Minimally invasive surgery
It has always been surgeons‘ and patients‘ dream to see through the body surface into its interior and to perform gentle procedures in there. First endoscopes were constructed already in the second half of the 19th century, but the quick development of endoscopic surgery was possible only after the advances in technology had created the necessary conditions. Optics and video systems had to become available, as well as instruments adapted to this special purpose. In 1989 the first gallbladder removal in Germany was carried out laparoscopically; then a sensation, today - 25 years later - everyday routine.
Since then, the endoscopic technique continued to evolve and there is hardly any surgery that would not be possible (at least in theory) through a keyhole.
However, laparoscopic surgery is still a proper operation. The only difference is the gentle little access through the abdominal wall, while the operation essentially resembles conventional procedures. The advantages are clearly evident:
- Less pain
- Faster recovery
- Shorter incapacity for work
- Reduced chances of wound infections
- Less scarring
- For certain operations also more accurate feasibility
- Better appearance
There is no natural access to the abdominal cavity, so it must be cut in order to get inside.
During the intervention the abdominal cavity is inflated with CO2 gas, to receive space in order to see and work.
A video camera is connected to the optics, which is introduced into the abdominal cavity, that transfers the image to a screen. We have state-of-the-art "high definition" video technology (HDTV), which guarantees optimal representation and thus makes complicated operations possible.
The instruments are introduced via other small cuts. For optimal vision and working, the accesses must be separated from the operational area and from each other, e.g. on the other side of the abdomen. Nowadays accesses are done though natural body openings, e.g. mouth, vagina or anus. These methods are not yet ready for clinical use, because many problems (closure of the intestinal opening, instruments) are still unsolved. We are now carrying out operations such as e.g. gall bladder removal, only through a small incision in the navel ("single port laparoscopy = SILS").
The instruments are adapted for this specific type of surgery, but correspond in principle to the classical instruments. For the seam connection (anastomosis), but also for the severing and closing of the stomach and intestine in an operation, there are special stapling devices, that can also be angled.
For the safe closure of blood vessels or bile ducts, there are clips, which are placed with special forceps. Safety of operation depends on the rapid separation of the tissue avoiding bleeding. The high-frequency vessel sealing instrument Ligasure® is indispensable for us. The tissue, even smaller blood vessels, is first welded and then severed with a built-in knife. Despite the help of these apparatus, the endoscopic surgeon still needs to sew with a needle and thread in certain operations (for example diaphragmatic hernia, gastric bypass), inside the body under the camera light, which requires a very special prestidigitation.
Plastic nets are used to reinforce the abdominal wall during hernia operations. In the case of inguinal hernias, the net is placed in front of the abdomen, in the case of abdominal hernia it is usually placed below the abdomen. To prevent adhesions, these nets have special coating. Until the net has grown into the abdominal wall, it is held by dissolvable pins.
Sometimes, the removed organ (e.g., the lien) may be so small that it can be removed from the body without an abdominal incision despite its original size. In most cases, however, this procedure is impossible, also because this way a cellural assay, e.g. in tumors, is no longer possible. For the recovery (for example of the intestine) a small abdominal section must be done, often in the middle of the abdomen above the pelvic bone.
Despite all these techniques not every procedure is possible laparoscopically. Sometimes that fact is revealed during the operation, e.g. because of adhesions, severe inflammation or other difficulties. Safety is always a priority here.