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|"Surgery is the first and the highest division of the healing art, pure in itself, perpetual in its applicability, a working product of heaven and sure of fame on earth" - ---------------Sushruta (400 B.C.)|
MODERN OR POST MODERN ERA ( Click below to see appropriate section )
The approach to surgical treatment underwent a paradigm shift in 1987 which I would call as the year of watershed in surgical practice. Mouret performed the first human laparoscopic cholecystectomy (gall bladder removal) in France in 1987.
( Picture of author Dr Arun Prasad & Dr Philipe Mouret on the left )
The true significance of laparoscopic cholecystectomy was the cultural change it engendered rather than the operation it replaced. Focus was shifted onto the patient's experience rather than the surgeon's virtuosity. Because there was less pain and disability with laparoscopic than with open surgery, more patients sought treatment (ie, the threshold to submit to an elective operation was lowered). They challenged physicians to apply the concept of minimally invasive therapy to other disease states.
Surgeons have traditionally attempted to find new methods to treat their patients' afflictions which would concomitantly reduce the injury caused by the treatment. Surgical procedures have been plagued by high rates of morbidity and mortality throughout history. When confronted with diseases requiring more invasive therapy, surgeons attempted to develop minimally invasive techniques that not only treated the disease process but also minimized patient morbidity. Minimally invasive surgery thus has a rich history spanning over thousands of years. In the modern era, surgeons continued to develop minimally invasive techniques.
Access to body cavities in order to undertake surgical procedures by other means than making a large cut has been a technique waiting for its time. Laparoscopy is the technique of the new millenium for doing most of abdominal and thoracic operations. This is a form of Minimally Invasive Surgery and it is one of the most significant advancement of Surgery which took place in the 20th century. Currently, Minimal Access Surgery is the broad umbrella under which all endoscopic surgeries are placed.
Laparoscopic surgical techniques are being applied to a growing number of surgical procedures. Patient's are attracted to the reduced pain and faster recovery associated with the procedures, and surgeons are finding that laparoscopic surgery matches traditional open procedures in terms of effectiveness
Translated from the Greek, "Laparoscopy" means examination of the abdomen with a scope, which is also known as an Endoscope. If the procedure is done in the chest it is known as Thoracoscopy. An Endoscope in the bladder is cystoscopy and in the uterus is hysteroscopy and so on. The other terms loosely used are key-hole surgery and laser surgery.
Explaining laparoscopic surgery is best accomplished by comparing it to traditional surgery. With traditional or 'open' surgery, the surgeon must make a cut that exposes the area of the body to be operated on. Until a few years ago, opening up the body was the only way a surgeon could perform the procedure. Now, laparoscopy eliminates the need for a large cut. Instead, the surgeon uses a laparoscope, a thin telescope-like instrument that provides interior views of the body.
The earliest reference to laparoscopy dates to Biblical history, where Ezekiel wrote, "For the king of Babylon stood at the parting of the way, at the head of the two ways, to use divination: He made his arrows bright, he consulted with images, he looked in the liver (Ezekiel 21:21)."
The first endoscopic examinations of the peritoneal cavity were accomplished early in the 20th Century. Jacobeus performed the first human celioscopy in Sweden in 1910, advocating the technique for the evaluation of patients with ascites. In 1923, Kelling reported his 22 years of experience with laparoscopy to the German Surgical Society. Kelling became one of the earliest advocates of minimally invasive surgery. He encouraged surgeons to use diagnostic laparoscopy in order to spare patients the prolonged and costly stay of a laparotomy. The pioneers of laparoscopy believed that the technique was an important adjunct to surgical practice. Nonetheless, inadequate technology limited their vision, both literally and figuratively. Light sources in the first laparoscopes consisted of a distal light bulb with a rheostat to control intensity. The danger of thermal burns to intraabdominal contents from these primitive devices significantly limited their use. In 1938, Veress developed a needle with a spring-loaded obturator that allowed safe insertion and insufflation of the peritoneal cavity. Thereafter, pneumoperitoneum was established prior to instrumentation of the abdomen.
In 1966, Kurt Semm introduced an automatic insufflation device capable of monitoring intraabdominal pressures. This allowed for safer laparoscopy, and bowel perforations and retroperitoneal vascular injuries subsequently declined. Semm developed thermocoagulation, revolutionizing laparoscopic surgery by virtually eliminating thermal injuries. Semm also designed a high-volume irrigation/aspiration system and perfected the EndoLoop applicator as well as intra-and extra-corporeal knot-tying techniques and instruments.These technical advances elevated laparoscopy to a safe procedure which could be utilized in common clinical settings. Therapeutic uses of laparoscopy were rapidly developed. Along with the technical advances, Semm adapted numerous surgical procedures to laparoscopic techniques, including tubal sterilization, salpingostomy, oophorectomy, salpingolysis, and tumor reduction therapy. Beyond the realm of gynecologic surgery, Semm popularized laparoscopic procedures such as omental adhesiolysis, bowel suturing, tumor biopsy and staging, and notably, incidental appendectomy.Although interest was piqued, general surgeons still considered laparoscopy a "blind" procedure, fraught with risks of intraabdominal injuries, and thus did not incorporate the technique into the practice of general surgery.
Phillipe Mouret performed the first human laparoscopic cholecystectomy ( gall bladder removal ) in France in 1987. McKernam and Saye performed the first laparoscopic cholecystectomy in the United States in 1988, but the technique was refined and popularized by Reddick and Olsen. Patients suffer less postoperative pain, develop fewer infections, resume oral intake and are discharged sooner than after cholecystectomy performed through a standard Kocher incision. Laparoscopic cholecystectomy's tremendous success, along with the flood of new technology into general surgery, stimulated surgeons to apply laparoscopic techniques to treat other gastrointestinal diseases.
Tempton Udwadia of Hinduja Hospital, Mumbai is accepted by most as the father of Laparoscopic Surgery in India. Pradeep Chowbey of Sir Gangaram Hospital made laparoscopic cholecystectomy popular and acceptable in New Delhi and Northern India with his efforts in early 1990's. He was awarded the Padma Shri by President of India for his contribution. C Palanivelu of GEMS Hospital Coimbatore developed many advances in laparoscopic surgery and contributed significantly to the growth of Minimal Access Surgery in Southern India around the same time. His work on the pancreas has been appreciated internationally. The author Arun Prasad is associated with laparoscopy since 1989 in the UK and was part of the team that did the first laparoscopic gall bladder surgery at Charing Cross Hospital, London. He was one of the pioneers of laparoscopy for hernia and day care laparoscopic surgery. On his return to India in 1995, he performed the first ever thoracoscopic removal of a Lung Hydatid Cyst in New Delhi, India. His method of sutured laparoscopic hernia repair (SLHR) tremendously reduces the cost of this surgery which is of paramount importance in a country like India. He has contributed significantly to popularising advanced laparoscopy like weight loss ( bariatric ) surgery and thoracoscopy for hyperhidrosis and has the largest published series in India for this. Also a pioneer for single incision laparoscopic surgery (SILS) with the use of standard inexpensive instruments and robotic surgery for thymus, bariatric and gastrointestinal cancer.
Minimal Access Surgery is now practiced even in small towns in India and rural areas with great success and service to the people. The benefits of this technology are appreciated most by self employed people who have no access to concepts like medical leave, prolonged rest etc.
nHilar/ Mediastinal Node
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Exciting projects are under way to devise innovative techniques to improve laparoscopic surgical techniques. Robotic Surgery, Virtual Reality training and Telepresence Surgery are the areas to watch out.
The latter would make it possible for surgeons to transmit their training, sense of touch, and experience to injured patients on battlefields, at disaster sites, perhaps even in outer space.
History of surgery can be divided into three eras ( click on the following for further reading):