Endoscopy and laparoscopy
Endocsopy is a procedure by which a doctor
looks inside the body with an instrument, the endoscope.
Endoscopy is of various types, depending upon the site
that is looked into, consequently there are many types of
endoscopes. Examples are bronchoscopy (looking into the
lungs), gastroscopy (stomach) and cystoscopy (urinary
bladder). Gastroscopy is the most commonly performed
endoscopic procedure, therefore the word endoscopy is
used occasionally, but incorrectly, to mean gastroscopy.
Endoscopes have been available for several
years. The initial 'scopes were mere tubes with a bulb
and a simple lens system. It was possible to look at
relatively superficial organs, such as the anal canal.
Later with an improved system of lenses doctors could
look at more deeply placed structures such as the urinary
bladder. These endoscopes were rigid tubes. Fiberoptic
light- carrying bundles made it possible to go around
corners, and suddenly the feasibility of endoscopy
increased markedly with the development of flexible
endoscopes. The laparoscope was, and still is, a rigid
endoscope. It has has been available since the mid-
nineties. The diameters of laparoscopes has decreased
from about 15 mm to 10 mm, and more slender laparoscopes
are now available (the "microlaparoscopes").
Initially laparoscopy was used only for diagnosis of
abdominal disorders. Under anesthesia, a small puncture
was made in the abdominal wall, and a Veress needle was
inserted. Through this needle air was instilled to lift
the abdominal wall and thus give some room for
maneuvrability. The incision was widened and the
laparoscope was inserted. A light source was attached,
and the surgeon could look inside the abdomen to diagnose
diseases such as cancer and tuberculosis. When an
operation was needed, the abdomen was opened by an
appropriate incision. Even today, non-laparoscopic
operations are called "open" operations.
Having successfully removed thousands of
gall bladders through the laparoscope, surgeons began to
try other operative procedures. In some cases the new
operations were quite feasible, such as removal of the
appendix. In other cases the operations became feasible
only by the development of specific instruments, such as
the stapler for hernia surgery. The laparoscopes
themselves began to change, and 'scopes with angled
lenses came into use for being able to look at organs
situated in awkward places in the body. Laparoscopic
surgery began being used for chest diseases (only in the
chest it became essential to rename the operation as a
thoracoscopy, since laparoscopy means looking into the
Laparoscopic surgery is done through tiny holes in the skin. As compared to huge incisions that often split muscles, this approach is much less destructive. In the abdomen the organs are handled by fine instruments, rather than being roughly pushed by the large hands of the surgeon and his assistants. Consequently, pain after surgery is much less than if the abdomen was opened. Healing is quick, and in general the patient is back to work in half the time.
In the past trainee surgeons were taught that big surgeons make big incisions, and that wounds healed from side to side, not end to end. The objective was to adequately expose the organs so that the operation could be done "exactly right". It was argued that smaller incisions led to operations being done in cramped conditions, with increased risks of mistakes. This reasoning was correct, and trainee surgeons have frequently got into severe trouble (with harm to the patient) from making incisions that were too small. With the advent of laparoscopy it is being understood that the incision should be "adequate" and not "the larger the merrier". Nevertheless laparoscopic surgery usually has more complications than open surgery, because of the restricted access into the abdomen. In some cases this difference is negligible, as in cholecystectomy or tubectomy. If benefits in pain relief are marked, endoscopic surgery is worthwhile. If on the other hand the dangers and complications are significant, the operation should be done by the open approach. For gall bladder removal the benefits of laparoscopic surgery are unquestioned. For most other procedures the position today is evolving, and laparoscopy is not clearly better than open surgery.
If the operation is a gall bladder removal,
there is no doubt that laparoscopy is the procedure of
choice, unless there are complications such as the
presence of stones in the bile duct. In such a case the
benefits of laparoscopy are again questionable.
Name of the
endoscopy To look into the
Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a
practising surgeon attached to Dharamshila Cancer
Hospital, Sir Ganga Ram Hospital and to Noida Medicare
Center. Formerly Professor of Surgery, Himalayan
Institute of Medical Sciences, Dehradun, Dr Sood has a
special interest in gastrointestinal surgery. He has had
an active academic career, has published several papers
in national and international journals, and is the Editor
(with Dr Anurag Krishna) of a widely acclaimed book
titled Surgical Diseases in Tropical Countries.
Last revised: May 23, 2000