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Laparoscopy—a historical perspective: are gastroenterologists going to reclaim it?
EDITORIAL
Laparoscopyda historical perspective: are gastroenterologists going to reclaim it? Laparoscopy is one of the oldest GI endoscopic procedures. September 21, 1901, is considered the birth date of laparoscopy, when Georg Kelling, a surgeon from Dresden, Germany, described his new technique ‘‘coelioscopy’’ and use of pneumoperitoneum to create a visual intraabdominal space.1 Over the years, laparoscopy has seen multiple rediscoveries, coming full circle with its current dominance by surgeons with minimally invasive surgery, while in the interval primarily practiced by gastroenterologists as diagnostic laparoscopy with an emphasis on diseases of the liver and peritoneum. Von Ott in St Petersburg, Russia, independently described ‘‘ventroscopy’’ in 1901, mainly with an emphasis on gynecology.2 In 1910 Jacobaeus in Stockholm, Sweden, unaware of previous reports, published an article about use of a cystoscope to inspect the abdominal cavity in humans. He coined the term laparoscopy.3 Kalk, an internist in Frankfurt, Germany, who ‘‘reinvented’’ laparoscopy for the fourth time in the 1920s, ushered in the era of modern laparoscopy, which was dominated by gastroenterologists for more than 6 decades.4,5 Kalk developed the modern instrumentation, foroblique optics (135-degree side-viewing) which, through rotation, allowed a panoramic view of the abdominal cavity and its organs. Laparoscopy became an important diagnostic tool, especially in the differential diagnosis of liver disease with guided biopsy and staging of intra-abdominal malignancies. With the emergence of noninvasive imaging studies such as US, CT, and magnetic resonance imaging, laparoscopy by gastroenterologists declined dramatically in the 1980s in spite of its superiority in focal hepatic lesions and the staging of malignancies.6 At the same time, laparoscopy was rediscovered by surgeons, initially for cholecystectomy and then for a wide array of abdominal procedures, ushering in the era of minimally invasive surgery. Gynecologists, who had valued diagnostic laparoscopy for years, were the first to widely embark on operative laparoscopy, primarily tubal sterilization. It was actually a gynecologist who performed the first nongynecologic operative laparoscopy. Semm, in Kiel, Germany, who also developed the insufflator for pneumoperitoneum, reported the first
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.10.034
www.giejournal.org
laparoscopic appendectomy almost a decade before surgeons accepted the new techniques,7 but he was subjected to much (unjust) initial criticism by his colleagues. The first laparoscopic cholecystectomy by a surgeon was performed in 1986.8 Again, this ‘‘new’’ endoscopic technique was received with considerable skepticism. Community hospitals led the way, with academic medical centers getting late onto the band wagon. For those who have long practiced and believed in the value of laparoscopy and were challenged by our surgical colleagues with the phrase ‘‘Why peek through a key hole
The challenge for NOTES is to develop instruments with optically independent operating arms.
when you can open the door?,’’ it is no small satisfaction to witness the conversion to and enthusiasm for laparoscopy by surgeons with the new revelation: ‘‘Why kick in the door when you can look through the keyhole?’’ It is therefore only a small step from minimally invasive surgery to natural orifice transluminal endoscopic surgery (NOTES). In the current issue of Gastrointestinal Endoscopy, Steele et al9 report on the feasibility of flexible transgastric peritoneoscopy and liver biopsy at the time of laparoscopic gastric bypass surgery for morbid obesity. The authors demonstrated in 3 patients that adequate transgastric exploration of the peritoneal cavity can be performed with a flexible forward-viewing video gastroscope. Shortcomings of forward-viewing optics and the atypical gastric entry site high on the anterior gastric wall were compensated for by scope tip deflexion and torque. Liver biopsy by using a standard endoscopic forceps allowed adequate diagnosis of fatty liver. However, this was a hybrid procedure. The gastrostomy was created laparoscopically and not closed endoscopically because an anastromosis was constructed after peritoneal exploration. Several publications by Sanowski et al10 described laparoscopy by use of flexible endoscopes more than 20 years ago. However, this approach never caught on because at the time laparoscope glass rod lens optics were superior to fiberoptic images. Forward optics give a restricted field Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 67
Editorial
of view with large blind angles. Gastroenterologists preferred oblique (130-degree) view laparoscopes developed by Kalk more than 80 years ago, which through rotation along the longitudinal axis provide a superb panoramic view (eg, excellent en face images even of the dome of the liver), thereby eliminating the need for a flexible instrument. Biopsy or surgery through the forward-viewing endoscope operating channel is cumbersome because the optics have to constantly follow the accessory instruments because both operate in the same longitudinal axis; depth perception is an additional challenge. Gastroenterologists and surgeons have overcome this challenge through use of accessory trocars that permit optically independent maneuvers of accessories. The challenge for NOTES is to develop instruments with optically independent operating arms. Hepatic steatosis is a diffuse disorder and is generally adequately diagnosed with forceps biopsy. However, many hepatic lesions, including cirrhosis, are inhomogeneous, and require an adequate tissue cylinder of at least 2 cm.11 Needle biopsy, preferably under direct vision guided through the accessory trocar or direct percutaneous vision, is the biopsy technique of choice. As NOTES evolves to define its proper role compared with minimally invasive surgery, further research should be encouraged and studies on new and creative techniques such as the current study should be fostered. However, the fact that we can do something does not mean we should do it. Any new technology as it attempts to become mainstream must demonstrate value to our patients. Diagnostic laparoscopy with biopsy can be done quickly in the endoscopy suite with mild sedation and analgesia at a fraction of the cost of the same procedure done in the operating room under general anesthesia. In addition, laparoscopy by gastroenterologists has a superb safety record.12 Will gastroenterologists reclaim laparoscopy? Maybe. As surgeons and gastroenterologists work side by side on NOTES, as this article demonstrates, patients will ultimately benefit. Gastroenterologists can bring vast experiences in diagnostic laparoscopy to the table. Surgeons have bypassed diagnostic laparoscopy by moving directly toward operative laparoscopy. As our disciplines move closer
68 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
Nord
together we can ask: what is after all the difference between a surgical endoscopist and an endoscopic surgeon?
DISCLOSURE The author reports that there are no disclosures relevant to this publication. H. Juergen Nord, MD Division of Digestive Diseases and Nutrition University of South Florida, College of Medicine and Tampa General Hospital Tampa, Florida, USA Abbreviation: NOTES, natural orifice transluminal endoscopic surgery.
REFERENCES } 1. Kelling G. Uber die Besichtigung der SpeiserThre und des Magens mit biegsamen Instrumenten. Verh Ges Dtsch Naturf A¨rzte 1902;73:117. 2. Vecchio R, Macfadyen BV, Palazzo F. History of laparoscopic surgery. Panminerva Med 2000;42:87-90. } 3. Jacobaeus HC. Uber die MTglichkeit die Cystoskopie bei Untersuchungen serTser HThlungen anzuwenden. Mu¨nch Med Wschr 1910;57: 2090. 4. Kalk H. Erfahrungen mit der Laparoskopie. Z Klin Med 1929;111: 303-48. 5. Henning H, Lightdale CJ, Look D. Color atlas of diagnostic laparoscopy. Stuttgart: Thieme; 1994. 6. Brady PG, Goldschmid S, Chappel G, et al. Comparison of biopsy techniques in suspected focal liver disease. Gastrointest Endosc 1987;33:289-92. 7. Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59-64. 8. M} uhe E. Die erste Cholecystektomie durch das Laparoskop. Langenbecks Arch Chir 1986;369:804-31. 9. Steele K, Schweitzer MA, Lyn-Sue J, et al. Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos). Gastrointest Endosc 2008;68:61-6. 10. Sanowski RA, Bellapravalu S. Initial experience with a flexible fiberoptic laparoscope. Gastrointest Endosc 1986;32:409-12. 11. Nord HJ. Biopsy diagnosis of cirrhosis: blind percutaneous versus guided direct vision techniquesda review. Gastrointest Endosc 1982;28:102-4. 12. Nord HJ. Complications of laparoscopy. Endoscopy 1992;24:693-700.
www.giejournal.org
Laparoscopyda historical perspective: are gastroenterologists going to reclaim it? Laparoscopy is one of the oldest GI endoscopic procedures. September 21, 1901, is considered the birth date of laparoscopy, when Georg Kelling, a surgeon from Dresden, Germany, described his new technique ‘‘coelioscopy’’ and use of pneumoperitoneum to create a visual intraabdominal space.1 Over the years, laparoscopy has seen multiple rediscoveries, coming full circle with its current dominance by surgeons with minimally invasive surgery, while in the interval primarily practiced by gastroenterologists as diagnostic laparoscopy with an emphasis on diseases of the liver and peritoneum. Von Ott in St Petersburg, Russia, independently described ‘‘ventroscopy’’ in 1901, mainly with an emphasis on gynecology.2 In 1910 Jacobaeus in Stockholm, Sweden, unaware of previous reports, published an article about use of a cystoscope to inspect the abdominal cavity in humans. He coined the term laparoscopy.3 Kalk, an internist in Frankfurt, Germany, who ‘‘reinvented’’ laparoscopy for the fourth time in the 1920s, ushered in the era of modern laparoscopy, which was dominated by gastroenterologists for more than 6 decades.4,5 Kalk developed the modern instrumentation, foroblique optics (135-degree side-viewing) which, through rotation, allowed a panoramic view of the abdominal cavity and its organs. Laparoscopy became an important diagnostic tool, especially in the differential diagnosis of liver disease with guided biopsy and staging of intra-abdominal malignancies. With the emergence of noninvasive imaging studies such as US, CT, and magnetic resonance imaging, laparoscopy by gastroenterologists declined dramatically in the 1980s in spite of its superiority in focal hepatic lesions and the staging of malignancies.6 At the same time, laparoscopy was rediscovered by surgeons, initially for cholecystectomy and then for a wide array of abdominal procedures, ushering in the era of minimally invasive surgery. Gynecologists, who had valued diagnostic laparoscopy for years, were the first to widely embark on operative laparoscopy, primarily tubal sterilization. It was actually a gynecologist who performed the first nongynecologic operative laparoscopy. Semm, in Kiel, Germany, who also developed the insufflator for pneumoperitoneum, reported the first
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.10.034
www.giejournal.org
laparoscopic appendectomy almost a decade before surgeons accepted the new techniques,7 but he was subjected to much (unjust) initial criticism by his colleagues. The first laparoscopic cholecystectomy by a surgeon was performed in 1986.8 Again, this ‘‘new’’ endoscopic technique was received with considerable skepticism. Community hospitals led the way, with academic medical centers getting late onto the band wagon. For those who have long practiced and believed in the value of laparoscopy and were challenged by our surgical colleagues with the phrase ‘‘Why peek through a key hole
The challenge for NOTES is to develop instruments with optically independent operating arms.
when you can open the door?,’’ it is no small satisfaction to witness the conversion to and enthusiasm for laparoscopy by surgeons with the new revelation: ‘‘Why kick in the door when you can look through the keyhole?’’ It is therefore only a small step from minimally invasive surgery to natural orifice transluminal endoscopic surgery (NOTES). In the current issue of Gastrointestinal Endoscopy, Steele et al9 report on the feasibility of flexible transgastric peritoneoscopy and liver biopsy at the time of laparoscopic gastric bypass surgery for morbid obesity. The authors demonstrated in 3 patients that adequate transgastric exploration of the peritoneal cavity can be performed with a flexible forward-viewing video gastroscope. Shortcomings of forward-viewing optics and the atypical gastric entry site high on the anterior gastric wall were compensated for by scope tip deflexion and torque. Liver biopsy by using a standard endoscopic forceps allowed adequate diagnosis of fatty liver. However, this was a hybrid procedure. The gastrostomy was created laparoscopically and not closed endoscopically because an anastromosis was constructed after peritoneal exploration. Several publications by Sanowski et al10 described laparoscopy by use of flexible endoscopes more than 20 years ago. However, this approach never caught on because at the time laparoscope glass rod lens optics were superior to fiberoptic images. Forward optics give a restricted field Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 67
Editorial
of view with large blind angles. Gastroenterologists preferred oblique (130-degree) view laparoscopes developed by Kalk more than 80 years ago, which through rotation along the longitudinal axis provide a superb panoramic view (eg, excellent en face images even of the dome of the liver), thereby eliminating the need for a flexible instrument. Biopsy or surgery through the forward-viewing endoscope operating channel is cumbersome because the optics have to constantly follow the accessory instruments because both operate in the same longitudinal axis; depth perception is an additional challenge. Gastroenterologists and surgeons have overcome this challenge through use of accessory trocars that permit optically independent maneuvers of accessories. The challenge for NOTES is to develop instruments with optically independent operating arms. Hepatic steatosis is a diffuse disorder and is generally adequately diagnosed with forceps biopsy. However, many hepatic lesions, including cirrhosis, are inhomogeneous, and require an adequate tissue cylinder of at least 2 cm.11 Needle biopsy, preferably under direct vision guided through the accessory trocar or direct percutaneous vision, is the biopsy technique of choice. As NOTES evolves to define its proper role compared with minimally invasive surgery, further research should be encouraged and studies on new and creative techniques such as the current study should be fostered. However, the fact that we can do something does not mean we should do it. Any new technology as it attempts to become mainstream must demonstrate value to our patients. Diagnostic laparoscopy with biopsy can be done quickly in the endoscopy suite with mild sedation and analgesia at a fraction of the cost of the same procedure done in the operating room under general anesthesia. In addition, laparoscopy by gastroenterologists has a superb safety record.12 Will gastroenterologists reclaim laparoscopy? Maybe. As surgeons and gastroenterologists work side by side on NOTES, as this article demonstrates, patients will ultimately benefit. Gastroenterologists can bring vast experiences in diagnostic laparoscopy to the table. Surgeons have bypassed diagnostic laparoscopy by moving directly toward operative laparoscopy. As our disciplines move closer
68 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
Nord
together we can ask: what is after all the difference between a surgical endoscopist and an endoscopic surgeon?
DISCLOSURE The author reports that there are no disclosures relevant to this publication. H. Juergen Nord, MD Division of Digestive Diseases and Nutrition University of South Florida, College of Medicine and Tampa General Hospital Tampa, Florida, USA Abbreviation: NOTES, natural orifice transluminal endoscopic surgery.
REFERENCES } 1. Kelling G. Uber die Besichtigung der SpeiserThre und des Magens mit biegsamen Instrumenten. Verh Ges Dtsch Naturf A¨rzte 1902;73:117. 2. Vecchio R, Macfadyen BV, Palazzo F. History of laparoscopic surgery. Panminerva Med 2000;42:87-90. } 3. Jacobaeus HC. Uber die MTglichkeit die Cystoskopie bei Untersuchungen serTser HThlungen anzuwenden. Mu¨nch Med Wschr 1910;57: 2090. 4. Kalk H. Erfahrungen mit der Laparoskopie. Z Klin Med 1929;111: 303-48. 5. Henning H, Lightdale CJ, Look D. Color atlas of diagnostic laparoscopy. Stuttgart: Thieme; 1994. 6. Brady PG, Goldschmid S, Chappel G, et al. Comparison of biopsy techniques in suspected focal liver disease. Gastrointest Endosc 1987;33:289-92. 7. Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59-64. 8. M} uhe E. Die erste Cholecystektomie durch das Laparoskop. Langenbecks Arch Chir 1986;369:804-31. 9. Steele K, Schweitzer MA, Lyn-Sue J, et al. Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos). Gastrointest Endosc 2008;68:61-6. 10. Sanowski RA, Bellapravalu S. Initial experience with a flexible fiberoptic laparoscope. Gastrointest Endosc 1986;32:409-12. 11. Nord HJ. Biopsy diagnosis of cirrhosis: blind percutaneous versus guided direct vision techniquesda review. Gastrointest Endosc 1982;28:102-4. 12. Nord HJ. Complications of laparoscopy. Endoscopy 1992;24:693-700.
www.giejournal.org