Advanced Laparoscopy
– from the Research and Development Department
to Day Care Surgery
By Bjørn Edwin
Contents
1. Acknowledgements 3
2. List of papers 5
3. Introduction 6
3.1 History of laparoscopic surgery 9
3.2 New Procedures 14
3.2.1. How to develop 15
3.2.2 Where to develop 16
3.2.3 How to convince 17
3.3 Day care surgery 19
4. Aims of the study 21
5. Summary of papers 22
6. Discussion 30
6.1 Development of new laparoscopic procedures 30
6.2 Complications associated with laparoscopy 31
6.3 Laparoscopy in oncologic surgery 33
6.4 Education 41
6.5 Future aspects ”The Hospital of Tomorrow” 42
7. Conclusions 44
8. Reference list 45
1. Acknowledgement
The present work was carried out at the Interventional centre, Rikshospitalet, University of Oslo and the Surgical Department, Ullevål University Hospital.
The thesis is a result of skills, contributions, never ending enthusiasm and a very good team spirit of many persons.
First I will express my sincere gratitude to my supervisors, Prof.dr.med. Trond Buanes, Prof.dr.med. Erik Fosse and dr.med. Tom Mala. Without Trond Buanes and his great enthusiasm, great knowledge, great capacity of work and accept of my ideas this thesis had never been a reality. Erik Fosse, as an excellent leader and with a genuine interest and great knowledge in new techniques has given an invaluable support that has made these studies possible .Tom Mala, with his enthusiasm, interest, knowledge and great capacity of work have given an inestimable contribution and made this thesis possible. I also thank all of them for encouraged me to do the doctorate study and that they have kept encouraging and given me self-confidence throughout the work.
My sincere thank to my very good friend and colleague Prof.dr.med Arne R. Rosseland for teaching me a lot of different types of surgery and endoscopy, always encourage me in new ideas and studies and always to be available when I needed him, whatever the reason was.
I am very thankful to Prof.dr.med Anstein Bergan and Prof.dr.med.Odd Søreide that always encourages me, believed in my ideas and trusted my laparoscopic skills so that I got the opportunity to do the advanced laparoscopy.
A great thank to my colleague’s dr.med Øystein Mathisen, dr.med. Ivar Gladhaug and dr.med. Per.F Pfeffer, for their help and support in the clinical part of the thesis and as co-authors. I am also thankful for the support given by my other colleagues in the Surgical Deparment.
Dr.med. Airo M. Kazaryan’s co-authorship and willingness to contribute has been of great help and is highly appreciated.
A great thank to dr.med. Erik Trondsen for his enthusiasm, invaluable support in the clinical part of this study and as co-author.
I also want to thank Prof.dr.med Tor Inge Tønnesen and Prof.dr.med Johan Ræder for their inestimable cooperation, support, enthusiasm and co-authorship.
A sincere thank to all the other co-authors, dr.med. Ole Christian Lunde, Prof.dr.med. Rolf Kåresen, dr.med. Odd Mjåland and Jorunn Skattum, for their help and support in this thesis.
Special thanks to Prof.dr.med Frode Lærum whose idea led to the establishment of the Interventional centre.
Also a great thanks to Julia Ferkis that made it possible for me to share my ideas with Russian colleagues, the inspiring discussions and that she never gave up telling me how important the doctorate study was.
A special thank to Marianne Berg and her wonderful temper and for always helping me when needed.
My sister Nusse Belton and my brother in law Peter Beaumont have been of great help turning some of the text from bad into good English.
The great enthusiasm and cooperation of the staff at the centre have been of great help and joy. I want to thank:
- Isabelita Fiksdal, Jennifer Alcoriza, Carina Olofson, Anne-Marie Marstein and Linda Nes
with their invaluable support and assistance during the different procedures.
- Esther Frydenlund and her staff for always supporting me when necessary.
- The staff of anaesthesiology with Steinar Halvorsen, Andreas Espinoza, Olav Hustvedt
Helga Teigland, Carmen Louwerens, Kjersti Bent, Anne Marie Halstensen for their eminent
support
- Lena Slaatsveen and her staff that took so good care of the patients
- Gunn Goksøyr and her staff in the Day Care Department, Ullevål University Hospital
- The rest of the staff at the Interventional centre for great support.
Finally, I will express my sincere appreciation to my mother, friends, my children Gorm, Snorre , Catarina, Natasha and the rest of my family that have accepted my unpredictable working schedule and sometimes disharmonious temper.
At last but not least a special thank to my love Anita for her tolerance in the last turbulent year and that she always has supported my job and research and encouraging me to continue this thesis. Without her this had not been possible.
Sætre 230605 Bjørn Edwin
2. List of papers
Paper I. Edwin B, Kazaryan AM, Mala T, Pfeffer PF, Tønnessen TI, Fosse E.
Laparoscopic and open surgery for pheochromocytoma.
BMC Surg 2001;(1):2.
Paper II. Edwin B, Mala T, Gladhaug I, Fosse E, Mathisen Ø, Bergan A, Soreide O.
Liver tumours and minimally invasive surgery: a feasibility study.
J Laparoendosc Adv Surg Tech A 2001;11(3):133-9.
Paper III. Mala T, Edwin B, Gladhaug I, Soreide O, Fosse E, Mathisen O, Bergan A.
A comparative study of the short-term outcome following open and laparoscopic liver resection of colorectal metastases. Surg Endosc 2002 16(7):1059-63.
Paper IV. Edwin B, Mala T, Mathisen Ø, Gladhaug I. Buanes T, Lunde OC, Soreide O, Bergan A, Fosse E. Laparoscopic resection of the pancreas: a feasibility study of the short-term outcome. Surg Endosc 2004;18(3):407-11.
Paper V. Edwin B, Raeder I, Trondsen E, Kaaresen R, Buanes T. Outpatient laparoscopic adrenalectomy in patients with Conn’s syndrome. Surg Endosc 2001;15(6):589-91.
Paper VI. Edwin B, Skattum J, Trondsen E, Ræder J, Buanes T. Outpatient laparoscopic splenectomy. Surg Endosc 2004;18(9):1331-1334.
Paper VII. Skattum J, Edwin B, Trondsen E, Mjåland O, Ræder J, Buanes T. Outpatient laparoscopic surgery: feasibility and consequences for education and health care costs. Surg Endosc 2004;18 (5): 796-801
3. Introduction
Since the beginning of the 20th century physicians have promoted laparoscopy as a valuable adjunct to the diagnosis and treatment of diseases of the abdominal cavity. Laparoscopy, however, failed to become widely accepted among abdominal surgeons until Philippe Mouret did his first laparoscopic cholecystectomy in 1987. This new surgical approach to the treatment of gallbladder stones gave rise to such enthusiasm among general surgeons that a revolutionary development of the laparoscopic technique has been the result.
Laparoscopic procedures have been promoted in ever-increasing numbers and the general surgeon has again become the leader in the introduction of a new surgical approach1.
Laparoscopic surgery has been shown to give less pain and fatigue, fewer incisional hernias, better cosmetics and in general a quicker return to daily life during the postoperative course compared to open surgery2. These improved parameters have traditionally been the main arguments for the development and incorporation of new laparoscopic procedures in clinical practice.
Several laparoscopic procedures are now the method of choice within different fields, e.g. laparoscopic reflux surgery3, appendectomy4, adrenalectomy5, some forms of obesity surgery6 and within the treatment of subgroups of inguinal hernia7.
The technology continues to increase at an exponential rate and some predict that almost every abdominal operation will eventually be performed by this method.
The past decade was characterized by the question “what can be accomplished laparoscopically” but in the near future the focus will be on “which procedures should be performed laparoscopically”. Furthermore, with the increased use of laparoscopy, patient logistics also needs to be assessed: Which procedures can successfully be made as day care surgery, and what sort of hospitals should perform and educate surgeons in laparoscopic surgery? : Ordinary or specialized hospitals reorganized towards minimal invasive therapy?
Laparoscopy has to be developed with great care, and there must be strict criteria for its use, critical analysis of the technique and honest reporting of results, particularly serious complications.
There is an increasing demand for efficiency and cost effectiveness in hospitals but safety must always be in focus, asking the question: How can this new procedure best undergo safe development?
A change in the strategy for development and introduction of new techniques and technologies in clinical practice is required. Traditionally all developmental work has been done in locations where routine procedures are being performed, in competition with the everyday work. This mixture of routine and developmental work is inefficient. Our solution has been to use an independent Research and Development (R&D) department i.e. the Interventional Centre at Rikshospitalet to create a link between clinical practice and applied and basic research. This department is designed as a testing ground for new interventional and diagnostic procedures before they are put into clinical practice.
Advanced Laparoscopy
During the last years a huge amount of different laparoscopic procedures has been described. Procedures concerning parenchymal organs such as adrenal glands, spleen, liver, prostate and pancreas have gained more and more attention. Surgery on these organs requires special surgical expertise with detailed knowledge of the anatomical structures, pathophysiology, pathology, different surgical procedures and advanced technical equipment. Reconstructive surgery like anastomosis of tubular structures often has to be performed and therefore these procedures require advanced endoscopic skills. The laparoscopic surgeon must be trained in careful dissection especially around vessels, intra corporal suturing, working from different optical angles and over multiple quadrants. The advanced laparoscopic surgeon also has to work equally well with the left and right hand. Furthermore the surgeon must be familiar with new laparoscopic equipment including laparoscopic ultrasound, stapling devices and dissecting instruments such as AutoSonix and CUSA (cavitronic ultrasound surgical aspirator). Accordingly, our definition of advanced laparoscopy is surgical procedures requiring the above mentioned skills.
The optimal venue for introducing new laparoscopic techniques
If we compare the introduction of new methods and workflow before and after1996 i.e. when the Interventional centre was introduced, it is apparent that the main operation room has been unloaded and both every day work and developmental work can be efficient. (fig.1)
Fig.1
Day Care Surgery
With the introduction of new mini invasive surgical techniques and modern anaesthetic drugs a shift from treatment and nursing in hospital to treatment in specially designed departments with the postoperative period at home or in hotels has been possible. This type of surgery has been described in literature under different names such as day surgery, day care surgery, outpatient surgery or same day discharge (SDD) surgery.
Another reason for the increased interest in outpatient surgery is the economic pressure on hospitals and the attempt to reduce healthcare costs, to release hospital beds and to shorten the waiting time for the patient before treatment.
This type of surgery will probably expand in the future and ”The Hospital of Tomorrow” is probably going to be reorganized towards day care, ERAS (enhanced recovery after surgery) or “fast track” surgery and hotel stay instead of expensive in-hospital solutions.
3.1 History of Laparoscopic surgery
Endoscopic examinations have their origin in the Kos school led by Hippocrates (460-375 BC). They described a rectal speculum similar to the ones used today. In the ruins of Pompeii were discovered speculums to be used in the vagina for inspection of the cervix, examine the rectum and obtain a view of the ear and nose hollow8-10.
The word laparoscopy is derived from the Greek words lapara, meaning, “the soft part of the body between ribs and hip, flank, loin”, and skopein, which means “to look at or survey”11.
The endoscope
In 1806 Philip Bozzini built an instrument called the Lichtleiter that could be introduced into the human body to visualize the internal organs. The instrument projected light from a candle into the cavity with the help of a concave mirror.
Bozzini has been credited as the inventor of the first endoscope although his endoscope was never tested in humans. As usual with great inventors, he did not understand the usefulness of this invention and it was condemned as a toy by the medical faculty of Vienna12;13.
In 1853, almost fifty years later, the French surgeon Antoine Jean Desormeaux demonstrated an invention very similar to the Lichtleiter. The candle was replaced with a brighter burning mixture of alcohol and turpentine. It was intended to examine the bladder and urethra but could also be used as a rectoscope. Problems related to his intervention were thermal burns on the inside of the patient’s thighs and on the surgeon’s forehead. In 1865 he published a monograph, “De l’endoscopie”, on his clinical findings and it is said to have stimulated American instrument makers to take up the production of endoscopes. This is one of the reasons that he, for many, is considered the father of the endoscope14.
The light source was one of the main problems during the development of endoscopic instruments. The first internal light source was invented by Julius Bruck, a dentist from Breslau, who in 1867 examined the mouth of a patient using an overheated electrically plated platinum wire as the light source10.
Maximillian Nitze used this light source when he together with Joseph Leiter developed the so called “ Kystoskop”12;15. This instrument was a telescope with lenses and intended for examinations of the bladder.
With Thomas Alva Edison’s indispensable contrivance of 1879, the electric incandescent lamp, Nitze and Leiter, independently of each other, manufactured in 1887 a new, more useable cystoscope with the an electric lamp12.
The start of laparo/thoracoscopy
In 1901, an experiment called “Lufttamponde” was performed where air was insufflated into the abdominal cavity of a dog to create a high intra abdominal pressure (100mmhg). The idea behind this experiment was that this could decrease or stop intra abdominal bleedings. The investigator was the German surgeon Georg Kelling who observed the intra abdominal process through a Nitze cystoscope. He published this experiment in 1901 and mentioned “Kolioskopie” for the first time as an endoscopy of a closed cavity. Kelling saw no future in the technique, and he did not pursue it16-20.
As many other important inventions laparoscopy was born as a side effect of an unsuccessful experiment.