Chapter 1
Introduction and objectives
Introduction and objectives
Minimally invasive or endoscopic surgery encompasses those surgical procedures employing minimal access to anatomical structures in contrast to the large incisions of conventional open surgical procedures. Started with the visualization of the abdomen for diagnostic purposes almost a century ago, endoscopic surgery is now one of the fastest growing surgical approaches to perform surgery on various parts of the human body.
The technique of creating a space in the abdomen and the use of an optical instrument introduced through the abdominal wall to visualize the abdominal contents for diagnostic purposes was first reported by Kelling [1] in Hamburg in 1901. A Swede named Jacobaeus [2] coined the word laparoscopy around 1910 in an article in which he reported the first clinical use of this technique to diagnose patients with ascites. In 1933 Ferves described a surgical procedure for intra-abdominal adhesiolysis by laparoscopy [3]. It had taken thirty years for the technique to develop from a diagnostic tool into a therapeutic procedure. Now, almost seventy years after this first laparoscopic procedure, the technique is applied in almost every field of surgery.
Although the basic setup for laparoscopy has not changed, ongoing technological advances have resulted in far more refined tools.
In the beginning a hollow tube was used to look inside the abdomen and candlelight was reflected through the tube to illuminate the abdominal contents. Nowadays the hollow tube is replaced by an optical system using rod lenses and fiber optics for cold light illumination, and all this will most certainly be replaced in the near future.
Why did it take almost seventy years for this elegant technique to mature? One of the reasons was that this was for so long a one-man technique, meaning that only the surgeon was able to visualize the operating field, which limited the surgical applications of this procedure. The microchip revolution that started in the 1950s changed all this. Miniaturization of almost all electronic equipment made it possible to create sufficiently small video cameras. Attaching a video camera to an optical instrument and displaying the image on monitors made it possible for all present in the operating theatre to see the operating field. The difference between open surgery and laparoscopy was reduced to a different method of access to the anatomical structures.
Laparoscopic surgery has undergone tremendous change and development in the last fifteen years or so. After the isolated introduction of laparoscopic appendectomy by de Kok [4] in 1977 and the laparoscopic cholecystectomy by Muhe [5] in 1982, there came the astonishing presentation by Philippe Mouret [6] of laparoscopic cholecystectomy in 1987 followed by the Nissen fundoplication by Dallamagne [7] and the laparoscopic colonic resection by Jacobs et al., both in 1991. In this last paper by Jacobs et al. [8], several indications for laparoscopic colectomies were included. Most of the cases involved colonic cancer, but a varied group of benign colonic processes such as diverticulitis and Crohn’s disease were also described. Since 1991, a myriad of publications have appeared on all the benign colon processes and colon cancer concerning extensive descriptions of approaches, operative techniques, feasibility studies, prospective series and finally some prospective randomized studies [9].
The aim of this thesis is to delve into the merits of the laparoscopic approach for the surgical treatment of the various benign colonic diseases. In this context, the following questions were to be addressed:
a) Is the laparoscopic approach feasible for benign colonic diseases?
b) What are the benefits of the laparoscopic approach?
Due attention is given in this thesis to the reported advantages of skilfully performed laparoscopic procedures such as faster convalescence of the patient (reduced pain, rapid return of bowel functions and a shorter hospital stay) and a better cosmetic outcome. Also, the operative techniques of various procedures are described and cost effectiveness is discussed.
The studies presented in chapter 2 report a comparison between the use of two different laparoscopic approaches to the elective surgical treatment of diverticular disease [10, 11]. The techniques used in the two approaches are described step-by-step and a cost comparison is made. In chapter 3 the combined experiences of two academic centers, Leiden and the Vrije Universiteit in Amsterdam, in the laparoscopic approach of inflammatory bowel disease are discussed, and an extensive description is given of the techniques for ileocecal resection, subtotal colectomy and proctocolectomy [12].
The separate experience with laparoscopic-assisted subtotal colectomy for benign colonic diseases (including a group of patients with polyposis coli) is also presented [13]. The study in chapter 4 presents the techniques for the laparoscopic creation of stomas, colostomy and ileostomy as well as clinical data [14].
Chapter 5 describes a technique for the laparoscopic approach of colonic polyps, a discussion of the indications and clinical results [15]. In chapter 6 the feasibility and effectiveness of the laparoposcopic approach for rectal prolapse are reported [16] and finally, chapter 7 discusses the benefits for transsexual patients using laparoscopic rectosigmoid colpopoiesis and describes its superior cosmetic results [17].
References
1. Kelling G [1902] Über Oesophagoskopie, Gastroskopie und Kölioskopie. Münch Med Wschr (94):21-24.
2. Jacobeaus H [1910] Über die Möglichkeit die Zystoskope bei Untersuchung seroser Höhlung Anzuwenden. Münch Med Wschr 57:2090-2092.
3. Fervers C [1933] Die laparoscopie mit dem Cystoskop. Ein Beitrag zur Vereinfachung der Technik und zur endoscopischen Strangdurchtrennung in der Bauchhöle. Med. Klin Chir 178:288.
4. de Kok HJ [1977] A new technique for resecting the non-inflamed not-adhesive appendix through a mini-laparotomy with the aid of the laparoscope. In: Arch Chir Neerl 29(3):195-8.
5. Muhe E [1991] Laparoskopische Cholezystektomie - Spatergebnisse. Langenbecks Arch Chir Suppl Kongressbd 416-23.
6. Mouret P [1990] La coelioscopique. Evolution ou revolution? Chirurgie 116(10):829-32.
7. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S, Lombard R (1991) Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1(3):138-43.
8. Jacobs M, Verdeja JC, Goldstein HS. Minimal invasive colon resection (laparoscopic colectomy) Surg Laparosc Endosc 1991;1:144-150.
9. Lacy AM, Garcia Valdecasas JC, Pique JM, et al., Short-term outcome analysis of a randomized study comparing laparoscopic versus open colectomy for colon cancer. Surg Endosc 1995;9:1101-1105.
10. Eijsbouts QAJ, Cuesta MA, de Brauw LM, Sietses C [1997] Elective laparoscopic-assisted sigmoid resection for diverticular disease. Surg Endosc 11:750-753.
11. Eijsbouts QAJ, de Haan J, Berends F, Sietses C, Cuesta MA Laparoscopic elective treatment of diverticular disease. A comparison between laparoscopic assisted and resection facilitated techniques. In press.
12. Meijerink WJHJ, Eijsbouts QAJ, Cuesta MA, van Hogezand RA, Ringers J, Meuwissen SGM, Griffioen G, Bemelman WA [1999] Laparoscopic assited bowel surgery for inflammatory bowel disease: the combined experiences of two academic centers. Surg Endosc 13:882-6.
13. Q.A.J. Eijsbouts, C. Sietses, S.G.M. Meuwissen, M.A. Cuesta A feasibility study of laparoscopic assisted subtotal colectomy and proctocolectomy for benign diseases. Surg Endosc. In press.
14. Q.A.J. Eijsbouts, C. Sietses, F.J. Berends, M.A. Cuesta. Laparoscopic techniques for stoma creation. Submitted.
15. Q.A.J. Eijsbouts, G. Heuff, C. Sietses, S. Meijer, M.A. Cuesta. Laparoscopic surgery in the treatment of colonic polyps . Br J Surg 1999;86:505-8.
16. Q.A.J Eijsbouts, M.A. Cuesta, R.J.F. Felt-Bersma. Laparoscopic rectopexy for complete rectal prolaps. In “Laparoscopic Surgery” McGraw-Hill International, editor J Cueto. In press.
17. S.M. Maas, Q.A.J. Eijsbouts, J.J. Hage, M A. Cuesta. Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients? Plast Reconstr Surg 1999;103:518-24.