Dr. med. Dirk Manski



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Laparoscopy and Robotic Surgery in Urology (1/3)

History of Laparoscopy

Diagnostic laparoscopy:

After the invention of the cystoscope by Nitsche in 1879, Kelling used this cystoscope in 1901 for the first diagnostic laparoscopy in animals. Jacobaeus performed in 1910 the first diagnostic laparoscopy in humans. The diagnostic laparoscopy remained until the mid-20th century in the hands of specialist of internal medicine, who further developed the method. Important steps of progress were the invention of the Veress needle , CO2-insufflation, trocars, powerful light sources and improved optics.


figure laparoscopy of hepatic cirrhosis

Laparoscopy: liver cirrhosis and splenomegaly.


Operative Laparoscopy:

The gynecologist Semm is acknowledged as the founder of laparoscopic surgery. The development of insufflators , the loop ligation, and various instruments are attributed to him. Many laparoscopic procedures were introduced by Semm: e.g. first uterine fibroids (1972 ), ovariectomy (1977 ) and laparoscopic appendectomy (1980). After the establishment of laparoscopy in the surgical community (first laparoscopic cholecystectomy by Mouret 1987), urologists slowly began to use laparoscopy. Table laparoscopic history informs about the time line of laparoscopic urologic surgery.


Time line of the history of laparoscopic urologic surgery.
Year Author Procedure
1976 Cortesi Laparoscopy for cryptorchidism
1990 Sanchez-de-Badajoz Varicocelectomy
1991 Schuessler pelvic lymphadenectomy
1991 Clayman Nephrectomy
1992 Schuessler Prostatectomy
1992 Parra Cystectomy
1992 Gagner Adrenalectomy

Robotic Laparoscopy:

Another milestone in the development of laparoscopic surgical technique is the development of robotic-assisted laparoscopy. The only provider in the market is the company Intuitive Surgical with the da Vinci Surgical console. The console consists of two components: a control console for the surgeon and a patient-side robotic unit. The da Vinci Surgical console has 3–4 arms depending on the modell which carry the surgical instruments and the camera unit. The camera unit provides a true stereoscopic view with magnification of the surgical field. In addition, the surgical unit enhances dexterity, greater precision and ergonomic comfort. The articulated instruments allow movements that are not possible with rigid standard instruments of laparoscopy. In sum, the da Vinci Surgical System enables more complex minimally invasive procedures involving complex dissection or reconstruction (partial nephrectomy, prostatectomy, cystectomy with urinary diversion).

The main disadvantage are the huge costs consisting of the investment, the maintenance contract with the manufacturer and the need for expensive disposable instruments. If 300 cases per year are performed with the da Vinci Surgical console, additional costs of 2500 Euros will have to be calculated per operation. So far, randomized trials are lacking which justify the high costs for the health system.

Indications for Laparoscopy in Urology

Diagnostic laparoscopy:

A diagnostic laparoscopy is rarely indicated in urology: e.g. testicular search in cryptorchidism.

Operative laparoscopy:

The spectrum of laparoscopic surgery in urology is continuously growing. Vital for the success is, however, the level of training of the individual surgeon. Frequently performed laparoscopic operations are pelvic or retroperitoneal lymph node dissection, nephrectomy, partial nephrectomy, adrenalectomy, prostatectomy and surgery for UPJ obstruction. With the help of robotic-assisted laparoscopy, complicated reconstructive procedures in urology are becoming possible, such as complicated partial nephrectomy of hilar tumors or cystectomy with intracorporal urinary diversion.

Contraindications of Laparoscopy

Underlying diseases:

Previous operations:

After uncomplicated appendectomy, cholecystectomy or hysterectomy, laparoscopy is often possible and sucessful. If severe adhesions are present, laparoscopy should not be forced and a secure open approach is advisable.







Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z





References

Merseburger, A. S.; Herrmann, T. R. W.; Shariat, S. F.; Kyriazis, I.; Nagele, U.; Traxer, O. & Liatsikos, E. N.
EAU guidelines on robotic and single-site surgery in urology.
2013, 64, 277-291.
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  Deutsche Version: Laparoskopie in der Urologie