The development of laparoscopy, like all new medical technologies, was difficult and took a long time. The origin of endoscopy can be traced back to BC. As early as the Hippocrates period in 460-375 BC, people described using a speculum to look into the rectum. At that time, people were eager to see the various organs and tissues in the dark body cavity in order to make a clear diagnosis of the disease.
Laparoscope is a type of endoscope used to directly observe the organs in the abdominal cavity. Gynecological laparoscopy is used to diagnose and treat certain gynecological diseases. Gynecological laparoscopy technology is constantly developing and progressing. It has gone through three stages: ① pelvicoscopy, i.e., posterior concave laparoscopy; ② diagnostic laparoscopy; ③ surgical laparoscopy.
(I) Pelvicoscopy (posterior concave laparoscopy)
In 1901, at the German Biomedical Conference, Georg Kelling reported on the use of cystoscopy to examine the internal organs of a dog after instilling gas into the abdominal cavity. In the same year, Russian gynecologist D. 0. Ott also cut the posterior vaginal fornix under the illumination of the forehead mirror and inserted a cystoscope to examine the abdominal cavity of a woman. This was the first pelvicoscopy, and the method of intraperitoneal inflation that is still used today originated from this. However, during the operation, the patient needs to lie on his knees and chest, and the injected air can push the intestines and expose the pelvic cavity. This position is not easily accepted by patients, so its use is subject to certain restrictions.
(II) Diagnostic laparoscopy
In 1910, Jacobaeus H. C successfully examined 3 patients with a cystoscope, and he named this technology laparoscopy. During the operation, a cannula puncture needle was inserted into the abdominal wall and air was introduced into the abdominal cavity through the cannula, and then a cystoscope was placed for examination. At that time, most physicians used laparoscopes.
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In 1944, Raoul Palmer of France officially applied laparoscopy to the field of gynecology and examined a large number of infertile patients. During the operation, the head was low and the hips were high in the supine position (1-1), and it was emphasized that the abdominal pressure should be monitored. In the next 20 years, Europe mostly used laparoscopy, but the United States tended to still use posterior concave endoscopes. Palmer R continued to practice and developed laparoscopic operation routines. In 1963, he published a monograph that systematically introduced laparoscopic operation routines. In 1963, he published a monograph that systematically introduced some relatively simple operations under laparoscopy, such as fallopian tube ventilation and fluid perfusion; simple organ adhesion separation; cyst puncture and aspiration; endometriosis foci electrocoagulation and electrocautery; biopsy; fallopian tube electrosterilization, etc. Although many doctors have made unremitting efforts for the popularization and development of laparoscopy, until the 1960s, there were still very few obstetricians and gynecologists in Europe who used endoscopes, and most parts of the world did not understand this technology at all. In the United States, it was also rejected by most university obstetrics and gynecology departments.
There was a turnaround after the 1970s. Laparoscopy suddenly developed rapidly in Europe and North America, which was mainly based on two reasons: ① Because of the improvement of instruments. Major advances in medicine are often closely related to the improvement of instruments. Due to the invention of cold light sources and fiberglass endoscopes at that time, the advent of Semm's artificial pneumoperitoneum monitoring device, the automatic pneumoperitoneum machine, and the further improvement of electrocoagulation and electrocautery, the safety of artificial pneumoperitoneum was increased, avoiding the burns of the intestinal tube by hot incandescent bulbs. ② At that time, the world's population was booming, and countermeasures were urgently needed. Obstetricians and gynecologists shouldered a heavy responsibility and had to find a safe and acceptable sterilization method immediately. In this way, laparoscopes were used to solve this urgent problem. Because it is less invasive and does not require laparotomy, it can be accepted by both patients and gynecologists.
Some people describe the explosive spread and promotion of laparoscopy in the United States at that time. In 1972, the Association of Gynecological Laparoscopy (AAGL) was established in the United States with Phillips as the chairman. By 1984, 13 laparoscopic conferences had been held in the United States, with 51 countries participating and more than 4,000 members. In just a few years, statistics on millions of laparoscopic sterilizations were published. At that time, about 95% of laparoscopic operations in the United States were used for tubal sterilization.
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Although gynecological laparoscopy is developing vigorously, its application still has certain limitations. First, the surgeon is operating in a forced position, the intraoperative field of view is small, and the physical exertion is considerable. In the 1960s-1980s, laparoscopy was performed by the surgeon alone under the direct vision of the eyepiece (Figure 1-2), and the assistants and visitors could only directly view the surgical field through the teaching mirror (Figure 1-3, Figure 1-4). The surgeon is a passive and restricted position stander, bending over to observe the surgical field through the eyepiece, and it is difficult to operate with ease. Secondly, with the increase in the types and difficulty of surgery, when encountering more difficult hemostasis and accidental organ damage, they are often helpless, because there are not many means of treatment at that time, and the grasp is not great, and often need to be transferred to open surgery for treatment. Therefore, until the mid-1980s, gynecological laparoscopy was limited to diagnosis and the above-mentioned surgery with lower risks, and still belonged to the category of diagnostic laparoscopy.
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(III) Surgical laparoscopy
The application of television camera systems in laparoscopy and accurate and effective hemostasis techniques have enabled laparoscopy to move from diagnosis to surgery.
In the late 1970s, some people tried to use cameras for laparoscopy. Dr. Nezhat of the United States was an active advocate. He himself began to use television laparoscopy for surgery in 1980. However, because the camera was heavy and the resolution of the monitor was low, there were still not many users in the early 1980s. With the development of electronic industry technology, the miniaturization of cameras, the advent of micro cameras, and the emergence of high-resolution monitors, it was not until the mid-1980s that television laparoscopy technology like today was available. The surgical field is clearly displayed on the screen, the field of vision is expanded, and many doctors can see the surgical process at the same time, which is conducive to technical exchanges and discussions, and also facilitates the cooperation of assistants and the assistance of anesthesiologists (Figures 1-5).
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In the 1980s, Professor Kurt Semm of the University of Kiel in Germany made great contributions to gynecological laparoscopic surgery. He constantly explored accurate and effective methods of hemostasis under the microscope and invented many newer surgical instruments and equipment as well as new technologies. Such as laparoscopic suturing instruments, internal coagulation devices, flushing pumps, various forceps, scissors, tissue crushers, cutters, etc. Now there are various means of laparoscopic hemostasis, including monopolar electrocoagulation, bipolar electrocoagulation, thermal coagulation, ligation loops and sliding knot technology, sliding knot internal ligation with extracavitary knotting, internal suturing technology with intracavitary or extracavitary knotting, titanium clips, staplers, etc. Technological advances have made it possible to complete more complex operations under the microscope. In 1988, Reich H performed the first laparoscopic total hysterectomy, which was an important milestone in gynecological laparoscopic surgery. In the late 1980s, the scope of gynecological surgery has expanded. Ovarian teratoma and adnexal cyst surgery, salpingostomy and adhesion separation for infertility, endoscopic conservative surgery and salpingectomy for ectopic pregnancy, etc., have become unanimously recognized surgical indications and have begun to expand into the field of general surgery.
With the expansion of surgical types, the increase in difficulty and the lack of experience of beginners in the popularization process, surgical complications have increased. However, the improvement of endoscopic surgical techniques, the accumulation of surgeons' experience and the success of repairing ureteral and intestinal injuries have enabled laparoscopic surgery to develop to the stage of organ function reconstruction, enhancing the emergency response and control of various complications.
Now, gynecological surgeries that can be performed by traditional laparotomy are all completed by laparoscopy, even extensive hysterectomy, radical hysterectomy for early cervical cancer, pelvic lymph node removal, para-aortic lymph node resection, etc. At present, 70% of gynecological laparotomies in some European and American hospitals with advanced endoscopic technology have been replaced by laparoscopic surgery.
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II. Development and current status of gynecological laparoscopic surgery in China
my country began to introduce laparoscopy in gynecology in the 1960s. However, due to the light source being electric lamps, the effect was not satisfactory and could not be promoted. Since 1979, Jordan Phillips, president of the American Laparoscopy Society, has led his team to my country more than 10 times, giving lectures and performing surgeries in many major cities in China, which has promoted and promoted the development of laparoscopy in China.
Before the 1990s, it was a stage dominated by diagnosis, including ovarian biopsy, small cyst puncture, and fallopian tube sterilization. After the 1990s, laparoscopic technology developed rapidly and entered the stage of endoscopic surgery. In recent years, not only medical schools, provincial and municipal hospitals, but even some county and town hospitals have developed laparoscopic technology. The vast majority of operations are for benign lesions, and some people have tried to use it to replace the second laparotomy for malignant tumors.
At present, both domestic and foreign gynecological laparoscopic surgeries are classified according to the complexity, from easy to difficult. The editorial committee of the Chinese Journal of Obstetrics and Gynecology organized relevant experts to discuss in 1997 and proposed a draft of the gynecological laparoscopic operation specification. This has become a routine regulation that everyone agrees on.
In recent years, most hospitals in my country that have performed laparoscopic surgery have reached the level 2 level, and few can skillfully complete level 3 surgery, and there are few reports of completing level 4 surgery. At present, more and more hospitals are preparing to carry out or are just starting.
III. Comparison of the advantages and disadvantages of laparoscopic surgery and traditional surgery
The outstanding advantages of laparoscopic surgery are small surgical trauma, less pain for patients, fast postoperative recovery, early resumption of work, and can achieve the same or even better therapeutic effects as traditional laparotomy.
The recovery of gastrointestinal motility after laparoscopic surgery is significantly faster than that after open surgery. Some people used gastrointestinal manometry to record gastrointestinal migration motility complex waves to compare the changes in gastrointestinal motility after laparoscopic cholecystectomy and open cholecystectomy. The results showed that both surgeries eliminated normal gastrointestinal motility. The time for gastrointestinal migration complex waves to return to normal in the endoscopic resection group and the laparotomy group was 14.3h±2.5h and 38.7h±4.2h after surgery, respectively (P<0.01), and the time for anal exhaust was 23.3h±6.1h and 43.4h±7.2h after surgery, respectively (P<0.01).
The lesser effect of endoscopic surgery on gastrointestinal function may be related to its small abdominal wall incision, less intestinal manipulation, less postoperative wound pain and less traumatic response of the body.
However, laparoscopic surgery has certain limitations and potential risks in its application, mainly in the following aspects:
(I) The application scope of laparoscopic surgery is narrower than that of open surgery
For example, patients with cardiovascular diseases, pulmonary insufficiency, intestinal obstruction and diffuse peritonitis, blood system diseases, abdominal masses larger than the 4-month uterus, or previous abdominal surgery history and extensive intra-abdominal adhesions are all contraindicated for laparoscopic surgery. Whether malignant surgery can be performed under a microscope is still controversial among clinicians.
(II) There is a certain percentage of conversion to laparotomy in laparoscopic surgery
During laparoscopic surgery, there is always the possibility of conversion to laparotomy due to the lack of experience of the surgeon, the complexity of the lesion, or problems with the performance of the equipment or instruments. This is also one of the issues that medical staff should explain to the patient's family before surgery.
(III) The incidence of complications is higher when experience is insufficient
Many complications are not present in laparotomy, such as complications related to pneumoperitoneum, such as subcutaneous emphysema, pneumothorax, gas embolism, hypercapnia, etc. There are also some that rarely occur in laparotomy: abdominal wall puncture damages the abdominal aorta, left and right iliac arteries and veins, and internal organs, etc. If these are not discovered in time and treated as soon as possible, they will endanger the patient's life. In addition, common complications of laparotomy can also occur in laparoscopic surgery, such as damage to adjacent organs, bleeding, infection, etc.
It is particularly important to point out the rare and serious complications after laparoscopic surgery. Such as intestinal ischemia, bilateral adrenal hemorrhage and acute adrenal crisis. These are new problems that have only been recognized in recent years as the number of surgeries has increased.
Of course, with the continuous improvement of technology and the further improvement of equipment and instruments, the incidence of complications will decrease significantly.
IV. Key issues in the promotion of laparoscopic technology
The types of laparoscopic surgeries are gradually increasing, and the scope of application is expanding. This technology will be promoted in more hospitals. However, at this stage, laparoscopic surgery has more complications than laparotomy, which has a lot to do with the skills and experience of the surgeon. In particular, many laparoscopic surgeons in China currently lack formal training, and there is a lack of recognized standards for the evaluation of surgical quality. Moreover, as a new branch of discipline, laparoscopic surgery has not yet been fully standardized. A new technology may also encounter problems that have never been discovered during its implementation. How to master the indications, prevent and reduce the occurrence of complications has been put on the agenda without delay. In order for laparoscopy to develop smoothly in the future, two issues must be paid attention to:
(I) Standardizing laparoscopic operations
A complete set of surgical routines should be formulated, and surgeons should be required to follow the operation.
Laparoscopic surgeons must have experience in laparotomy and be attending physicians in this specialty. They must have at least 3 years of qualifications as attending physicians and must be proficient in the techniques of diagnostic laparoscopic surgery before they can perform laparoscopic treatment surgery.
The first step of laparoscopic surgery is to make a clear diagnosis, which requires rich professional clinical experience. The second step is to fully estimate whether the surgery can be completed under the microscope, and try to avoid switching to laparotomy due to the difficulty of the surgery. Personal experience is very important at this time. Do not violate surgical routines, expand the scope of indications, or overestimate your own abilities and perform surgeries that are beyond your ability, otherwise the incidence of serious traumatic complications will increase. The third step is to perform laparoscopic surgery according to operating procedures.
(II) Establish a sound training system for surgeons
Even experienced doctors in this specialty must undergo systematic training. They must understand and learn to use the equipment, instruments, and various accessories of the laparoscope, be familiar with the operating routines of laparoscopic surgery, and must remember to use this as a criterion for performing the surgery. Only through training can we improve laparoscopic recognition, surgical agility, and coordination, accuracy, and safety of movements.
Doctors receiving training should first be tested by experienced doctors for their ability to diagnose under the microscope. Before performing laparoscopic suturing, knotting and other surgical operations, they should do sufficient preoperative training and practice on the trainer first. They should operate accurately and skillfully, and have the skills to operate with both hands skillfully before going to the operating table. They should be assistants first, and find more opportunities to observe other people's operations carefully and watch surgical videotapes, and then perform operations under the guidance of senior doctors. They can perform laparoscopic surgery independently only after they have enough experience and have passed the assessment of their operating skills. From easy to difficult, start with Class I surgery, and gradually transition to complex surgery after learning simple operations. A sound training system should be established, and training classes of different levels should be divided according to Class IV surgery. Complex surgery should have special training.
V. New topics for the future development of laparoscopy
The further popularization of gynecological laparoscopic surgery is the general trend. Its position in the field of gynecology is becoming increasingly important, and it has a very broad prospect. In the future, this technology will continue to develop and continue to improve. At present, many scholars are studying and exploring further topics, mainly including the following aspects:
(I) B-mode ultrasound examination during laparoscopy
Laparoscopy is difficult or cannot make valuable diagnosis for the internal part of the abdominal solid organs, retroperitoneal organs, gastrointestinal mucosal lesions and problems covered by adhesions.
