From microsurgery to laparoscopic surgery: a progress

Transcription

1 FERTILITY AND STERILITY Copyright 1995 American Society for Reproductive Medicine Printed on acid-free paper in U. s. A. From microsurgery to laparoscopic surgery: a progress Victor Gomel, M.D. Professor Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada Received November 7, Excerpted from a presentation at the International Meeting on Gynecological Surgical Endoscopy, Chia Laguna, Cagliari, Italy, September 7 to 10, Reprint requests: Victor Gomel, M.D., Department of Obstetrics and Gynecology, University of British Columbia, Room 2H30, 4490 Oak Street, Vancouver, British Columbia, Canada V6H 3V5 (FAX: ). The opinions and commentary expressed in Editor's Corner articles are solely those of the author. Its publication does not imply endorsement by the Editor or the American Society for Reproductive Medicine. 464 Gomel Editor's corner The title of the editorial "From Microsurgery to Laparoscopic Surgery: A Progress" is an affirmative statement which implies that microsurgery has been supplanted by laparoscopic surgery and that this change reflects progress. Is this truly the case, and for that matter are the two disciplines "microsurgery" and "laparoscopic surgery" even related? These questions provide the opportunity to review the two disciplines from an historic perspective, summarize their evolution, discuss their principles, which so profoundly have influenced our specialty, and consider outcomes. Microsurgery was introduced into gynecology, primarily to improve the outcome of infertility surgery (1-3). The results yielded by conventional surgery were disappointing, and the rate of tubal infertility was increasing significantly due to the incidence of sexually transmitted diseases, which had reached almost epidemic proportions. Also, it had been recognized that adhesions and structural distortion caused by prior pelvic surgery were important causes of female infertility and pelvic pain (2). When compared with conventional surgery, the use of microsurgery resulted in the doubling or more than doubling of the success rates associated with salpingostomy, correction of pathological cornual occlusion, and tubo-tubal anastomosis (2, 3). Many equate microsurgery with surgery under magnification. In fact magnification is only a single facet of microsurgery, which embraces a broader concept of tissue care, designed to minimize tissue damage. Magnification simply permits avoidance and recognition of injury, prompt visualization of abnormal changes, and the practice of a delicate surgical technique using fine instruments and suture materials. Thus, microsurgery is a surgical attitude as much as a technique. The introduction of microsurgery into gynecology has had greater implications than simple improvement in the outcome of fertility operations. It created a great awareness of the effects of peritoneal trauma, postoperative adhesions, and the recognition of the need for conservation. The assimilation of microsurgical principles within our specialty made the gynecologist a more delicate surgeon, careful in tissue handling and tissue care. This, I believe was the major impact of microsurgery in gynecology (2, 3). What about laparoscopy? By the end of the first decade of the 20th century the fundamental principles of diagnostic laparoscopy had been established: Kelling (1901) distended the peritoneal cavity with gas (room air), Jacobeous (1910) used a trocar and cannula for the introduction of the telescope, and Nordentoft (1912) demonstrated the

2 value of placing the patient in the Trendelenburg position (4). Raoul Pamer was largely responsible for the wider acceptance of laparoscopy in gynecological practice. By as early as 1946 he had collected over 250 personal cases. Although originally introduced as a diagnostic tool, surprisingly, the wide dissemination of laparoscopy in North America, in the early '70s, was due to its application to perform female sterilization, a procedure that until then required laparotomy or colpotomy (4). Except in some pioneering centers, the use oflaparoscopy as an access route for procedures other than tubal sterilization, biopsies, puncture and aspiration of ovarian cysts, and retrieval of foreign bodies' lagged. Prominent among these centers were Kiel in Germany and Vancouver in Canada. In 1979 Semm and co-workers reported oophorectomy, salpingectomy, and adnexectomy (4). A ligation technique using a modified Roeder's loop was introduced by the Kiel group who also produced several new laparoscopic instruments through Semm's own company. In 1973 Gomel presented his initial experience with operative laparoscopy and demonstrated the value and safety of this approach for salpingo-ovariolysis, fimbrioplasty, and salpingostomy, and tubal pregnancy managed by segmental excision (4). By the end ofthe decade the CO 2 laser was being used in Clermont-Ferrand where a prominent endoscopic team was being established by Bruhat (4). Thus, by the end ofthe 1970s the principies of operative laparoscopy using electrical (unipolar and bipolar), thermal and laser energy, sharp and blunt dissection, ligation and suturing techniques already were established and the value and advantages of this approach for several gynecologic procedures recognized. Microsurgery is a surgical philosophy, a delicate surgical approach designed to minimize peritoneal trauma and tissue disruption. On the other hand, laparoscopy is a mode of access into the peritoneal cavity as are laparotomy or colpotomy. Microsurgery and laparoscopy are two different entities. It must be acknowledged that laparoscopic access yields several important advantages when a laparotomy is avoided, provided the specific procedure undertaken is completed successfully. In such circumstances the elimination of a sizeable laparotomy incision results in less postoperative discomfort, reduced requirements for postoperative analgesia, a shorter convalescence, and quicker return to normal activity (4, 5). Operative laparoscopy has been termed "minimally invasive surgery." This is a misnomer. Adnexectomy or hysterectomy are equally invasive ir- respective of the approach. A more realistic term for the laparoscopic approach is "minimal access surgery," since only the access route has been minimized. The term minimally invasive surgery also creates the perception that the operation is minor. This may sway the decision in favor of an intervention in the face of doubtful indications. It is the perception of many that the laparoscopic approach results in less postoperative adhesion formation. This is a misconception because a given peritoneal trauma will produce the same degree of inflammatory response irrespective of the mode of access. This was demonstrated clearly in an animal experiment carried out in our department (6). Rats were assigned, in a random fashion, to laparotomy or laparoscopy. The left uterine horn of each animal was injured using laparoscopic scissors by placing three incisions, 1 cm apart, through the serosa and supraficial muscularis. A second-look laparotomy was performed 2 weeks after the initial procedure. There was no difference in the nature of the resultant adhesions; however, the surface area involved in adhesions was surprisingly greater in the laparoscopy group (8.88 versus 4.29 mm 2 ), but this difference did not reach statistical significance (6). The limitations of operative laparoscopy in performing certain procedures with a satisfactory degree of precision and delicacy make it important to incorporate microsurgical principles in laparoscopic procedures (7) so that the advantage of minimal access are not negated by the occurrence of greater tissue trauma. There are microsurgical advantages inherent to laparoscopic access. Operating within a closed peritoneal cavity largely prevents desiccation of the peritoneal surfaces. Working within a closed environment eliminates the need to use packs and prevents the introduction of foreign materials such as lint and talcum powder. The laparoscope provides a degree of magnification. In addition, it is possible to bring the distal end of the laparoscope close to the area of interest and achieve excellent visibility and illumination. It is possible to carry out intraoperative irrigation of tissues to keep them moistened and expose any bleeding vessels. Furthermore, the pressure effect of the pneumoperitoneum diminishes venous oozing and permits spontaneous coagulation of minor vessels to occur. The use of fine electrodes to achieve precise electro surgical hemostasis is also possible. Like microsurgery, laparoscopic procedures are performed with few instruments, but these laparoscopic instruments still require further refinement (4). There are limitations to the laparoscopic ap- Gomel Editor's corner 465

3 proach. The length of the instruments and the cannula in the abdominal wall acting as a fulcrum increase the force applied to tissue by the working end of the instruments. This may generate undue trauma. Laparoscopic suturing is awkward and more time consuming. The use of fine sutures is difficult, which frequently leads to the use of larger material and the application of fewer sutures. Hand-eye coordination is somewhat hampered by the lack of stereoscopic vision. This and the less precise instruments in use hinder the surgeon's ability to handle tissues with the same degree of delicacy and accuracy that can be achieved by microsurgery. Many of these limitations are simply technical problems that undoubtedly will be overcome (4, 7). Some authors, including ourselves, have questioned the performance of certain procedures by laparoscopic access before thorough evaluation of the results. In an address "Operative Laparoscopy: Time for Acceptance" to the American Fertility Society Annual Meeting in 1987, I said: "Although appropriate training and instrumentation render these procedures technically possible, they must be evaluated as to their therapeutic value, the benefits and risks to the patient, the length of the operating time, and complications" (5). In an editorial published in Obstetrics and Gynecology in 1992 Pitkin raised the same concerns. Some comparisons and evaluations have already been made. The efficacy and safety of the laparoscopic approach was first shown with procedures designed to correct distal tubal occlusion. The results yielded by laparoscopic salpingo-ovariolysis and fimbrioplasty were similar to those obtained by microsurgical techniques (2-5, 7). The intrauterine pregnancy rates (PRs) were under 60% and under 50%, respectively. With laparoscopic salpingostomy the reported intrauterine PR of approximately 25% appears to be somewhat inferior to that yielded by microsurgery (2,4,7-9). However, for the majority of patients the laparoscopic approach, which can be effected at the same time as the diagnostic laparoscopy, while offering a marginally reduced likelihood of successful outcome, has distinct advantages because of the decreased costs and the avoidance of a second procedure (10). Although it is possible to perform tubo-tubal anastomosis by laparoscopic access, the reported results have been much inferior to those yielded by microsurgery (11). Since 1986 we have modified our microsurgical technique and perform such procedures through a mini-laparotomy incision (12). Before and after the operation the site of the incision is infiltrated with a long-acting local anesthetic agent. Once the incision has been closed a regional nerve block is established. Because of the smaller incision, the local anesthetic and minimal bowel manipulation, patients require only small amounts of postoperative systemic analgesics. These patients are admitted on the same day for their surgery and are discharged and return to normal activity almost as rapidly as those who have had their procedures performed laparoscopically (12). Although we are enthusiastic proponents of laparoscopic surgery, we do not let this enthusiasm blind us to the possibility that some procedures may still be performed better by improvements in the traditional methods. The efficacy and safety of the laparoscopic approach has also been demonstrated in the surgical treatment oftubal pregnancy. In a study of216 consecutive tubal pregnancies, we found the operating time and the amount of postoperative analgesia to be significantly less with patients treated by laparoscopy compared with those treated by laparotomy. There was no difference in rates of post operative morbidity and retained trophoblast between the two groups (13). The subsequent fertility outcome was similar in both groups (14). Other studies have confirmed these findings and also demonstrated a saving of health care costs of approximately $1500 per patient (15). In addition, the patients usually returned to full activity within 1 week of the surgery. There have been enormous advances in other laparoscopic surgical techniques in the last decade. It would take less space to list the gynecologic procedures that cannot be performed laparoscopically than those that can. The future will be charted by the coming together of forces internal and external to our discipline (4). The external forces include [1] the rate of technological change, [2] the effect of costs, [3] the influence of regulatory bodies, and [4] the way in which consumer pressure can influence subtly or not so subtly medical practice. The internal forces include [1] the innate drive of the innovator who will "push the envelope." (Even 10 years ago the concept of laparoscopic hysterectomy was inconceivable.) [2] The "me too effect"; once a procedure has been described by an innovator, the practicing gynecologist feels pressure to introduce it into daily practice and [3] the willingness to appraise critically the outcome of any new technique (4). Only some of these factors will be discussed here. Any critical appraisal must consider the following questions. Have th-: indications been developed 466 Gomel Editor's corner

4 properly? Does the rate of complications compare favorably with those yielded by more traditional techniques? Is the procedure effective? What are the costs? Are there other and preferably nonsurgical treatment options? Uterine leiomyomas will serve as one example. Myomectomy is undertaken frequently because of concomitant infertility. However the issue of leiomyomas and infertility has never been submitted to rigorous scrutiny (submucous lesions will be excluded from this discussion). Vercellini and coworkers (16) summarized data collected from 13 published series of myomectomy, all of which were performed to correct infertility. Fifty-five percent of the women so treated conceived. Regrettably all of the studies included had used the patients as their own controls. As such it is not possible to determine how many women would have conceived if no surgery had been performed. There are many limitations to laparoscopic myomectomy, which include location, size and number of myomas, and proper repair of the myometrium after removal of deeply situated large fibroids. There have been several reports of uterine rupture during subsequent pregnancy. The operating time is prolonged frequently, resulting in increased costs. The outcome may be improved by using a combination of laparoscopic access and mini-laparotomy; the first to dissect and excise the fibroid(s) and the second to remove the fibroid(s) from the peritoneal cavity without the need of extensive morcellation and to close the uterine defect properly (4). Finally newer techniques such as myolysis are under trial. This technique appears to cause significant postoperative adhesions but seems to be effective and thus may be applicable in women who have no further desire of fertility (17). Laparoscopic hysterectomy has been practiced since There is no advantage to the laparoscopic approach when it replaces a vaginal hysterectomy. The laparoscopic procedure takes longer to perform and requires abdominal incisions, albeit small. In a well-designed, randomized prospective study, Summitt and coworkers (18) compared out patient, laparoscopic-assisted vaginal hysterectomy with standard outpatient vaginal hysterectomy (VH). Fifty-six women scheduled for VH were assigned randomly to either laparoscopic-assisted vaginal hysterectomy (n = 29) or standard VH (n = 27). The criteria used to decide upon the vaginal route were [1] uterine size under 16 gestational weeks, [2] presence of uterine mobility, and [3] a pubic arch of at least 90. The presence of preopera- tive pelvic pain, the need for oophorectomy, or previous pelvic surgery did not influence the decision to use a vaginal approach. There were no differences between the two groups with regards to age, gravidity, and parity, in preoperative indications and previous operations. All of the procedures, including unilateral or bilateral oophorectomy when indicated, were completed without incident. The mean operating time was significantly longer for the laparoscopic-assisted vaginal hysterectomy group, 120 versus 65 minutes for vaginal hysterectomy. Those in the laparoscopic-assisted vaginal hysterectomy group required more pain medication and had lower postoperative hematocrit levels. Although the differences were statistically significant, they did not appear to make a clinical difference in the postoperative course. The difference in cost was startling; the mean hospital charges for laparoscopic-assisted vaginal hysterectomy were $7,905 versus $4,891 for VH (18). Although the relative contraindications to VH include endometriosis, prior pelvic surgery, adhesive disease, adnexal lesions, limited uterine mobility, and uterine enlargement, initial laparoscopic evaluation alone may demonstrate the absence of such relative contraindications and permit the surgeon to carry out the hysterectomy conventionally, by vaginal route. This has been demonstrated clearly by Kovac and coworkers (19). Hidden costs may accrue to laparoscopic surgery. Although the reported rates of major complications are relatively low, informal surveys reveal a different story. We are aware of deaths, severe vascular, and enteric and urinary complications. Ureters have been included within stapling devices and transected. It should be clear that an operation is no less invasive whether it is carried out vaginally, abdominally, or by laparoscopic access. We must select the approach that will yield the best outcome for the patient. Peritoneal trauma will produce the same degree of inflammatory response irrespective of the mode of access; thus, it is essential to incorporate microsurgical principles to the performance of reproductive procedures to reduce postoperative complications and adhesions and preserve the woman's reproductive potential. "Technical feasibility is not a sufficient reason to perform a procedure. There must be a real indication and the procedure must yield a benefit to the patient.... Imagination and daring must be coupled with a healthy coefficient of skepticism. While explore we must, it is essential to remind ourselves that the Gomel Editor's corner 467

5 truth of today may be the fallacy of tomorrow" (5). Imagination and daring have been shown by gynecolgists who spearheaded the development and acceptance oflaparoscopic surgical techniques. It now behooves gynecologists to bring the same virtues to the judicious assessment of these techniques. Key Words: Microsurgery, operative laparoscopy, tubal pregnancy, tuboplasty, myomectomy, hysterectomy. REFERENCES 1. Swolin K. Electromicrosurgery and salpingostomy: long term results. Am J Obstet Gynecol 1975;121: Gomel V. An odyssey through the oviduct. Fertil Steril 1983;39: Gomel V. Microsurgery in female infertility. Boston: Little, Brown and Co., Gomel V, Taylor PJ. Diagnostic and operative gynecologic laparoscopy. St. Louis: Mosby, Gomel V. Operative laparoscopy: time for acceptance. Fertil SteriI1989;52: Filmar S, Gomel V, McComb PF. Operative laparoscopy versus open abdominal surgery: a comparative study on postoperative adhesion formation in the rat model. Fertil Steril 1987;48: Munro MG, Gomel V. Fertility-promoting laparoscopicallydirected procedures. Reprod Med Rev 1994;3: Dubuisson JB, Bouquet de Joliniere J, Aubriot FX, Darai: E, Foulot H, Mandelbrot L. Terminal tuboplasties by laparoscopy: 65 consecutive cases. Fertil Steril 1990;54: Canis M, Mage G, Pouly JL, Manhes H, Wattiez A, Bruhat MA. Laparoscopic distal tuboplasty: report of 87 cases and a 4-year experience. Fertil Steril 1991;56: Gomel V, Taylor PJ. In vitro fertilization versus reconstructive tubal surgery. J Assist Reprod Genet, 1992;9: Reich H, McGlynn F, Parente C, Sekel L, Levie M. Laparoscopic tubal anastomosis. J Am Assoc Gynecol Laparoscop 1993;1: Gomel V, Taylor PJ. Reconstructive tubal surgery in the female. In: Insler V, Lunenfeld B, editors. Infertility, male and female. Edinburgh: Churchill Livingstone, 1993: Zouves C., Urman B, Gomel V. Laparoscopic surgical treatment of tubal pregnancy. J Reprod Med 1992;37: Urman B, Zouves C, Gomel V. Fertility outcome following tubal pregnancy. Acta Eur Fertil 1991;22: Murphy AA, Nager CW, Wujek JJ, Kettel LM, Torp VA, Chin HG. Operative laparoscopy versus laparotomy for the management of ectopic pregnancy: a prospective trial. Fertil Steril 1992;47: Vercellini P, Bocciolone L, Rognoni MT, Bolis G. Fibroids and infertility. In: Shaw RW, editor. Advances in reproductive endocrinology. Uterine fibroids: time for review. Park Ridge, New Jersey: The Parthenon Publishing Group, 1992; Goldfarb HA. N d: Y ag laser laparoscopic coagulation of symptomatic myomas. J Reprod Med 1992;37: Summitt RL Jr, Stovall TG, Lipscomb GH, Ling FW. Randomized comparison of laparoscopy-assisted vaginal hysterectomy with standard vaginal hysterectomy in an outpatient setting. Obstet Gynecol 1992;80: Kovac SR, Cruikshank SH, Retto HF. Laparoscopy-assisted vaginal hysterectomy. J Gynecol Surg 1990;6: Note. Additional references are available upon request. 468 Gomel Editor's corner