Laparoscopy has been in development for 100 years, and before 1987, because it could only be observed by one or two people, it could be used as an important diagnostic tool and for simple procedures, but not for complex ones. 1986 saw the successful transplantation of a miniature camera system (microchip) to endoscopy and the introduction of electronic endoscopy, where the images to be observed could be displayed on a television fluorescent screen that could be seen by several people at the same time. In 1987, the television laparoscope was created. In the same year, the first laparoscopic cholecystectomy was performed by Dr. Philippe Mouret in France. The TV laparoscope allowed several people to see the surgical field at the same time, making it possible to perform more complex operations in coordination with each other. Once this procedure was introduced, it quickly became popular among patients and of interest to some physicians because of its minimally invasive nature, and it was rapidly expanded worldwide. Based on the widespread development of laparoscopic cholecystectomy, the accumulation of doctors’ experience and the continuous improvement of technical level, as well as the successful development of new camera imaging system and separating hemostatic instruments have led to a rapid increase in the variety of laparoscopic surgical procedures and the rapid formation of a laparoscopic surgical boom in the field of surgery, not only in general surgery to carry out complex surgeries such as gastrointestinal, spleen, liver, pancreas; but also in thoracic surgery, obstetrics and gynecology, urology, etc. It is a rare technical innovation in the field of surgery, and has become one of the fastest developing topics in surgery today. Zhu Jianwei, Department of Gastrointestinal Surgery, Nantong University Hospital
A. Features of laparoscopic surgery
1.Little local trauma
The local trauma of laparoscopic surgery is small mainly in: (1) lighting deep into the surgical field, small abdominal wall opening. Open surgery requires a large opening, mainly because the lighting source is outside the body and the operator’s hand has to enter the abdomen for operation and field exposure. The illumination used in laparoscopic surgery reaches deep into the operative field and is well illuminated, so that the operator’s hand does not enter the body and the operation can be performed outside the body, using position changes and pneumoperitoneal pressure and appropriate traction to achieve the required operative field exposure. Multiple small incisions in the abdominal wall and protected by trocars should cause less damage than the sum of it. (2) The hand does not enter the abdominal cavity can reduce the damage to the organ peritoneum and interference with organ function, and the postoperative gastrointestinal function recovers quickly with less abdominal adhesions. (3) Laparoscopic surgery requires a bloodless surgical environment, and the principle is bloodless surgery, with coagulation and hemostasis before separation or separation while hemostasis. Most laparoscopic gallbladder surgeries rarely bleed, generally bleeding an average of 25 ml, with laparoscopic surgery for low rectal cancer bleeding only 5-80 ml. average 45 ml, laparoscopic splenectomy group also bleeds less than open group, small wound is also a reason for less bleeding. (4) The operation time was shortened. In the early stage of laparoscopic surgery, the operating time was longer than that of open surgery due to unskilled technique; with the improvement of technique and accumulation of experience, as well as the development of new and applicable instruments, the operating time of experienced doctors and mature surgery was gradually shortened. A typical cholecystectomy takes about 20-30 minutes; a colectomy takes about 2 hours, and a splenectomy takes about 30-100 minutes. Shortening the operation time can reduce trauma.
2.Light systemic reaction
With the widespread development of laparoscopic surgery, the research on systemic reactions caused by laparoscopic surgery has been increasing. The systemic reactions caused by surgical trauma are mainly manifested in: (1) neurohumoral system; (2) immune system; (3) recovery of organ function. The neurohumoral system: Adrenocorticotropic hormone (corticosterone) is mostly used as the measurement index, and KuntzC et al. did an experimental study on colon resection surgery in rats, and the animals were divided into three groups: anesthesia only, traditional surgery and laparoscopic surgery. BerguerR did an experimental study with rats, and the animals were divided into three groups: (1) anesthesia-only unoperated group, (2) open fundoplication group, and (3) laparoscopic fundoplication group. The results were that plasma corticosterone levels were significantly lower in the laparoscopic fundoplication group than in the open fundoplication group. The results of these experiments showed that laparoscopic surgery induced a significantly lower organismal stress response than open surgery. Immune system: interleukin has a strong response to trauma and infection and is a commonly used indicator to determine the degree of tissue damage. Interleukins are elevated after laparoscopic cholecystectomy and open cholecystectomy, and the elevated levels are more pronounced in the open than in the laparoscopic, as has been reported in several articles. kuntzC used IL-1 and neopterin as observational indicators in experiments on murine colectomy. neopterin belongs to the pteridine group, which is a biochemical indicator of the cellular response to surgical biochemical indicator of the immune response to trauma. Its biosynthesis increases in the presence of inflammatory diseases, trauma and surgical stress. The experimental results showed that neopterin was significantly elevated in the open surgery group after surgery and returned to its original level on the first postoperative day, while the changes in the laparoscopic and simple anesthesia groups were minimal and the difference between the two was significant. It peaked on the first day and did not return to its original level until the seventh day. There were mild changes in the laparoscopic group and no significant changes in the anesthesia group. The difference between the results of the postoperative open group compared with those of the laparoscopic group was significant. Therefore, he concluded that laparoscopic colectomy caused less changes in the immune system than open surgery.
3. Fast recovery of organ function
Combining the above results, it can be seen that laparoscopic surgery is less traumatic to the surgical local area, less systemic stress and less impact on the immune system. Patients can resume normal activities in a short period of time, thus some pulmonary complications, wound complications can be avoided. Early feeding and nutrition from normal sources are possible. Laparoscopic cholecystectomy allows the patient to move and eat on the same day or the next day after surgery, and he is usually discharged on the third postoperative day and resumes normal activities 7-10 days after surgery. Bowel function is restored 2 days after laparoscopic splenectomy and fluid is allowed, with an average stay in the hospital of 5 days after surgery. The recovery of bowel function and the time to eat after laparoscopic colectomy and the postoperative stay in the hospital were also significantly shorter than those after open surgery.
In summary, laparoscopic surgery has outstanding advantages compared with traditional surgery: (1) the surgical field is well illuminated, the images are magnified, and the surgical instruments are excellent, with the characteristics of microsurgery; (2) the nerves or muscles of the body wall are avoided or rarely cut, and the incisional complications are reduced; (3) the visceral interference is light, and the organ function is recovered quickly; (4) the poke hole is tiny, flexible and mobile, which facilitates the joint diagnosis and treatment of multiple surgical diseases; ( (5) facilitates cooperation and teaching as the participating surgical personnel can share the same picture; (6) reduces the threat of disease to the surgical personnel and also allows sitting down for surgery, reducing labor intensity. However, laparoscopic surgery also has its limitations: (1) the precision and fragility of laparoscopic equipment and instruments and the many links greatly increase the dependence of the surgeon on the instruments, (2) the loss of stereoscopic vision, increased operational difficulty, and the stereoscope is far from ideal, (3) the loss of the surgeon’s ability to use direct sensing of the fingers, probing, traction exposure, and emergency treatment, and (4) the high cost of surgery. Therefore, the principles of laparoscopic surgery should be based on its superiority and limitations to master the surgical indications and strictly follow all the basic principles of surgery to achieve the same safe and effective surgical purpose as open surgery. In China, the design of complex types of laparoscopic surgery should be based on national conditions, with the premise of minimally invasive surgery, as far as possible to make the operation economical and safe, simple and easy, practical and fast, easy to promote.
Second, the application of laparoscopic surgery in the diagnosis and treatment of general surgical diseases
1, the application of laparoscopic technology in the diagnosis and treatment of biliary tract diseases
The application of laparoscopic technology in biliary tract diseases is an example of successful application of laparoscopic technology, and is also an important backing for the promotion of laparoscopic technology. Laparoscopic cholecystectomy soon emerged from the shadow of high initial complications and became accepted by almost all surgeons, gradually becoming the “gold standard” in the treatment of gallbladder diseases. The laparoscopic choledochotomy for extraction of stones on this basis is also becoming mature, and laparoscopic bile-intestinal drainage, laparoscopic choledochal cystectomy and biliary malignancy surgery are being attempted.
Laparoscopic cholecystectomy is one of the most widely used and technically most mature procedures in general surgery. With the continuous improvement of technology and accumulation of experience, its indications have been expanded, and the previous contraindications can now be changed into indications. The main indications are: (1) various types of symptomatic gallbladder stones, including acute and chronic calculous cholecystitis, gallbladder stone impaction, atrophic cholecystitis with stones, etc. Laparoscopic cholecystectomy during acute inflammatory attacks is difficult and should be decided according to technical conditions to avoid the attack period, as is the case with atrophic cholecystitis with stones. Forced surgery when the technical conditions are not mature will increase the incidence of complications, and if intraoperative difficulties are found, timely consideration should be given to intermediate open abdomen. (2) Recurrent non-stone cholecystitis is generally more cautious, but laparoscopic cholecystectomy should be considered if the symptoms are more severe and other diseases have been excluded as possible causes. (3) Polyp-like lesions of the gallbladder, such as large and fast-growing polyps, single polyps, neck polyps, etc. with suspected malignant changes, or combined with stones. (4) Asymptomatic gallbladder stones, such as large stones (greater than 2CM), porcelain-like gallbladder, long history (greater than 10 years), full of stones and other susceptible to malignant change, or gallbladder has irregular thickening. The main contraindications are: (1) severe heart, lung, liver and kidney diseases, and inability to tolerate general anesthesia. (2) Severe bleeding tendency, which may cause intraoperative bleeding that is difficult to handle and control. (3) Severe infection in the abdominal cavity, and laparoscopic surgery may cause the spread of infection. (4) Severe cholangitis. (5) Severe cirrhosis and portal hypertension, surgery may cause hemorrhage. (6) Those with suspected malignant change of gallbladder.
Complications of laparoscopic cholecystectomy (LC) and their management: 1. Biliary tract injury is the most common complication of LC. In 1998, there were 114,005 cases of LC in the United States, and the rate of biliary tract injury was 0.5%, and domestic statistics of biliary tract injury are generally lower than those abroad. LC biliary tract injury is generally more difficult to deal with because the common bile duct is generally not dilated in LC patients, and the bile duct may have been freed during surgery, and injury is more common with pad cautery, and in severe cases the common bile duct has been removed. At this time, the blood supply of the bile duct should be fully considered, do not force end-to-end anastomosis, which will lead to scar growth and biliary stricture, at this time, biliary intestinal drainage is often the best choice, if necessary, biliary ductoplasty should be performed, suturing must be fine, and should try to avoid postoperative bile leakage and other complications, otherwise it will also cause biliary stricture.2. Bile leakage is one of the common complications of LC. Domestic and international statistics show that the complication rate of bile leak is between 0.14-0.29%. It mostly occurs when the bile duct stump leaks and the bile duct paracolic duct is injured. The occurrence of bile leak causes biliary peritonitis and in severe cases can cause toxic shock. If a drainage tube has been placed intraoperatively and can be completely drained, the injury will generally heal on its own as long as it is not a bold duct. If not completely drainage or intraoperative tube is not placed, often should be the second surgery to solve the problem. 3, intraoperative, postoperative bleeding LC intraoperative operation should be gentle, avoid violence, acute inflammation is easy to bleed, when the blood vessels are brittle and easy to fracture, dissection should be kept in place, the tension should not be too great when disconnecting smaller vessels, otherwise it will also cause bleeding. Some of the vessels are closed at the time of dissection, but there is a possibility of recanalization after surgery, so titanium clips should be left in place. 4. Residual bile duct stones About 15-20% of gallbladder stones are combined with common bile duct stones, so the preoperative examination should be based on the presence or absence of bile duct stones, if the diagnosis of bile duct stones is clear, ERCP can be performed first, if bile duct stones are suspected, intraoperative imaging is feasible, and after the diagnosis is clear, laparoscopic choledochotomy is feasible. Laparoscopic choledochotomy choledochoscopy for stone extraction, or ERCP can be performed two days after LC.
2.The application of laparoscopic technology in the diagnosis and treatment of gastrointestinal diseases
(1) Progress of laparoscopic gastric surgery
The earliest laparoscopic partial gastrectomy was done by Peter Goh, a Singaporean doctor, in February 1992, and the first laparoscopic subtotal gastrectomy in China was successfully performed by Qiu Ming and others in 1993. After more than 10 years of efforts, the laparoscopic gastrectomy technique has been greatly improved and the scope of clinical treatment has been broadened. The clinical application of laparoscopic gastric surgery in China has involved ① treatment of peptic ulcer and its complications; ② local excision of benign tumor of gastric wall; ③ subtotal resection of gastric ulcer with atypical hyperplasia; ④ radical surgery of early gastric cancer; ⑤ palliative surgery of advanced gastric cancer; ⑥ fundoplication for gastric reflux Esophageal reflux ⑦ Gastric reduction surgery for morbid obesity.
(2) Progress of laparoscopic colorectal surgery
In the early 1990s, Fowler and Jacobs were the first to report laparoscopic colectomy, and in 1993, laparoscopic-assisted colorectal resection was started in Hong Kong, and the following year, Shanghai Ruijin Hospital started research in this area, but the development was much slower than other laparoscopic surgeries, mainly because of the difficulty of surgery, expensive surgical instruments, and doubts about the treatment effect. The introduction and clinical use of the ultrasonic knife in the 1990s led to the rapid development of laparoscopic colorectal surgery. Laparoscopic colorectal surgery has obvious advantages over traditional surgery in terms of recent recovery, and the follow-up data of several groups showed no statistical difference in survival rates at 3 and 5 years. This work has been performed in dozens of hospitals in China, and the surgical procedures involved are right hemicolectomy, transverse colectomy, left hemicolectomy, sigmoid colectomy, anterior rectal resection, combined abdominoperineal resection, sigmoid fixation, and colostomy. There are total laparoscopic surgery, laparoscopic-assisted colorectal surgery and hand-assisted laparoscopic surgery, and the types of diseases covered include benign and malignant colorectal tumors, congenital megacolon, sigmoid redundancy, etc.
3.Application of laparoscopic technology in liver surgery
The liver is the largest substantial organ in the human body, and with the development of liver surgery so far, the abnormally rich vascular liver is no longer a forbidden area for surgery. With the invention of laparoscopic ultrasonic knife and endo-gia etc. making laparoscopic hepatic resection also possible, despite the relatively prominent difficulties encountered, it has still been developed to some extent, from the initial partial hepatectomy to left outer lobe resection of liver, right anterior and posterior lobectomy of liver and regular left and right hemicolectomy, and the diseases involved also range from benign hepatic cysts. hepatic hemangioma, intrahepatic bile duct stones to hepatocellular carcinoma. However, the development of laparoscopic hepatectomy has been relatively slow because there is not yet a good way to control the liver gate and laparoscopic hepatectomy is often encountered with hemorrhage. At present, dozens of liver resection cases can be seen in China, and we have reason to believe that with further improvement of laparoscopic instruments, all livers that can be resected openly can be done laparoscopically.
4.The application of laparoscopic technology in pancreatic surgery clinic
The pancreas is an important digestive gland, and pancreatic surgery is complex and difficult, and its tissues are brittle and prone to bleeding and pancreatic leakage. The advantages of laparoscopic surgery are good illumination and magnified view, and if the technique is skilled, it has certain advantages in stopping bleeding and preventing pancreatic leakage. Due to technical reasons and risk factors, laparoscopic pancreatic surgery is rarely performed, but a variety of procedures have been involved, such as laparoscopic pancreatitis drainage and laparoscopic internal drainage of pancreatic cysts. laparoscopic islet cell tumor resection, laparoscopic pancreatic body and tail resection, laparoscopic pancreaticoduodenectomy, and palliative surgery for advanced pancreatic cancer. Diagnostic staging of pancreatic cancer. Resection of pancreatic body caudal tumor is currently considered the most appropriate laparoscopic pancreatic surgery and has the largest number of surgical cases; resection of insulinoma requires a certain distance of the tumor from the pancreatic duct; the biggest controversy of pancreaticoduodenectomy is the incomplete resection of the pancreatic hook. China has also carried out all of the above procedures, pancreatic body tail resection has also been reported in dozens of cases, more than ten cases of insulinoma reported, laparoscopic pancreaticoduodenectomy has been carried out in 8 cases in China, although there are not many cases carried out, but it can be seen that the role of laparoscopic technology in pancreatic surgery will become increasingly important.
5, laparoscopic technology in the clinical application of neck surgery
As early as the early 1990s laparoscopic technology was applied in thyroid surgery, the benefits of the operation to patients are obvious, and therefore quickly accepted by patients, in foreign countries has become the first choice of benign thyroid disease, even early thyroid cancer has also been completed under the lumpectomy. In China, the procedure was carried out almost simultaneously to treat thyroid diseases, but since most of the doctors who carried out the procedure in the early days were not thyroid surgeons, there were some complications and the thoroughness of the procedure was also problematic. With further development, the procedure has now been recognized and participated by thyroid surgeons, and the incidence of complications has decreased significantly, even lower than that of open surgery, and the benefits brought by the procedure have The benefits of the procedure have been not only in its cosmetic effect, but the good illumination and vision of laparoscopic surgery can further reduce intraoperative bleeding and the possibility of intraoperative nerve and parathyroid gland injury. A good vision is still the basis for complete but not excessive resection, thus laparoscopic thyroid surgery will definitely be the mainstream surgical approach for thyroid disease in the future.
Parathyroid adenoma resection is also a very suitable lumpectomy procedure because the number of cases is low and the number of surgical cases is still small. Hyperparathyroidism caused by parathyroid hyperplasia is one of the complications of chronic renal failure and long-term hemodialysis, and is more common in clinical practice. Traditional surgery can make patients have more bleeding and greater trauma. Laparoscopic surgery can avoid all the drawbacks brought by traditional surgery and bring cosmetic effects at the same time.
6.The application of laparoscopic technology in the emergency surgery clinic
Acute abdomen is a common clinical disease, and most acute abdominal diseases can be diagnosed through clinical manifestations. The basic examination and laboratory tests clearly diagnose, such as acute appendicitis, acute cholecystitis, acute pancreatitis, gastroduodenal perforation, etc. Some acute abdominal conditions are difficult to diagnose definitively, but once signs of peritonitis are present a dissection should be performed, and the exploration incision is often separated from the lesion or far more complicated than expected. The application of laparoscopic techniques can avoid the difficulties and surgical trauma associated with dissection, and the diagnosis can generally be clarified. At the same time, as long as the good illumination and field of view of the laparoscope can be fully utilized, and the basic laparoscopic operating techniques can be skillfully applied, the surgery can be completed laparoscopically except for acute abdominal conditions that are difficult to expose and closely adherent. Acute rupture of substantial organs should depend on the condition. If it is a life-threatening hemorrhage, immediate open surgery should be performed, and laparoscopic surgery can be considered if the vital signs are stable. However, laparoscopic emergency surgery must require laparoscopic surgeons with considerable experience in open surgery and superb laparoscopic surgical techniques, otherwise it is difficult to ensure the safety of surgery.
The conditions for the development of minimally invasive surgery are already in place, and the key is to change the concept. First of all, as an advanced medical practitioner should recognize and keep up with the form of scientific development, establish the patient-oriented medical principles, choose and master the treatment methods that make the patient get reasonable treatment and suffer the least damage. Minimally invasive surgery and traditional surgery are complementary relationships, minimally invasive surgery must be based on traditional surgery, traditional surgery standards to measure the effectiveness of minimally invasive surgery, but also traditional surgery as the backbone, minimally invasive surgery and traditional surgery are to follow the principle of minimally invasive. Minimally invasive surgery is the direction of development, and there is a process of concentration, proliferation, promotion and popularization, which requires the efforts of all surgeons.
From: Jiangsu Provincial Hospital of Traditional Chinese Medicine, Department of General Surgery, Dr. Ren Ming’s personal website