MINIMALLY INVASIVE SURGERY - HISTORY
Dr. RAMKUMAR RAGHUPATHY*
G. Kuppuswamy Naidu Memorial Hospital, President Indian Association of Pediatric Surgeons (2004-2005), Coimbatore.*
Minimally invasive therapy for afflictions of the gastrointestinal tract date back to the time of Hippocrates, who described non-invasive remedies for conditions such as intestinal obstruction, rectal prolapse, and hemorrhoids. Hippocrates also detailed the use of the speculum, or primitive anoscope, for examining hemorrhoids. Early endoscopists were hampered by the lack of a satisfactory light source. Thus, until the nineteenth century, physicians relied on sunlight reflected by mirrors or focused through flasks of water. In the early 1800's physicians began using candles lamps for illumination; however, the idea of "a magic lantern into the human body" was for the most part scorned and ridiculed.

The first experimental laparoscopy was performed in Berlin in 1901 by the German surgeon Georg Kelling, who used a cystoscope to peer into the abdomen of dog after first insufflating it with air. Kelling was an early advocate of the ability of minimally invasive surgery to avoid unnecessary laparotomy and decrease hospital stays. The first human laparoscopy was performed in Sweden by Jacobeus in 1910 to investigate ascites. Diagnostic laparoscopy enjoyed some popularity in the early twentieth century, but early laparoscopists were limited by a lack of technology. The first laparoscopes had a light source at the distal end, and pneumoperitoneum was achieved by means of air insufflation through the scope. Initially, intra abdominal thermal injury and vascular injuries, posed the most significant problems. In 1929, Kalk advocated a second puncture site for the establishment of pneumoperitoneum, described several diagnostic and therapeutic laparoscopic procedures, and devised a sophisticated lens system. He has been called by some as the father of modern laparoscopic surgery. Fibre-optic technology and closed circuit video laparoscopy evolved in the 1950s. This development enabled surgeons to deliver more intense light with less heat, and allowed the participation of an assistant in the procedure. As a result, more sophisticated procedures could be undertaken, and the modality was embraced primarily by gynecologic surgeons. Kurt Semm in particular became a powerful advocate of laparoscopy and was responsible for the development of numerous laparoscopic instruments, including an automatic air insufflation device, electrocoagulator and an aspiration / irrigation system. In addition, he described techniques for laparoscopic tubal thermo coagulation, oophorectomy, and adhesiolysis and is credited with performing the first laparoscopic appendicectomy in 1983.

While the majority of general surgeons remained skeptical of laparoscopy, a few groups recognized its potential. Initially, however, only diagnostic procedures were considered. By 1982, the first laparoscopic liver biopsy had been reported. Meanwhile, surgeons in Chicago and Dundee were developing the technique of laparoscopic cholecystectomy in animal models. The first human laparoscopic cholecystectomy was performed by Mouret in France in 1987, and groups in the United States and the United Kingdom followed in 1988 and 1989, respectively. Soon afterward, the lay press applauded the new surgery, and popularity in the public domain culminated in patients demanding this Band-Aid surgery instead of traditional techniques.

This began the modern laparoscopic era. It had in a short time earned a unique niche in general and gastrointestinal surgery. Virtually no abdominal organ is exempted from laparoscopic techniques. The application of more sophisticated technology will no doubt yield more refinements and applications. Thoracic cavity has been once such Diaphragmatic Hernia, Eventration of diaphragm, mediastinal node biopsy, mediastinal cyst excision are but a few to name. In fact, recently six neonates had been thoracically operated on for Esophageal Atresia with Tracheo - Esophageal fistula.

Robotic surgery has come to stay though prohibitively expensive. Third degeneration Robotics are already in existence. Telemedicine from this juncture is but a stone's throw away. The resources and technology currently used to explore outer space has been better utilized resolving the problems of inner space of the human cavity, to shine a light on a surgical technique which has languished too long in the dark.
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