Laparoscopic Surgery

Laparoscopic surgery is commonly accepted as minimally invasive surgery to any part of the abdomen whether intra or extraperitoneal. The term minimally invasive surgery whilst frequently used in abdominal surgery as a substitute for laparoscopic surgery is not strictly accurate as minimally invasive surgery is used in other parts of the body such as the thorax (thoracoscopy) and in joints (arthroscopy)

Laparoscopy has been commonly used by the gynaecologists since the 1960’s for both diagnostic and therapeutic treatment of their patients. Their use of laparoscopy however was limited by the equipment such as the direct viewing laparoscope, the paucity of appropriate instruments and the inability of assistants to give meaningful help without a direct view. The development of the computer chip TV camera attached to the laparoscope in the 1980’s allowed video guided surgery to be performed allowing the assistants to become involved in the operation. Specialised instruments were developed to perform the increasingly more complex and variety of operations. The rapid developments in the 1990’s and the early part of the 2000’s of video technology, including digital imaging, has allowed more detail to be viewed in the operative field and this allows finer and more complex dissection to be performed. The basic equipment for laparoscopy is the Video laparoscope, an insufflator, CO2 and a source of energy for cutting or burning i.e. diathermy, or laser.

There were considerable technical considerations by the surgeons that had to be overcome before laparoscopic surgery became mainstream. The most obvious was transporting a 3D image in open surgery to a 2D view on a screen with the added loss of depth of field and the view was significantly magnified and sometimes distorted. There was also a loss of tactile sensation transmitted to the surgeon’s hands as well as the instruments being in a fixed position thus creating some limitation of movement and the development of a fulcrum for the various movements.

Entering the abdomen initially was via a wide bore needle using the Veress needle, which was a blind puncture, a pneumoperitoneum was then created and the laparoscope was then inserted. Safety with this technique was always a concern for the general surgeons and an open technique was soon developed (Hasson) allowing a safer entry under direct vision before the laparoscope was inserted. The other ports for the instruments were then inserted under direct vision minimizing injury to the intra abdominal organs. This was particularly important in patients who had had a previous operation and may have developed adhesions.