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Minimal Access: Why Laparoscopy is Better
Better known as keyhole surgery, laparoscopy as a surgical
technique has made headway in the field of medicine. Sonal Shukla gives
offers a peek into the recent advancementsin laparoscopy.
 Access
to body cavities for surgical procedures by means other than making a large
cut constitutes laparoscopy. A form of minimal access surgery, laparoscopy has
gained prominence as a technique of the new millennium for most abdominal and
thoracic operations and is being applied to a growing number of other surgical
procedures. Patients are attracted by the reduced pain and faster recovery associated
with the procedures and surgeons are finding that laparoscopy matches traditional
open procedures in effectiveness.
"Because there is less pain with laparoscopy, more patients
sought treatment (ie their threshold to submit to an elective operation was
lowered). They challenged physicians to apply the concept of minimal access
therapy to other diseases," states Dr Arun Prasad, Senior Consultant, General
Surgery, Indraprastha Apollo Hospital, New Delhi. Today, with the development
of the technique and increasing application in various fields of surgery, laparoscopy
is rapidly evolving.
Bigger Bag of Tricks
Improvements in the telescopes, camera systems, better optics
enabling better vision and smaller sized instruments, availability of good technology
for arresting bleeding during surgery like harmonic scalpel/ligasure, new devices
to facilitate suturing inside the abdomen, newer ergonomically-designed instruments
to replicate hand movements inside the abdomen, high resolution LCD screens,
and advent of Da Vinci Robotic Surgery system have allowed surgeons to perform
increasingly complex operations by laparoscopy. Surgery has become safer for
patients.
Light source: Over the years, the light source has
changed from lamps, to ordinary bulbs to halogen light to Xenon lights. The
new Hopkins II Rod-Lens System has replaced the old lens system. Also, the cameras
used have changed from single-chip to three-chip, digital to high definition
and the recent three-dimensional ones. This, along with the high quality medical
grade monitors, has given surgeons clear vision. "3D cameras have brought
better vision. The two point discrimination—which is not possible to show
with single chip camera—can now be seen," explains Dr Raman Goel,
Laparoscopic and Bariatric Surgeon and Associate Professor of Surgery at Grant
Medical College, Mumbai. As Dr Shabeer Ahmed, Gastrointestinal and Minimal Access
Surgeon, Wockhardt Hospital, Bangalore explains, the 2D image of the laparoscope
was a major limitation for some procedures because of the poor depth perception.
Ultrasonic shears: “The surgeon can choose from
the basic diathermy electro-cautery to harmonic scalpel (ultrasonic shears)
to sealing device like ligasure," explains Dr Pradeep Chowbey, Chairman,
Department of Minimal Access Surgery, Sir Ganga Ram Hospital, New Delhi. Haemostasis,
arresting of bleeding from an injured blood vessel, is a key component for successful
surgery. The initial use of laser to ablate bleeding during laparoscopic cholecystectomy
proved to be cumbersome and ineffective.
However, the development of devices like ultrasonic shears
and vessel sealing systems has taken minimal access surgery to greater heights,
believes Dr Deepraj Bhandarkar, Consultant, Department of Minimal Access Surgery,
PD Hinduja Hospital, Mumbai. The blades of ultrasonic shears vibrate 55,000
times a second, cut through tissues and simultaneously seal the blood vessels
in them, reducing the blood loss significantly. Vessel sealing devices allow
the surgeon to seal vessels up to seven mm in diameter without having to tie
or clip them.
Insufflators: Better insufflators, which blow gas into
the abdomen to move away muscle and skin from the intestine, have changed from
low to high flow. With low insufflators, the rate of flow was 8 to 10 litres
per minute. With high flow insufflators, the gas can be pushed at the rate of
20 to 40 litres per minute. This helps during difficult surgeries as the dome
remain intact and if bleeding occurs it can be dealt with faster. With newer
insufflators, the gas is supplied at body temperature, rather than at room temperature,
reducing the possibility of the telescope getting fogged.
Endo-staplers: Laparoscopic bowel surgery for removal
of diseased portions of intestine is becoming increasingly common. Suturing
ends of bowel by laparoscopy is tedious. Endo-staplers allow surgeons to divide
and anastomose parts of the bowel and speed up the surgery.
Trocars: The diameter of trocars used to perform laparoscopic
surgery has reduced from 15 mm to five mm. The availability of two-mm trocars
today has made mini laparoscopy possible. Today's bloodless trocars have moved
from metal to plastic, and have became standard in Western countries. They have
made surgery safer.
Ligasure vessel sealing system: The ligasure vessel
sealing system was initially created for open procedures. Despite its effectiveness,
the first ligasure generator for open procedures never got wide acceptance,
since the surgeon could not cauterise and cut the vessel using the same instrument.
With the new generation ligasure, the surgeon can grasp, cauterise, and transect
permanently tissue bundles and vessels up to and including seven mm in diameter.
"The process is simple and uncomplicated: tissue is grasped by the ligasure.
After the jaws of the instrument are closed, tissue is compressed. The instrument
is activated by the surgeon. When the instrument determines that the seal is
complete, a tone sounds and output to the hand piece is automatically shut off
avoiding damage to nearby structures," explains Dr Ahmed. It can be used
for several open and laparoscopic procedures, including adhesiolysis, nissen
fundoplication, colectomies, appendectomy, hysterectomy, salpingo-oophorectomy,
and splenectomy.
Hand-assist laparoscopy: In certain advanced laparoscopic
procedures where the size of the specimen being removed would be too large to
pull out through a trocar site (as would be done with a gallbladder), an incision
larger than 10 mm must be made. The most common of these procedures are removal
of all or part of the colon (colectomy), or removal of the kidney (nephrectomy).
Some surgeons perform these procedures completely laparoscopically, making the
larger incision toward the end of the procedure for specimen removal, or, in
the case of a colectomy, to also prepare to reconnect the remaining bowel (create
an anastomosis). Many other surgeons feel that since they will have to make
a larger incision for specimen removal anyway, they might as well use this incision
to have their hand in the operative field during the procedure to aid as a retractor,
dissector, and to be able to feel differing tissue textures (palpate), as they
would in open surgery. This technique is called hand-assist laparoscopy. Since
they will still be working with scopes and other laparoscopic instruments, CO2
will have to be maintained in the patient's abdomen, so a device known as a
hand access port (a sleeve with a seal that allows passage of the hand) must
be used.
According to Dr Arbinder Kumar Singal, Assistant Professor,
Department of Paediatric Surgery, MGM Hospital, Navi Mumbai, human and social
factors have also fuelled the positive change in the advancement of this surgical
technique. "More surgeons are getting trained in laparoscopic surgery with
the training courses available at least in five centres in India and in many
centres abroad. New procedures are added everyday to the list of possible laparoscopies,"
he adds.
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 In
the 1970s and 80s, some of the surgical pioneers used laparoscopy for diagnosis
of intra-abdominal conditions that could not be diagnosed with the help
of investigations then available. The surgeons had to introduce the laparoscope
inside the abdomen and literally put an eye to it to be able to see inside.
A significant breakthrough came around 1985 with the introduction of the
computer camera. This camera housed a charged couple device (CCD) in the
form of a tiny silicon chip acting as a sensor. The sensor picked up the
image from the laparoscope; the image was transmitted electronically through
a cable first to the camera-processing unit and then to a television screen.
As the team members shared the view with the operating surgeon, they were
able to assist effectively at the operation. "This was one of the most
significant advances responsible for propelling laparoscopy to its present
heights. Appreciating the potential for treating diseases, instruments to
allow surgeons to perform laparoscopic surgery were developed in the late
1980s and early 1990s. This culminated in the arrival on the surgical scene
of laparoscopic cholecystectomy and the embracing of laparoscopic surgery
by surgeons around the world within a few short years," states Dr Deepraj
Bhandarkar, Consultant, Department of Minimal Access Surgery, PD Hinduja
Hospital, Mumbai. |
Proving Credentials
One concern is training of surgeons. According to Dr Bhandarkar,
at present, the exposure gained by surgical residents in India to laparoscopy
surgery appears inadequate and haphazard. "For the development of the speciality
and its safe practice the formal incorporation of theoretical as well as practical
aspects of laparoscopic surgery in postgraduate surgical training is important,"
he opines. According to Dr Arvind Kumar, Professor of Surgery, AIIMS, New Delhi,
training has been and continues to be an issue as unfortunately bureaucracy
initially kept Indian medical colleges away from adopting this technology.
A recent case, in which Silverman, the wife of a London lawyer
died in a private hospital from peritonitis after perforation of the bowel during
a laparoscopic procedure, has resulted in some private London hospitals demanding
accreditation before allowing consultants to perform laparoscopic procedures.
There has recently been much media attention on the complications of minimal
access surgery, and this has raised public concerns over training and accreditation.
According to Dr Ahmed, the question of accreditation in minimally invasive surgery
needs to be addressed urgently. "Criteria for accreditation would have
to be laid down, and clearly a mechanism of appeal for those who fail accreditation
would also need to be organised," he adds.
If accreditation is to be introduced, who should be responsible
for it? This could be done in association with the surgical societies with a
specific interest in minimally invasive surgery. "Surgical societies should
form centres in various cities. These centres will teach with simulators and
videos, and trainees will be able to observe surgical procedures being performed.
However, they will not be able to use porcine models. The centres may act as
a focus for the organisation of hands-on courses and proctorships in the regions
but are unlikely to be able to run them by themselves," states Dr Ahmed.
Moreover, experts feel that comprehensive audit should be
introduced with training and accreditation. The centres for minimally-invasive
surgery may have an important part to play in the development and running of
such audits on a regional basis and co-ordinating results to produce a national
picture.
With the new generation ligasure, the surgeon can grasp, cauterise, and
transect permanently tissue bundles |
The robotic technology may also bring the more difficult technical operations
within the realm of laparoscopic surgery |
Lowering Expense
Development of new instruments and innovation in technique
is also required for widespread use of advanced laparoscopy for the treatment
of abdominal conditions. "New technologies may overcome many of the limitations
of standard laparoscopic techniques. Two particularly promising technologies
are hand access devices and robotic surgery," opines Dr Ahmed. He feels
the cost of the surgery is high although much cheaper than in Europe where disposable
instruments are almost exclusively used. Manual suturing reduces this cost,
but obviously needs training. Another way to cut costs is to get local manufacturers
to produce instruments indigenously.
The success of a laparoscopic operation can be measured in
terms of patient outcome and complications encountered. If the patient is adequately
assessed prior to surgery and the surgeon is well trained to perform it, the
laparoscopic surgery can be completed by laparoscopy without complications.
However, all the patients undergoing laparoscopic surgery are made aware that
if for any reason the operating surgeon feels that it is unsafe to proceed with
laparoscopy, the surgery is converted to open surgery and the operation completed
that way. "Such a conversion is not a complication but rather prudent judgment
exercised by a mature surgeon who puts the safety of his patients above everything
else. Despite best efforts on part of the surgical team, complications may occur
after laparoscopic surgery-as with any form of surgery. Patients are given a
fair idea of what the complications are likely to be, but their likelihood is
put in proper perspective. When complications do occur, they are recognised
promptly and treated diligently to ensure a good outcome for the patient,"
explains Dr Bhandarkar.
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Over the years, many specialities other than general surgery have embraced
laparoscopic surgery. Removal of a diseased organ like gall bladder, uterus,
appendix, kidney, adrenal gland and spleen are the most commonly performed
laparoscopic surgeries. Surgeries which require reconstruction are difficult
to perform laparoscopically, but they are also increasingly done these
days with excellent results like hernia repairs, correction of oesophageal
reflux, gynaecological surgeries, renal surgeries, pancreatic surgeries,
liver resections, cysts in belly, and resection of intestine. Widespread
use of laparoscopic bariatric surgery (for treating patients who are morbidly
obese) has been another exciting advance. For patients who are significantly
overweight, surgery is the only option to lose weight in the long term.
Particularly in obese high-risk patients, operations performed through
small incisions significantly reduce the potential for complications and
allow for faster recovery. "Laparoscopic obesity surgery has come
to the rescue of the morbidly obese who are struggling not only with their
weight but also with various co-morbidities they develop because of obesity,"
explains Dr Muffazal Lakdawala, Bariatric Surgeon, Dr LH Hiranandani Hospital,
Mumbai.
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Robotic Future?
Experts opine robotic surgery is the next big thing in the
field of laparoscopic surgery. Robotic devices for use in general surgery have
now been developed. The latest is the Da Vinci Robotic System for laparoscopic
surgery, approved for use in the US in July 2000. It allows a three dimensional
view and more precision for certain surgeries. It offers the promise of improvements
to laparoscopic surgery that will allow most surgeons to perform complex laparoscopic
operations. The robotic technology may also bring the more difficult technical
operations (currently performed via incisions) within the realm of laparoscopic
surgery. Experts think even more substantial advantages are likely to emerge
in the future as technology advances.
3D CT imaging will be added to the already digitised image
stream, so that the surgeon will be able to 'see' the structures beneath the
visual operative surface. Also, heart motion will be 'gated', which will allow
coronary artery bypass to be performed on the beating heart with robotic arms
that move in parallel with the heart motion, while the surgeon sees a still
heart. Even though not the first commercially available surgical robot (that
distinction should probably go to the orthopaedic robotic device, Robodoc),
it is part of a family of budding robotic instruments in various stages of research
and clinical use in the US and around the world. Common to these devices is
a remote surgeon interface which transmits the hand movements of the surgeon
to robotic arms that enter the abdomen via laparoscopic ports and manipulate
tissue. These machines cost approximately $1 million. "While this sounds
expensive for surgical equipment, most invasive radiology suites have equipment
worth that much and a great deal more. Whether such expense is justified is
as yet undetermined," states Dr Ahmed. According to him, the objective
of these devices is not to replace surgeons, but to add technology to improve
surgery, "Laparoscopic surgery has hit a roadblock somewhere between the
technical expertise required for a cholecystectomy and anti-reflux surgery.
Only select surgeons are moving beyond these to more technically difficult operations,"
he laments. For Dr Arvind Kumar, the only major drawback of robotic surgery
today is its extravagant cost, "There is only one company providing this
technology, making it even more expensive for the end users due to lack of competitive
pricing—a handicap which is barring its rapid spread worldwide,” says
Dr Arvind Kumar. About the cost dynamics he says, "Apart from Rs 5-10 crore
of initial investment, every instrument used in Da Vinci Robotic System has
a life of only 10 uses, and every instrument costs about Rs 3-4 lakh. In one
procedure we need at least four to five such instruments. Thus if we have one
set for about Rs 12 lakh, that will give us about 10 cases."
According to Dr Bhandarkar, currently there is no clear evidence
that operations performed with the robots result in better outcome for the patients.
"Moreover, the prohibitive initial outlay as well as enormous costs required
to use the robot per case does not make robotic surgery a viable or attractive
option right now in our country. It is possible that over the years, robots
may become a cost effective way of performing complex laparoscopic operations,"
he concedes.
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
Today, the medical fraternity is also gung ho about an experimental
surgical technique whereby scarless abdominal operations can be performed with
an endoscope passed through a natural orifice (mouth, urethra, anus, etc.) then
through an internal incision in the stomach, vagina, bladder or colon, thus
avoiding any external incisions or scars.
Proponents and researchers in this field recognise the potential
of this technique to revolutionise the field of minimally invasive surgery by
eliminating abdominal incisions. The potential advantages include reduced anaesthetic
requirements, faster recovery and hospital stay, avoiding potential complications
of abdominal wound infection and hernias, less immunosuppression, better postoperative
pulmonary and diaphragmatic function. However critics challenge the safety and
advantage of this technique in the face of effective minimally invasive
surgical options such as laparoscopic surgery.
Says Dr Tarun Gupta, Laparoscopic & Consultant Surgeon,
Rockland Hospital, New Delhi, "The concept of NOTES
challenges surgical norms taught to us in college. Going through an oral cavity,
which is an infected area does not sound good surgically." According to
Dr Arvind Kumar, NOTES is still nascent and can only be considered as an experimental
tool. "For this technology to really come of age we need to wait till the
industry makes better equipment, which will happen definitely in the next 5
to 10 years," he predicts. "Only time will tell whether in the future
NOTES as is being practiced today develops into a form of patient-friendly,
and safe surgery, or fades into oblivion as yet another chapter that never had
its potential fully realised," says Dr Bhandarkar.
sonal.shukla@expressindia.com
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