performed with this system in different centers around the world. In comparison with normal laparoscopy, however, there were no measurable advantages for the patient. However, it has been proven that the surgeon can learn complex laparoscopic interventions faster with the system. In the United States and Germany, the system is used very successfully to remove the prostate in malignant tumors. In addition to the high costs involved, there seems to be room for improvement in many ways.

The future lies in lighter, more flexible and more cost-effective systems that support the surgeon with real computer assistance. The display of important anatomical structures and landmarks in the operating field ("Augmented Reality") is intended to improve orientation and bring greater security. An additional navigation of the instruments could calculate the ideal surgical route in advance and be controlled by the system during the operation.

The latest development in endoscopic surgery is "Natural Orifice Transluminal Endoscopic Surgery", or NOTES for short. The aim of this so far experimental procedure is to forego skin incisions and to use only natural openings for access to the body. To do this, it is necessary to perforate the stomach, intestines or vagina in order to reach the target organ in the free abdominal cavity with a mostly flexible endoscope. Access via the vagina in combination with normal laparoscopy (hybrid technology) already appears to be practicable. In the case of the stomach and intestines, many technical questions that have to be asked of NOTES have not yet been adequately solved. There is still considerable development work to be done before such operations can be performed laparoscopically.

Prof. Dr. Carsten Gutt is the first senior physician and head of the "Minimally Invasive Surgery" section at the Heidelberg University Surgical Clinic. As the main applicant and scientific secretary of the DFG-funded graduate school "Intelligent Surgery", he is involved in the development of innovative surgical procedures. At the University Clinic in Frankfurt (1993 to 2001) he carried out the first robot-assisted surgery in the abdominal cavity in Germany.
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