REVIEW OF LITERATURE

. .

HISTORY

Endoscopic .surgery .is .rapidly .becoming .a .popular .alternative .to .traditional .oper

ative .procedures .for .a .variety .of .diseases.

The .Arabian physician

. . Abulkasim . (936-

1013) .is .often .credited .with .being .the .first .to .use .reflected .light .to .inspect .an .internal .or

gan, .the .cervix. .Later .instruments .for .viewing .nasal .recesses .and .urinary .bladder .devel

oped .with .the .aid .of .artificial .lights .and .mirrors.

The .first .endoscopes .incorporated .an .optical .viewing .component .using .a .glowi

ng .platinum .wire .at .one .end .as .a .light .source. .Usefulness .of .photography .to .record .the .e

ndoscopic .findings .was .recognized .early .and .by .1874, .Stem .modified .existing .cameras .

to .record .images .of .bladder .pathology.

In .1901 .Kelling .used .cystoscope .to .inspect .peritoneal .cavity .of .a .dog .after .insuf

flation .of .air. .He .then .coined .the .term .celioscopy .to .describe .this .technique. .The .first .re

port .of .using .this .procedure .in .man .was .by .Swedish .physician .Jacobaeus .in .1990. .Pneu

moperitoneum .was .used .prior .to .insertion .of .the .first .cannula. .Goetz .and .Veater .Veress .

developed .an .insufflation .needle .for .safe .introduction .of .gas .into .the .abdomen.

In .1946 .Becker .introduced .an .alternative .method .of .placing .laparoscope .into .ab

dominal .cavity .in .an .attempt .to .minimize .complications. .He .inserted .the .scope .into .the .

pelvis . through the

. . cul-de-

sac .and .named .the .procedure .as .culdoscopy. .For .this .the .patient .was .placed .in .knee .che

st .position.
 In .1964 .Kurt .Semm .in .Keil, .Germany .developed .an .automatic .insufflation .devi

ce .that .monitored .abdominal .pressure .and .gas .flow. .Development .of .rod .lens .system .in .

1966 .was .by .British .optical .physicist .Hopkins. .His .design .resulted .in .improved .image .

brightness .and .clarity. .These .same .principles .are .still .used .in .laparoscopes .today. .In .19

86 .there .was .a .new .development .in .which .computer .chip .TV .camera .was .attached .to .la

paroscope.

This .made .the .beginning .for .the .era .of .video .guided .surgery .in .which .laparosco

pic-

guided .surgical .techniques .could .be .used .for .more .complicated .gastrointestinal .proced

ures. .Video .imaging .has .also .facilitated .the .education .of .other .surgeons .and .house .staff

. .In .addition .videotapes .can .now .be .used .to .document .the .diagnostic .or .operative .proce

dure. .Introduction .of .laparoscopy .in .general .surgery .was .made .in .an .attempt .to .improv

e .on .the .diagnosis .of .acute .appendicitis. .First .laparoscopic .procedure .performed .by .gen

eral .surgeons .appears .to .have .been .liver .biopsies .under .direct .vision. .Warshaw, .Jepper .

and .Shipley .utilized .laparoscopy .in .1986 .for .staging .of .pancreatic .carcinoma .and .demo

nstrated .an .overall .accuracy .rate .of .95%.

 EQUIPMENT AND INSTRUMENTATION
. .

The .laparoscopic .instruments .necessary .to .perform .surgery .are .expensive. .Som

e .key .factors .should .be .considered .when .planning .to .purchase .the .instruments. .Ensure .t

hat .all .instruments .are .compatible .and .fits .into .the .cannulae .and .various .cables .will .con

nect .to .one .another. .Back- .up .service .and .technical .support .should .also .be .considered.6

VIDEO .IMAGING .SYSTEMS

The .high .quality .video .systems .that .allow .surgeons .to .work .together .while .watc

hing .a .video .monitor .have .been .the .most .important .technological .advance .in .the .laparo

scopic .field.

The .basic .components .require .for .video .laparoscopy .include:

1. Light .source

2. Fibre .optic .light .guide .cable

3. Telescope

4. Video .camera .system

5. Video .monitor

6. Video .recorder

As .laparoscopic .surgery .entails .simultaneous .vision .via .a .television .camera .on .

a .monitor .screen, .usually .with .recording .of .the .operative .procedure, .either .a .Xenon .ligh

t . source . or . a 250-
.

watt .Halogen .lamp .is .required. .A .Storz .light .source, .which .has .a .dual .manual .and .video

. function .with .a .self- .adjusting .light .intensity, .can .be .used. .The .term .‘cold’ .light .is .a .mis

nomer .since .the .tip .of .the .light .conducting .cable .could .easily .ignite .linen .drapes. .Moder
n .light .sources .are .equipped .with .thermal .shield .that .reduces .the .amount .of .heat .transm

itted .through .the .cable .to .minimize .the .risk .of .burns .internally.

A .fibre .optic .light .guide .cable, .which .is .5mm .thick .and .225cm .long, .is .desirable

. .Thick .cable .carries .more .light. .Long .cable .is .more .convenient .and .less .likely .to .be .stre

tched .and .damaged. .The .cable .should .be .handled .with .utmost .care, .after .all .it .is .glass. .It

. should .not .be .bent .sharply .anywhere .along .its .entire .length .either .during .use .or .when .st

ored.

Most .commonly .used .telescopes .are .rigid .instruments .that .employ .Hopkins .rod .

lens .system .of .optics. .The .basic .components .of .rod .lens .system .include .a .series .of .quart

z .rod .lenses .and .image .reversal .system, .optical .fibers .for .transmission .of .light, .an .objec

tive .lens .and .an .eyepiece. .Rigid .laparoscopes .come .in .sizes .ranging .from .3mm .to .10m

m .in .diameter .and .a .variety .of .viewing .lenses. .The .0 .degree .or

. end/forward .viewing .laparoscope .is .easiest .to .use .and .its .use .results .in .least .amount .of .

image distortion
. as
. well
. . as . the brightest
. image.
. Angled
. . scopes .

(30,40 .degree) .provide .greater .versatility .by .operator .to .look .around .corners .and .over .s

urface .of .solid .structures. .Recently .flexible .laparoscopes .have .been .developed .using .fi

bre optic
. . bundles . for visualization
. . and . that provides
. .ever-

greater .flexibility .in .the .viewing .angle.

Video .Camera .System .is .composed .of .a .‘chip .camera’, .controller, .a .high- .resol

ution .video .monitor .and .a .videotape .recorder. .A .video .printer .is .optional. .The .video .ca

meras, .which .are .used .for .video .endoscopy, .are .specially .modified .for .endoscopic .use. .

These .cameras .are .available .in .1.25 .and .1.67 .cm .diameters .and .are .based .on .either .a .sin

gle .or .a .triple .chip .design. .The .single .chip .cameras .can .provide .450 .lines .of .horizontal .r

esolution. .The .newer .triple .chip .design .provides .over .700 .lines .of .horizontal .resolution,
. but .is .more .expensive. .Cameras, .which .attach .directly .to .the .laparoscope, .are .preferabl

e .to .those, .which .require .additional .couplings. .Focusing .is .critical .and .should .be .easy .t

o .achieve.

Automatic .white .balance .and .color .bars .are .essential .features. .The .white .balanc

e .automatically .optimizes .the .appearance .of .the .color .image. .The .color .bars .permit .the .

surgeon .to .adjust .the .monitor .against .a .known .standard. .The .camera .should .be .steriliza

ble .and have

. a
. .sufficiently long
. cord
. .

(5m) .to .permit .easy .placement .of .the .camera .controller.

The .video .monitor .should .be .ideally .recorded .on .videotape .for .subsequent .revie

w. .This .permits .the .surgeon .to .assess .his .own .technique .and .also .provides .an .accurate, .

permanent .documentation .of .the .procedure.

INSTRUMENTS .FOR .EXPOSURE .AND .MANIPULATION

INSUFFLATOR

Laparoscopic .surgery .demands .uniform .abdominal .distension, .which .is .always .

maintained .at .certain .pre-set .safe .limits .of .intra .abdominal .pressure .(12-

14mmHg). . Lost gas

. should
. be
. . rapidly . replaced so
. . that . the intra-
.

abdominal .pressure .remains .constant. .Electronically .controlled .insufflators .are .availabl

e .which .are .capable .of .delivering .flow .rates .of .at .least .6 .liters/min, .preferably .8-

10

. liters/min. .The .gas .used .to .obtain .pneumoperitoneum .is .also .important. .Atmospheric .ai

r .is .not .suitable .because .it .will .increase .the .risk .of .air .embolism .during .prolonged .surge

ry. .Nitrous .oxide .could .be .absorbed .in .variable .quantity .creating .problems .for .the .anae

sthetist. .Hence .the .most .suitable .gas .used .is .Carbon .dioxide, .as .it .is .easily .available, .no

n-combustible, .cheap .and .soluble .in .plasma.