AN NTRODUCTION TO THE NEWER MINIMALLY INVASIVE OPERATIVE PROCEDURES : Laparoscopy and Retroperitoneal Laparoscopy

AN NTRODUCTION TO THE NEWER MINIMALLY INVASIVE OPERATIVE PROCEDURES : Laparoscopy and Retroperitoneal Laparoscopy
D D Gaur
Associate Professor, Department of Urology, Bombay Hospital Institute of Medical Sciences, 19 Marine Lines, Mumbai 400 020. India.

What is Laparoscopy?

Laparoscopy means inspection of the inside of the abdomen with a telescope passed inside the abdomen through a small hole. Though, initially one used to peep inside the abdomen directly through the telescope, with the development of small video cameras, the inside view of the abdomen is now continuously transmitted live to the monitor to make the sugeon’s job much easier. This means that the surgeon’s hands are now free and he can make some more holes in the abdomen and pass the necessary instruments into the abdominal cavity to enable him to perform an operative procedure on the diseased abdominal organ.

Though the term ‘laparoscopy’ is being universally used to indicate inspection of the peritoneal cavity through a small hole, it is etymologically not correct. The word ‘lapara’ in Greek means flank and ‘scopy’ means inspection. Therefore, only the procedure for inspecting the structures in the flank should be called ‘laparoscopy’. However, since the term was first used by Jacobeus [1] in 1910, for the inspection of the peritoneal cavity with a telescope, it is still being used to indicate its historical significance rather than its literal meaning.

Though, laparoscopy is close to 100 years old, it was mostly limited to diagnostic procedures and its regular use for performing abdominal operative procedures started only slightly more than a decade back.

What is retroperitoneal laparoscopy?

Though, most people know about laparoscopy, even many surgeons do not have an idea about retroperitoneal laparoscopy (also called retroperitoneoscopy), due to its being a relatively new procedure. Retroperitoneal laparoscopy means inspection of structures or organs forming part of the abdominal wall using the technique of laparoscopy. These structures or organs are lying between the muscles of the abdominal wall and the innermost lining of the abdominal wall called the peritoneum. This means that if you inspect the adrenal gland, the kidneys, the upper and the lower urinary tract with a telescope inserted into the abdominal wall through a small hole, you would be doing retroperitoneal laparoscopy or retroperitoneoscopy. Now, if you can perform a surgical procedure using this technique, you would be doing a minimally invasive surgery, which is much less invasive than laparoscopy, as by not transgressing the peritoneal cavity, the sanctity of this sterile cavity is maintained.

How to explain a layman the difference between open surgery, laparoscopy and retroperitoneal laparoscopy?

With the education of the masses through the media the present day patient is much more informed than his olden times counterpart and before submitting himself for an operative procedure would like to be explained in simple terms the difference between open surgery, laparoscopy and retroperitoneal laparoscopy. This should not be a problem if the patient understands your language and you, by your good command of the language, are able to explain to him the details of the operative procedure using simple layman terminology. However, once in a while you may be caught in a situation, where you are forced to use some alternative method to explain the audience the significance of the new technique of retroperitoneal laparoscopy. Following my guest lecture on ‘Retroperitoneoscopy’ in the Republic of China in 1995, I was asked to explain its significance to a group of Chinese journalists. Though, they did understand a little bit of English, I though that the best way to explain to them the difference between open surgery, laparoscopy and retroperitoneal laparoscopy was to give a analogy between the abdominal cavity and a temple’s sanctum sanctorum.

The analogy

The abdominal cavity can be compared to the sanctum sanctorum of a temple. Entry to the sanctum sanctorum of the temple is restricted to the high priest, in order to maintain the sanctity of the place. Similarly, under normal conditions, entry into the abdominal cavity is not allowed to any one for fear of disturbing the sanctity of the place and vitiating the sterile internal atmosphere. Because, if the inner abdominal atmosphere becomes unsterile, it might lead to a possibly lethal complication of peritonitis. Thus, the inner abdominal cavity is even more sacrosanct than the sanctum sanctorum of the temple. Just like the high priest can manage some of the smaller problems inside the sanctum sanctorum himself, there is a ‘policeman’ posted inside the abdomen, called the omentum, which can fight with the invaders to some extent and make the patient disease free.

Now, imagine there is a problem in the sanctum sanctorum, like the nonfunctioning of the overhead light, which can not be solved by the high priest.

Some expert e.g. an electrician has to enter the sanctum sanctorum for a corrective measure, even at the risk of spoiling the sanctity of the sanctum sanctorum. This act of personally entering the sanctum sanctorum for rectification of a fault can be compared to ‘an open operative procedure’ performed by the surgeon in the abdominal cavity. But there is a slight difference in the two procedures. The expert entering the abdominal cavity e.g. the surgeon has to make a large cut in the wall of the abdomen, which takes a long time to heal. Though, he takes utmost care, unwittingly he might contaminate the abdominal cavity or damage some of the vital organs producing serious complications. So, if there were a better choice, the patient or the high priest would naturally opt for it.

Now, take an example of a very rigid high priest, who would not permit anybody to enter the sanctum sanctorum for the repairs.

Because, he knows that some skilled person should be able to do the job without entering the sanctum sanctorum. So, here comes an out of town expert who makes three holes (also called ports) in the wall of the sanctum sanctorum, places a spy camera through one hole, a screw driver and a grasper through the other two holes and does a neat job without ever entering the sanctum sanctorum (Fig. 1). If a surgeon can perform an operative procedure on the contents of the abdominal cavity using a similar technique, this would be called ‘laparoscopy’. Removal of a diseased appendix, ovary or gall bladder through small holes are examples of laparoscopic surgery. Naturally both the high priest and the patient would be delighted, as the sanctity of the sanctum sanctorum in both the cases would not be much disturbed. This means that if the surgeon is really an expert, he can do a great service to the patient by not too much spoiling the sanctity of the abdominal cavity. In expert hands the complication rate would be less, the post operative discomfort would be less and the patient would be able to return to work much earlier. Well, this does not mean that it is always free of complications, as little knowledge can sometimes be dangerous.

Beware of an inexperienced laparoscopic surgeon, who might be able to do the job without an incision but might kill you by inadvertently damaging the vital internal organs. Laparoscopy is a real boon to the human society but its name has been spoiled by indiscriminate use of the laparoscope by the novices in this field.

Fig.1: Showing how a laparoscopic expert would repair a defect in the cavity of the sanctum sanctorum through keyholes made in the front wall.

Now take an example, where the fault lies in the electrical wiring, concealed in the wall of the sanctum sanctorum and this has to be repaired.

What are the options available?

Option one : Break the wall of the sanctum sanctorum, replace the defective wires and then repair the damaged wall (Fig. 2).

Such a procedure is unlikely to be approved by the high priest, as it is definitely going to spoil the sanctity of the sanctum sanctorum by spilling dust and debris all over the place. This can be truly compared to an ‘open operative procedure’ done on the structures lying in the wall of the abdomen, like the adrenal, the kidney and the urinary tract, as in both instances the wall is first broken down and then repaired. A well informed patient, like the rigid high priest is unlikely to accept such an invasive procedure, if a less invasive alternative can be available.

Option two : The second choice is use the technique of laparoscopy as described above.

That is, standing outside the sanctum sanctorum explore the holy space through three holes made in one of the walls of the sanctum sanctorum. Using a spy camera through one hole, the plaster over the defective wires is removed with a drill passed through the second and a grasper through the third hole (Fig. 3). After the repairing work is over, the plastering and painting work is done with the expert still staying outside the sanctum sanctorum. When the surgeon performs a laparoscopic surgery on the kidney, adrenal or the urinary tract, this is exactly what he does. With the help of a spy camera, he first introduces his tools into the cavity of the abdomen through three or four holes. Then he strips away a wall paper like covering over these structures called the parietal peritoneum to expose the diseased organ lying in the wall of the abdomen, all the time monitoring his deeds through continuous live transmission from the spy camera to the TV screen. At no time during the surgery do the surgeon’s hands enter the abdominal cavity. This being a minimally invasive procedure should be quite acceptable both to the rigid high priest as well as the fussy and well informed patient, if nothing better is available to them in the market.

Fig. 2: Showing how a traditation expert would do a job by breaking down the wall of the sanctum sanctorum.

Option three : Use the new technique of laparoscopy of the wallTo give an analogy between the sanctum sanctorum and the abdomen, one would have to assume that the walls of the former are made up of an elastic material. A balloon made of an imaginary strong material is placed near the defective wires through a small hole in the outside wall of the sanctum sanctorum and is inflated to make some space for the expert to work. The balloon is then deflated and removed and the space is kept open by continuous insufflation of an inert gas like carbon dioxide. Two or three more holes are then made and using the technique of laparoscopy, the defect is repaired (Fig. 4). After the job has been done, the gas insufflation is stopped and the cavity created by the balloon collapses automatically due to the elasticity of the wall. By using this balloon technique of retroperitoneal laparoscopy the sanctity of the sanctum sanctorum has not at all been spoiled. As the pious cavity is not at all entered, there is no littering inside the sanctum sanctorum. Now if the same technique is used for performing surgical procedures on the structures in the abdominal wall e.g. adrenal gland, kidney and the urinary tract the sterile atmosphere inside the abdominal cavity would not be disturbed and the complications associated with accidental damage to the contents of the abdominal cavity during a laparoscopic surgery would not occur. As the abdominal wall is soft and elastic, an ordinary latex rubber balloon would be strong enough to create a space in the abdominal wall.

Fig. 3: Showing how a laparoscopic expert would repair a defect in the concealed wires in the wall of the sanctum sanctorum by keyhole surgery. Fig. 4: Showing how a retroperitoneal laparoscopic expert would repair a defect in the concealed wires in the wall of the sanctum sanctorum by keyhole surgery.

Which one would you prefer : Open Surgery, Laparoscopy or Retroperitoneal Laparoscopy?

Well, everything depends upon the availability of the expertise. In the absence of a well trained laparoscopic surgeon, one should opt for an open operation. At least you are sure that the procedure would be properly performed. In expert hands, the open operation is extremely safe. The only disadvantage would be a big scar and protracted convalescence. But this is not a big deal when your life is at stake.

However, if well trained laparoscopic surgeons are available, one should not hesitate in getting the surgery done by the laparoscopic technique. Whether laparoscopy or retroperitoneal laparoscopy is to be used, again depends upon the experience of the operating surgeon in these two fields and the type of disease you have got. If you have a diseased organ lying in the abdominal cavity, it has to be repaired by the technique of laparoscopy. But,if the organ is in the abdominalwall, should it be repaired by laparoscopy or retroperitoneal laparoscopy?

Now, if the whole process of laparoscopy is analyzed, a person with average intelligence would question the necessity of going through the pious cavity of the sanctum sanctorum just to repair the structures inside its wall. Well, if you have to repair the light hanging inside the sanctum sanctorum or have to repair an organ hanging inside the abdominal cavity, you are justified in entering the pious cavity by making a few holes in the wall. But, if the structure to be repaired is hidden inside the wall, why vitiate the sanctity of the sanctum sanctorum? Why not directly place the laparoscope into the abdominal wall from outside and do the repairing job? Most surgeons knew that this indirect approach was unjustified, but did not know how to approach the structures in the abdominal wall with a laparoscope without going through the abdominal cavity. As a matter of fact many attempts had been made by these surgeons in the past to discover an alternative method of laparoscopy which would obviate the need to go through the pious cavity of the abdomen for performing operations on the structures in the abdominal wall.

Unfortunately, success eluded these surgeons for almost 30 years as they tried to copy all the steps used for laparoscopy of the abdominal cavity in an attempt to perform laparoscopic surgery of the abdominal wall. They failed to realise that there were significant anatomical differences between the two areas. A large working space of about 10 liters is already present in the abdomen, which helps in surgical manipulations and makes the procedure much simpler. While in the abdominal wall, there is no such space and this lack of space does not permit free movements of the surgical instruments, which are necessary to perform a laparoscopic operative procedure. Somebody had to make a discovery to solve this problem of lack of space, to make direct laparoscopy of the abdominal wall successful. Such a discovery would make the minimally invasive laparoscopic procedure all the more minimally invasive. As this type of laparoscopic approach restricted the surgeon to stay between the muscular part of the abdominal wall and the thin elastic inner most layer of the wall called the peritoneum, it was called ‘retroperitoneal laparoscopy’.

Necessity is the mother of invention and it was this necessity which made an eccentric in India discover the balloon technique of retroperitoneal laparoscopy.2 This made it possible for surgeons all over the world to successfully perform ‘retroperitoneal laparoscopy’ to treat disorders of the organs lying in the wall of the abdomen. This is a rare example in recent years where medical technology was discovered in India and was later accepted all over the world.

What operations can be performed by laparoscopy and retroperitoneal laparoscopy?

The commonly performed laparoscopic operative procedures are for birth control, appendicitis, cholelithiasis (stones in the gall bladder), hernia, ovarian cyst, ectopic pregnancy, infertility and undescended testis.

The commonly performed retroperitoneal laparoscopic operative procedures are kidney stone disease, ablative or reconstructive procedures on the kidney or ureter, adrenal disorders and urinary incontinence.

However, the experts in India and all over the world are trying to achieve perfection in treating all types of disorders by the laparoscopic or the retroperitoneoscopic technique. Surgery for peptic ulcer disease, intestinal, renal or even adrenal malignancies are now regularly being treated by these techniques at many big centers. Donor nephrectomy, a very delicate procedure, is also being performed at many centres.

What is the future?

Routine laparoscopic and retroperitoneoscopicsurgery has only been started recently and however expert a surgeon might be, it is going to take a lot of time for him to achieve perfection in this field. Then, there is a learning curve for the surgeon for every new laparoscopic procedure, when out of necessity evolution of newer techniques and technologies takes place. Laparoscopic or retroperitoneoscopic surgery requires reproduction of same steps as for an open surgical procedure and sometimes due to technical reasons might force the surgeon to convert the keyhole surgery into an open operative procedure. Therefore, it is imperative that the person who wants to learn this new technique must first master the art of open surgery.

Human mind being very fertile, I have no doubt that in the very near future almost every surgical procedure would be done by the minimally invasive technique. I can foresee a time when our great grandchildren would scornful say, "Imaging our forefathers doing this by putting hands in the abdomen". During a later era I can also foresee surgeons completely forgetting the art of open surgery. My soul roaming around the universe would scornfully smile at the following incident happening hundreds of years later.

Place : Inter Planetary Minimally Invasive Surgery Centre (IPMISC), Moon Era : 2500

The incident

An expert in retroperitoneal laparoscopic removal of only the left kidney had been flown from a neighbouring interplanetary space centre to the IPMISC. He has been struggling to remove a very badly stuck kidney for the last 7 hours and is cursing his forefather for inventing this silly technique. His third assistant excitedly rushes into the Operation Theater shouting "Eureka" "Eureka". There is a pin drop silence as everyone intently listens to what he says "Sir, there is a word in the English Dictionary called Incision, which can help you getting out of trouble"

So what do we learn from this incident? This means that even an expert in laparoscopic surgery sometimes has to abandon the laparoscopic procedure due to technical reasons and resort to the open operative technique. This should not be made an ego issue as failures in medicine are considered to be part of normal life.

I can also foresee in the near future all these minimally invasive procedure becoming obsolete. A time would come when the surgeon would not be allowed even to touch your body, leave aside making a hole in your body. He would just point a magic wand at your diseased organ and you would be cured of your disease. High energy intracorporeal focussed ultrasound (HIFU) is recently being used at some centres for this purpose but has met with limited success. With the advancement in miniature technology, where spare parts would be as big as molecules, the dream of sending a miniaturized surgical team through the blood vessels into an otherwise inaccessible part of the brain for necessary repairs as shown in the movie. "A Fantastic Voyage", might become a reality.

REFERENCES

Jacobeus HC. Uber die Moglichkeiten, die Zystoscopie bie Untersuchung seroser. Hohlungen anzuwenden. Munchener medezinische Wochenschrift. 1910; 57 : 2090-2.

Gaur DD. Laparoscopic operative retroperitoneoscopy : Use of a new device. J Urol 1992; 148 : 1137-39.

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Fig. 3: Showing how a laparoscopic expert would repair a defect in the concealed wires in the wall of the sanctum sanctorum by keyhole surgery.	Fig. 4: Showing how a retroperitoneal laparoscopic expert would repair a defect in the concealed wires in the wall of the sanctum sanctorum by keyhole surgery.