For Doctors

History - Laparoscopic surgery

Even as early as 400 BC, Hippocrates detailed the use of speculum, or primitive anoscope, for examining haemorrhoids. Early endoscopists were hampered by the lack of a satisfactory light source.

In 1881, Johann Mikulicz a surgeon from Vienna, carried out the first clinically useful esophagoscopy. In 1901, Ott described ventroscopy. The first experimental laparoscopy was performed in Berlin in 1901 by the German surgeon Georg Kelling, who used a cystoscope to peer into the abdomen of a dog after first insufflating it with air.

Hans Christian Jacobaeus of Stockholm, Sweden, carried out the first clinical laparoscopy. The first laparoscopes had a light source at the distal end, and pneumoperitoneum was achieved by means of air insulation through the scope. Initially, intra-abdominal thermal injury, along with bowel and vascular injuries, posed the most significant problems.

In 1929, Kalk advocated a second puncture site for the establishment of pneumoperitoneum, described several diagnostic and therapeutic laparoscopic procedures, and devised a sophisticated lens system. In 1938, Veress described a blunt needle for insufflation, which is still being used. In the 1960s gynaecologists began to carry out small surgical intervention on a regular basis.

Modern endoscopic surgery has its origins in the University Women's Clinic in Kiel headed by Kurt Semm. Semm performed the first laparoscopic appendectomy (1980). Advances in video technology also were important. Video cameras became easier to operate, lighter, and less bulky than previous equipment.

The early 1980s saw the introduction of an alternative way to peer into the human body and obtain pictures. A miniature electronic camera (4 x 4 mm) took advantage of the Charge Coupling Device (CCD) and converted the incoming optical image into electronic impulses.

The first human laparoscopic cholecystectomy was performed by Mouret in France in 1987. Philippe Mouret, a general surgeon of Lyon, France, operated on a woman suffering from both a gynaecological disorder and gall stones. French surgeons, Dubois and Perissat, advocated laparoscopic cholecystectomy. News of the French work soon swept beyond the country's borders. It reached Berci and Phillips in the United States, Cuschieri in Scotland, Groitl and Troidl in Germany, Katkhouda in southern France, Klaiber in Switzerland.

Laparoscopy is a tool that can help an experienced ‘open surgeon’. He can use it for the right indication and for the right patient to the patient’s advantage.

Recent research

Health awareness is on the rise. Ultrasonography is now an indispensable diagnostic tool. It has led to the easy identification of stones in the gall bladder.

The familiar adage ‘fat, fertile, forty, female(FFFF)’ does not seem to be relevant. The percentage of asymptomatic gall stone disease is also less when compared to the West. A sample of over 500 stones that were removed from patients in Madras were subjected to analysis and the chemical composition was found to be entirely different from what is found in the rest of the country and the West.

The pigment stones are the majority and cholesterol stones are not all that common. The pigment stones are usually a sequel to sepsis. Ascending sepsis, from the GI tract, infects the gall bladder and the biliary tree and hence most of the stones are of pigment in nature.

The chemical analysis needs to be compared with spectroscopy and other newer methods. The ascaris, which is an inhabitant of the jejunum can also ‘peep’ in to the biliary tree and produce pigment stones. The patients who are prone to this are:

Males with

• Malaria
• Malnourishment
• Myxoedema

Therefore MMMM is more appropriate than FFFF (Fat,Fertile,Forty,Female).

Mirizzi's syndrome

This is due to stones impacted in the neck of the gall bladder producing obstruction to common hepatic duct and causing obstructive jaundice. It was first described by PABLO MIRIZZI of ARGENTINA in 1948. Constant pressure from within can create a fistulous communication between the gall bladder and bile duct. Csenders has classified this syndrome into four types.
[CSENDERS A et al, BJS 1989; 76; 1139.]

They are

TYPE I	EXTRINSIC COMPRESSION
TYPE II	CHOLECYSTOBILIARY FISTULA -- < 1/3 CIRCUM OF CBD
TYPE III	CHOLECYSTOBILIARY FISTULA -- < 2/3 CIRCUM OF CBD
TYPE IV	CHOLECYSTOBILIARY FISTULA –- FULL CIRCUM OF CBD