In March 1987, Dr. Mouret, a French obstetrician and gynecologist, performed the first laparoscopic cholecystectomy (LC) in the world’s medical history while performing gynecological surgery laparoscopically. The success of this operation immediately caused a sensation in the world of surgery. In the following years, with the most innovative American surgical community as the pioneer, the new technical revolution of laparoscopic cholecystectomy was rapidly emerging in the surgical community of developed countries worldwide, and a number of accomplished laparoscopic surgeons such as Philips, Berci, Reddick and Olsen emerged, which greatly promoted the rapid development and progress of LC surgical techniques.
What is most noteworthy here is that, due to the success of LC surgery and the rapid promotion and widespread use of this new technology, the medical concept and technical practice of minimally invasive surgery has been successfully implemented in more and more traditional surgical fields, thus making Minimally Invasive Surgery (MIS), a new technical discipline in which tradition and modern spirit are constantly fused, a new discipline in the new century. This new technical discipline has become the main theme of global surgical development in the new century. As academician Huang Zhiqiang said, “Surgery in the 21st century should be perfect surgery, and minimally invasive surgery is the sublimation of surgery in the 21st century.”
LC surgery in China began in February 1991, when Dr. Xun Zuwu of the Department of General Surgery of the Second People’s Hospital in Qujing, Yunnan Province, China, pioneered laparoscopic cholecystectomy in China, reflecting the enterprising spirit of our surgeon team to quickly follow the development of new technologies in the world. To date, laparoscopic and minimally invasive surgical techniques in China have undergone more than 10 years of development and have accumulated a lot of valuable experience. Here the author will make some cursory discussion on the theoretical and technical aspects of this field.
First, the selection of indications for laparoscopic surgery and the comprehensive evaluation of clinical efficacy
Compared with traditional open surgery, laparoscopic surgery has unique advantages such as less trauma, less pain, faster postoperative recovery and beautiful incision. In developed countries, laparoscopic surgery has accounted for 90-96% of all gallbladder resections. However, laparoscopic surgery is not suitable for all abdominal surgical diseases, and at present, the following diseases are the best indications for laparoscopic surgery.
1, gallbladder disease
These include gallbladder stones, gallbladder polyps and cholecystitis. Among them, gallbladder stones combined with symptoms of cholecystitis must be treated surgically. For asymptomatic gallbladder stones, recent studies have found that chronic inflammation caused by stones rubbing against the mucous membrane layer in the gallbladder for a long time can develop into atypical hyperplasia, i.e. precancerous lesions. These patients are prone to develop into gallbladder cancer, so they should also have their gallbladders surgically removed as early as possible. Although gallbladder polyps rarely have accompanying symptoms, they can be transformed into cancer in the process of long-term lesions, and the cancer rate is several times higher than that of normal people, so early surgery is more appropriate.
2.Hepatic cysts and liver abscesses
Liver cysts, especially liver abscesses, should be operated as soon as they are diagnosed. As the surgical operation of these two diseases is relatively simple and safe, both are open window drainage, which has become a good indication for laparoscopic surgery.
3. Appendicitis
According to the summary report of a large number of medical records at home and abroad, the biggest advantage of laparoscopic removal of diseased appendix is that the incision is not infected or rarely infected, and the incidence of postoperative intestinal adhesions and intestinal obstruction is extremely low. The incision is small and concealable, and it is difficult to see the abdominal surgery scars, so it is very popular among women.
4.Extra-abdominal hernia
For patients with extra-abdominal hernia such as inguinal hernia and straight hernia without a history of abdominal surgery, intra-abdominal tension-free hernia repair can be performed laparoscopically. However, this procedure is not recommended for patients with incisional hernia, incarcerated strangulated direct and oblique hernia.
5. Gastroduodenal ulcer perforation
Due to the revolutionary advancement of acid producing drugs, more than 94% of the patients with duodenal bulb ulcers can be cured by drugs. In case of duodenal ulcer perforation, laparoscopic surgery can repair the ulcer perforation successfully with minimal trauma.
6. Neck diseases
Diseases of the thyroid and parathyroid glands are relatively new indications for laparoscopic surgery. For female patients, especially young women, with neck disorders such as thyroid adenoma and nodular goiter, laparoscopic thyroid surgery can be performed aesthetically and safely. The procedure can be performed with a simple incision of about 1 cm in both axillae or areolas. According to the literature, Dr. Udelsman at Yale University School of Medicine has made minimally invasive lumpectomy for the removal of benign parathyroid tumors a routine outpatient procedure.
7.Breast Diseases
Due to the advancement of modern medical theory, aesthetic theory and artificial cavity technology, many hospitals at home and abroad have applied laparoscopic surgery to remove lesions and, if necessary, axillary lymph node dissection in patients with benign breast tumors and early breast cancer. The application of this technology, for young female patients can not only cure breast disease, but more importantly, to meet the psychological needs of patients for the beauty of the breast shape.
8. Other general surgery diseases
The application of laparoscopy for sigmoid resection, splenectomy, partial gastrectomy, etc. is also a good treatment in hospitals with mature technical conditions. If splenic cysts, splenic tumors, hypersplenism caused by various reasons, idiopathic thrombocytopenic purpura, hereditary spherocytosis, etc. require splenectomy, laparoscopic surgery is also feasible. Laparoscopic sigmoid colectomy can also be performed for sigmoid colon polyps and early sigmoid colon cancer that are difficult to be removed by colonoscopy. Because of the minimally invasive laparoscopic surgery, it avoids the disadvantages of traditional open surgery, such as long abdominal incision, postoperative intra-abdominal organ adhesions, slow recovery of visceral function and long hospitalization period.
Second, compared with traditional surgery, laparoscopic surgery has the superiority
According to the experience of domestic and foreign medical records, the superiority of laparoscopic surgery compared with traditional surgery is as follows.
(1) General anesthesia is generally used, and the monitoring measures are complete, so the safety of the operation is greatly increased.
(2) The abdominal wall poke hole replaces the abdominal wall incision, avoiding the injury to the abdominal wall muscles, blood vessels and corresponding nerves, and there is no postoperative weakness of the abdominal wall and abdominal wall incision hernia, no scarring of the abdominal wall muscles affecting the motor function, and no numbness of the corresponding skin caused by the abdominal wall nerve cut. Poke hole infection is far less than incisional infection or fat liquefaction of traditional open incision and can be almost disregarded.
(3) Traditional surgical scars are long and striped, such as those for cholecystectomy, which are more than 12 cm long and affect the appearance. In contrast, laparoscopic surgery requires only 3~10mm small poking holes in the abdominal wall, which are scattered and concealed, and can leave basically no scars in the abdomen after surgery, which is especially suitable for women’s cosmetic needs.
(4) The illumination used in laparoscopic surgery can reach deep into the surgical field, and it is well illuminated and has a magnifying effect. The operator’s hand does not enter the body and can operate outside the body. The small incision, lack of traction and the presence of trocar protection are important aspects that distinguish laparoscopic surgery from open surgery and are important factors in the minimally invasive nature of laparoscopic surgery.
(5) Since the operator’s hand does not enter the abdominal cavity, thus reducing the damage to the plasma membrane layer of the organs in the abdominal cavity and the interference with organ function, postoperative recovery of gastrointestinal function is rapid and there are very few organ adhesions in the abdominal cavity.
(6) Laparoscopic surgery requires a bloodless surgical environment and is in principle a bloodless surgery; the ultrasonic knife is used instead of the ordinary scalpel, and the high frequency (55.5Hz) mechanical vibration of the ultrasonic knife head can produce a high temperature of 80℃, which can induce tissue protein decomposition and coagulation, and produce the effect of hemostasis, cutting and separation. It effectively reduces intraoperative instrument replacement (saves time) and instrument configuration (saves money). Due to the above advantages of ultrasonic knife, surgical operations are mostly performed with coagulation and hemostasis before separation or separation while hemostasis. Most laparoscopic cholecystectomy operations rarely bleed, generally averaging 25 mL. Dr. Zhou Zongguang et al. did laparoscopic resection of low rectal cancer with only 5 to 80 mL of bleeding, averaging 45 mL. the bleeding in the laparoscopic splenectomy group was also less than that in the open group. Smaller wound bleeding was also a reason.
(7) The operation time is significantly shortened, i.e. with the improvement of technology and accumulation of experience, as well as the successful development of new applicable instruments, the operation time is gradually shortened by the experienced surgeons and the already mature operation. Similarly, the shortened operation time can also reduce the injury.
(8) The reason is that laparoscopic surgery is less traumatic to the surgical area, and the whole body has less stress and less impact on the immune system. Postoperative pain is mild, and generally patients no longer need pain medication after surgery. Patients can resume normal activities within a short period of time, thus avoiding pulmonary complications and wound complications.
(9) It allows early feeding and rapid restoration of the body’s regular supplemental nutrition via the mouth. Laparoscopic cholecystectomy can be discharged from the hospital on the same day or the next day after the operation and normal activities can be resumed 7~10 days after the operation. Bowel function is resumed 2 days after laparoscopic splenectomy, or a liquid diet. The average stay in the hospital after surgery is 5 days. The time to restore bowel function and the time to stay in the hospital after laparoscopic colectomy were also significantly shorter than those after open surgery.
(10) The video recording of the whole operation can be kept, and in case of medical disputes, it can be accessed at any time, which increases the transparency in medical practice.
In addition to the above advantages, the author believes that the following three special advantages of laparoscopic surgery over traditional open surgery need to be emphasized here.
First, for patients, because of the minimally invasive nature of laparoscopic surgery, they can generally be discharged from the hospital one to two days after surgery, and they can resume light physical labor 10-15 days earlier than in open surgery, and resume heavy physical labor 20-30 days earlier than in open surgery. From a social and medical economics point of view, the good results of laparoscopic surgery are very beneficial in terms of improving the survival and quality of life of the individual patient, as well as in terms of social and family stability and labor productivity.
In addition, in elderly patients and patients with a variety of other medical conditions, there are many contraindications to traditional open surgery. In contrast, laparoscopic surgery is less disruptive to the body and has a faster postoperative recovery, which can significantly expand the range of surgical indications for elderly patients compared with traditional open surgery, providing more opportunities for surgical treatment.
In addition, compared with traditional surgery, laparoscopic surgery can perform two or more types of abdominal surgery in the same incision without increasing trauma. For example, when a patient suffers from both gallbladder disease and appendiceal disease, laparoscopy can use the incision of cholecystectomy to perform appendectomy at the same time, while traditional surgery requires two incisions or a “through-the-sky” incision through the upper and lower abdominal wall.
III. Discussion on laparoscopic surgery for malignant tumors
According to the practice of domestic and foreign clinical surgeons for more than 10 years, today’s laparoscopic surgeons have made a qualitative leap in their surgical skills compared with the early stage, and their surgical experience has become increasingly rich, coupled with the use of laparoscopic ultrasonic knife and the introduction of hand-assisted laparoscopic technology, the number of malignant tumor diseases treated by laparoscopic surgery has increased significantly, and fundamentally changed the old concept that at the early stage of the development of laparoscopic surgery The old perception that laparoscopic surgery was only suitable for the treatment of benign diseases, which was formed in the early stage of laparoscopic surgery development, has been fundamentally changed. At present, reports of laparoscopic surgery for malignant tumors such as gastric cancer, liver cancer, colon cancer, pancreatic cancer, and esophageal cancer are increasing day by day, with the most reports on colorectal cancer. This indicates that the application of laparoscopic surgery has entered a new and broader field of surgery.
One of the principles of tumor treatment is to look at the long-term effects of treatment. Although the treatment of colorectal tumors by laparoscopic surgical methods began in 1991, even fewer were able to reach 5 years because of the small number of initial medical records. It is only in the last 4-5 years that there has been a significant increase in case reports regarding colorectal cancer.
According to a 2003 study in The Lancet, laparoscopic surgery was superior to open surgery in reducing complications, length of hospital stay and tumor recurrence, and prolonging patient survival in patients with metastasis-free colon cancer. Dr. Lacy, of the University of Barcelona, selected 219 patients with metastasis-free colon cancer for laparoscopic or open colectomy. Both groups received the same adjuvant treatment and postoperative follow-up, with the test being tumor-related survival.
It was found that after a mean follow-up of 43 months, tumor-related survival was significantly higher in laparoscopic patients than in open patients (p=0.02). Furthermore, laparoscopic surgery patients had faster postoperative recovery and bowel motility recovery, shorter fasting time and hospital stay than open surgery patients, and their overall complication rate was lower than that of open surgery patients, with a relative hazard ratio of 0.49. The researchers noted that laparoscopic surgery was independently associated with a reduced risk of tumor recurrence, all-cause complication rate and tumor-related complication rate compared with open surgery, with hazard ratios of 0.39, 0.48 and 0.38, respectively. In addition, these benefits were associated with a different proportion of stage III tumors in patients undergoing laparoscopic surgery than in patients undergoing open surgery. according to Dr. Lacy, laparoscopic surgery is superior to open surgery for patients with colon cancer, and therefore it is expected to become the standard of care for colon cancer.
The problem of tumor recurrence at the casing incision has been a major difficulty affecting laparoscopic surgery for malignancy, with a maximum incidence of 21%. With the increase in the number of cases, the surgeon’s surgical experience, and the corresponding preventive measures, the recurrence rate of trocar-incision tumors has now decreased to 0-1.3%. In contrast, incisional tumor metastasis may also occur in open surgery, and the average incidence of incisional tumors in the abdominal wall is also 1% according to two groups of >1000 open surgery cases.
The use of prophylactic measures to prevent recurrence of trocar incision tumors is crucial. dr. Bslli JE summarized 320 laparoscopic colorectal surgeries he performed in 8 years, each with measures to prevent wound tumor metastasis, with an average follow-up of 54 months and no case of trocar wound tumor metastasis. His preventive measures were.
(1) fixing the trocar to the abdominal wall ;
(2) avoid touching the tumor ;
(3) ligating the vessels at a high level;
(4) intraoperative colonoscopy and irrigation of the intestinal canal with a 5% solution of allylone shy (Iodinepovidone, a cancer cell cytocidal agent);
(5) isolate the specimen in a bag before pulling it and protect the wound when releasing it;
(6) Enter the gas first and then pull out the cannula to prevent the smoke tube effect;
(7) Flush the intraperitoneal cavity and trocar site with 5% povidone iodine deep solution.
The summary reports of the above related charts are increasing day by day and conclude that the incidence of wound tumors is similar in both procedures when compared with conventional open surgery, and the application of preventive measures is also effective. This will undoubtedly provide a reliable theoretical basis for more application of laparoscopic minimally invasive treatment techniques in the field of general surgery for effective treatment of malignant tumors in the future.
Fourth, the technical advantages of hand-assisted laparoscopic surgery
Laparoscopic surgery is to put a micro camera device connected with a monitor into the abdominal cavity, the micro camera can be moved at will, and through the monitoring of the screen, using micro electric knife, forceps, scissors and other surgical instruments to complete the surgical operation. Laparoscopic surgery today still requires continuous improvement of instruments and techniques due to the all-round refinement of the surgical operation in terms of freedom, three-dimensional view and tactile perception.
For more than 10 years, although the continuous improvement and enhancement of the tools and techniques of laparoscopic surgery have benefited numerous patients, there are still a significant number of procedures throughout surgery that cannot be performed under small incisions. In particular, when performing difficult and complex surgeries on the stomach, spleen, liver, pancreas, colorectum and other organs in the abdominal cavity, conventional laparoscopic surgery would expose the operator to many difficulties such as lack of palpation, the need to enlarge the incision in order to remove the specimen, invariably prolonging the operation time and incisional tumor cell implantation.
In recent years, the introduction of hand-assisted laparoscopic surgery has provided a new technical route to solve these problems. At present, hand-assisted laparoscopic surgery has been widely used in complex surgeries such as laparoscopic gastrectomy, splenectomy, hepatectomy, colectomy and pancreatic resection. Hand-assisted laparoscopic surgery has proven to have the following advantages.
(1) The surgeon has a sense of touch, which helps to determine the location, size, and extent of lesions and to detect unconsidered lesions, whereas previously it was more dependent on intraoperative use of endoscopy and ultrasound exploration;
(2) It helps in the exposure of the surgical field;
(3) The operator’s hand reaching into the abdominal cavity can safely perform blunt separation of tissues;
(4) The location of large vessels can be determined and large vessel bleeding can be controlled;
(5) Because of the above advantages, hand-assisted laparoscopic surgery can significantly shorten the operation time compared with conventional laparoscopic surgery;
(6) It reduces the chance of cancer cell spreading and implantation metastasis of trocar incision during tumor surgery.
Since 1991, the world’s first hand-assisted laparoscopic surgery has been widely used in liver, pancreas, gastrointestinal and esophageal surgeries by Professor Alfred Cuschieri, the president of the European Surgical Society and the top international expert in minimally invasive surgery, who is regarded as the “father of endoscopic laparoscopic surgery” in the international surgical community. surgery. In the past, a traditional pancreatic surgery usually took about 6h, but he can complete it in 2h with hand-assisted laparoscopic minimally invasive surgery, which achieves safety, saves time, simplifies the traditional surgery and improves the efficacy.
Since hand-assisted laparoscopic surgery has the common advantages of modern laparoscopic surgery and traditional open surgery, this is where its unique technical advantages lie. However, this surgical technique has not been used for a long time, the number of cases is small, and there is a lack of credible comparative study data. Especially in China, due to the high price of surgical cuffs, national conditions, the significance of its practicality also needs to be further observed.
Fifth, the concept of minimally invasive surgery and the practice of technology has been the modern surgeons must be discussed
In 1983, the British urologist Wickham first proposed the concept of minimally invasive surgery (Minimally Invasive Surgery, MIS). However, it was only after 1987, when LC surgery was successfully completed and widely performed, that this concept became widely accepted in the world medical community. In the following years, various minimally invasive techniques such as endoscopic surgery and interventional imaging surgery were rapidly developed in many fields such as abdominal, thoracic, head and neck, cardiovascular surgery, gynecology, bone and joint surgery.
There is still a debate on how to accurately define the concept of minimally invasive surgery, but the following points have been agreed upon by the medical community in China and abroad regarding some basic understanding, namely.
(1) In terms of surgical route, surgical instruments and surgical operation techniques, minimally invasive techniques should reduce the invasion and trauma to the body to the minimum;
(2) Minimally invasive techniques should minimize local and systemic traumatic reactions to the surgery itself;
(3) As a result of “minimally invasive”, it can effectively support the normal defense function and organ function of the body and promote wound healing;
(4) The “psychological minimally invasive” of the human body is equally important, and the timely regulation of the perioperative psychological state can effectively enhance the body’s adaptability and recovery ability.
In fact, minimally invasive surgery should be understood more comprehensively and systematically in its rich connotation from a holistic and broad sense. In a broad sense, any treatment measures that can reduce the surgical damage of tissues and facilitate the recovery of body functions should belong to the scope of minimally invasive surgery, including lumpectomy, endoscopic surgery, interventional radiosurgery, directional guidance surgery, telemedicine, and even microsurgery and gene therapy.
The intrinsic advantages and revolutionary progress of modern laparoscopic and minimally invasive surgery, as well as the fields that can be covered by the current surgery and the degree of patient acceptance, including economic costs and other elements, all fully illustrate that advanced minimally invasive surgery meets the requirements of human beings to improve the quality of healthy life, revealing the general trend and irreversibility of the continued development of minimally invasive surgery. Therefore, the renewal of the concept and practice of minimally invasive surgery will be a mandatory course for modern surgeons, which is the mainstream trend of the times.
So, what are the prerequisites to fix this course of minimally invasive surgery? The author believes that.
(1) First of all, a good foundation of traditional surgery and clinical experience are needed. Minimally invasive surgery is a surgical treatment that requires high hand-eye coordination through small incisions using various instruments under the guiding principles of traditional surgery and on the basis of meeting and achieving the treatment effect of traditional surgery. It is difficult to imagine that minimally invasive surgery can be successfully performed in the absence of clinical experience in traditional surgery.
(2) The ability to analyze the indications for decision making based on continuous accumulation of clinical experience, and the ability to accurately analyze and judge which diseases are suitable for treatment by minimally invasive surgery.
(3) To master various minimally invasive surgical instruments and equipment, in addition to being familiar with electronic imaging and transmission systems, various laparoscopes, endoscopes, ultrasonic knives, as well as safety pneumoperitoneum needles, puncture devices, single-issue and disposable continuous-issue applicators, intracavitary linear cutting and closing devices, intracavitary circular anastomoses, repair sutures, tissue retractors, traps, various imaging devices, etc., so that all kinds of surgical operations under laparoscopy can be performed with ease. The newest and most advanced technology has made it possible to perform a variety of surgical procedures under lumpectomy.
With the rapid development of high technology, all kinds of advanced science and technology are penetrating into medicine, including microelectronics, computer technology, photoelectric technology, telecommunication technology, etc., which will make the minimally invasive surgery technology itself more modern, rationalized, and more realistic simulation. It is believed that in the near future, surgeons will soon have the following on their learning agenda.
(1) Simulation of the hand: Since the present laparoscopic techniques cannot be felt during operation as the human hand can, scientists are working on using some sensing instruments and devices to make the surgeon’s hand “feel” through the operating instruments during operation, making the laparoscopic techniques approximate the operation of the surgeon’s hand.
(2) Robotics: At present, minimally invasive surgery is difficult for the operator to operate with the same precision as computer calculations, and automated systems are being used to operate various laparoscopic techniques using robots. Research in this area has been reported and is expected to be realized in the near future.
(3) Network remote operation: The establishment of a worldwide information network, a contact network, and an operating network via satellite allows the doctor to treat the patient by telecommunication and long-distance dialogue. Through the computer operation and control of the robot and can complete the long-distance surgery operation. In this way, the journey can be greatly reduced and patients can choose the doctor they think is suitable for their treatment.
In the author’s opinion, minimally invasive surgery, although it requires many additional instruments and equipment, which objectively increases the hospital cost, and therefore the cost of surgery is higher than that of traditional surgery, minimally invasive surgery is less traumatic than traditional surgery, with shorter wound healing time, faster postoperative recovery, and significantly shorter patient hospitalization, which relatively makes up for the gap between the overall treatment cost and traditional surgery, especially minimally invasive The quality of life and health that patients have improved as a result of surgical procedures cannot be measured in monetary terms. For this reason, patients all over the world, especially in developed countries, prefer minimally invasive surgeons for any disease that can be treated with minimally invasive surgery, such as gallbladder removal, which is clearly stated in American surgical textbooks as the first choice for minimally invasive laparoscopic surgery.
Therefore, the development of minimally invasive surgery is important in terms of hardware and material foundation, but the key to success or failure is still the software, especially the change of surgeons’ concept. As an advanced medical workers should keep pace with the times, recognize and keep up with the situation of scientific development, establish the principle of patient-oriented medical treatment, learn to choose and master the use of both reasonable treatment for patients, and the least damaged treatment methods.
Sixth, concluding remarks
Minimally invasive surgery and traditional surgery is a complementary relationship, minimally invasive surgery and traditional surgery are to comply with the principle of minimally invasive. Minimally invasive surgery must be based on traditional surgery, and the standard of traditional surgery to measure the treatment effect of minimally invasive surgery. Minimally invasive surgery is the direction of development, there is a process of concentration, proliferation, promotion and popularization, which requires the joint efforts of all surgeons.
No new thing, new technology or new method will be perfect or applicable to all cases. While we fully recognize the superiority of minimally invasive laparoscopic surgery, we should also clearly understand its weaknesses and shortcomings. For some cases with complex pathology, severe adhesions, anatomical difficulties or cardiopulmonary insufficiency, although the surgery can also be completed laparoscopically, it is often time-consuming and laborious, with many risk factors, and it is still appropriate to open the surgery in transit.
It should be fully recognized that it is impossible for laparoscopy to completely replace open surgery in the future when the technology and equipment are well established. However, laparoscopy with wide range of exploration, clear image display for all to see, integrated diagnosis and treatment, minimally invasive and efficient, to a certain extent represents the rise and development of minimal trauma surgery, and undoubtedly has the vitality of the times and broad prospects.