laparoscopy

Endoscopy and laparoscopy 
The development of laparoscopic surgery
Operations performed by laparoscopy
Benefits of laparoscopic surgery
Disadvantages of laparoscopic surgery 
Which technique should I opt for?
Other endoscopies


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.
Laparoscopy is an endoscopy of the abdominal cavity. The inner layer of the abdominal cavity is called the peritoneum. Peritoneoscopy is consequently another term which means laparoscopy. 

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The development of laparoscopic surgery 

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. 
Later, with the development of better instruments, it became possible to perform small, simple operations. The most commonly performed operation was the tubectomy, for female sterilization. Through a very tiny incision the laparoscope was inserted, and through a special channel in the 'scope a instrument was used to grasp the Fallopian tubes. This grasping attachment was specially designed for clipping the tubes. The entire operation took only a few minutes, and many thousands of women were sterilized in the last twenty years.
In the 1970s the French performed a technically demanding operation through the laparoscope. The were able to remove the gall bladder (cholecystectomy) after a prolonged and painstaking operation. Over the next 20 years the techniques of laparoscopic cholecystectomy were standardized. The instruments improved, and now laparoscopic cholecystectomy has become established as the method of choice for gall bladder removal, consistently giving overall better results than "open" cholecystectomy. The pain after surgery is less, and the operation is almost as safe as the open procedure. Laparoscopic surgery had finally arrived! 

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Operations performed by laparoscopy 

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 abdomen).
Endoscopic surgery is easier for organs that hang into the abdominal cavity, such as the gall bladder, the appendix, the ovaries and fallopian tubes, the uterus. It is more difficult for organs present more or less within the abdominal wall, such as the pancreas and the kidneys, or for removal of large organs such as the stomach and intestines. However presently many of these organs are also being successfully tackled endoscopically.

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Benefits of laparoscopic surgery 

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. 

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Disadvantages of laparoscopic surgery

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. 

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Which technique should I opt for? 

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.
For a few kidney procedures, laparoscopic surgery is again the method of choice, and the urologist can give clear advice depending upon the operation and conditions. 
Laparoscopic hernia repairs are improving, but except in the hands of a very small number of laparoscopists, the recurrence rates are higher. First time, one sided hernias are (today) better done by the open method. Patients who have a recurrent hernia or hernias on both sides will benefit from the laparoscopic approach.
Hiatus hernia repairs are frequently being done by laparoscopy. The advantages are many, but there is a recent report that the incidence of swallowing problems is much higher after laparoscopic surgery than after open repair of hiatus hernia. The open approach is probably better today, but within a couple of years this drawback will probably have been sorted out. 

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Other endoscopies (there are many, many more!)

Name of the endoscopy     To look into the
Arthroscopy                              joints
Bronchoscopy                          lungs 
Colonoscopy                            large intestine 
Colposcopy                              vagina 
Cystoscopy                               urinary bladder 
Gastroscopy                             stomach
Hysteroscopy                           uterus 
Laparoscopy                            abdominal cavity 
Thoracoscopy                          chest cavity 

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Author

Dr Suneet 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. 
Contact Nos: 2486788, 9811052966, suneetsood@vsnl.com


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Last revised: May 23, 2000