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SURGICAL WEBSITES             KIDNEY SURGERY         POSTGRADUATE SURGERY LINKS 

BREAST DISEASE     Breast cancer Breast lump Breast awareness Breast calcifications  Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis                                                                                                                                                 

LIVER ABSCESS      Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study.  Result Result continued  Discussion                                                                 

CHOLECYSTECTOMY    Introduction   Historical Review  Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology  of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications  Treatment modalities for gallstones.  Anaesthesia                                                                                                                       

INGUINAL HERNIA    HOW SURGICAL OPERATION IS DONE     THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT      SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA     BRONCHOGENIC CARCINOMA     TETANUS AND ANAEROBIC INFECTIONS 

HISTORICAL REVIEW

HISTORICAL MILESTONES OF BILIARY TRACT

Every field has its great contributors and its heroes. I am trying to gather here the of work and names renowned scientists who had the honour to add new horizons in development of BILIARY surgery and did done their best efforts for a better understanding of this field.

“The only thing that is universal is competence” and surgical competence may be traced back to Babylonian (2000 BC), who observed the anatomical knowledge of the liver, bile duct and gall bladder and laid down the ethics ¹. To be sure, we can be specific about Egyptian’s strengths of preserving the history and to there credit is the earliest known gall stones, discovered in the mummy of a Priestess of Arnan (1085-945 BC) so the gallstone disease can be traced back to the 21st Egyptian dynasty. AD Galen is known for his outstanding contribution to the field of surgical sciences by describing the storage function of the gall bladder. Recognition of gallstones was first recorded in the fifth century, by a Byzantine Greek physician Alexander Trallianus (Alexander of Trales) 525-605 BC who practised in Rome. The first clinical description of gallstone disease to be recorded was in 4th century BC by Gordon Taylor, in his description of the symptoms manifested by Alexander the Greatin 323 BC Soranus of Ephesus (2nd century AD) a Greek physician who practised in Rome also provided the first attempt at differential diagnosis of biliary tract disease, his work was duly translated by Auerliams Caelius a fifth century physician

In the 13th century observations of human gallstones were first demonstrated during autopsy by Gentile da Foligno (1341) in Padua. Andreas Vesalius (1514-1564) gave a description of gallstones including that, they represent a disease and described some of the consequences. Slowly the physicians started to acknowledge the presence of gallstones with symptoms of abdominal pain, peritoneal inflammation and jaundice, as indicated by various descriptions by Jean Fernel (1558) and Marcellus Donatus (1586)

Before 15^th century physicians were unfamiliar with gall bladder diseases, in this era the physicians started to recognise gall stone diseases and did the excellent job specifically in the field of hepatobiliary surgery research by recognising obstructive jaundice and there clinical manifestations. The term Hyperbilirubinaemia was first established as a cause of jaundice in this century and liver functions were carried out. Fabricus Hildanis, removed gallstones from a human cadaver gallbladder in 1618.

In 1667 Michael Entmuller said, “There are no medicine which will cure gallstones” the position has not altered. French surgeon by the name of Jean Lovis Petit over 250 years ago (1674-1750) have furthered the knowledge in this field by identifying the biliary colic and other signs of this disease and had developed practical applications of that knowledge in surgery by removing the gallstones after puncturing the gall bladder with trocar and cannula in 1743.

“The museum of surgical art is an operation theatre”. The credit belongs to the John Stough Bobbs who got a competitive edge in surgical art by bringing new life to biliary surgery after performing, first elective cholecystostomy in Indianapolis for hydrops of the gallbladder.

Nobel Prize symbolises man’s commitment to seeking truth about our world. Emil Theodar Kocher (1841-1917) a Swiss surgeon was the first surgeon to be awarded with this prize in 1909, his ultimate goal was to make the gall bladder surgery easier in all practical ways especially by starting subcostal incision and standardising the mobilisation of the second part of the duodenum and sphincteroplasty that will lighten the suffering of those with distal choledochal obstruction and brought them all an improved quality of life. In  1878 Kocher drained the gallbladder empyaema.

One man with courage makes a majority,” Ludwig Georg Courvoisier (1843-1918) a Swiss surgeon of Basal has a particular of devising the law for the painless jaundice by his name which has been practically applicable through the years. He also got recognition by performing first choledocholithotomy. He was the first to remove a stone successfully from the common bile duct on 21st January 1890

Kuster in Germany - 1883 and Mc Redity in U.S.A. - 1884 advocated an ideal gallstone operation, “an incision into the gallbladder, evacuation of stones or sand, curettage of the mucosa and closure of the gallbladder without drainage

Carl Langenbuch of Berlin has the highest achievement of this field and it is a recorded fact that he was the German person to perform cholecystectomy ², not only did he remove the gallbladder but said the early principle, “the gallbladder needs to be removed not because it contains stones, but because it forms them ³. In 1896 Halsted described his surgical treatment of gallstone disease.

Bernard Naunyn (1839-1925) call attention to In 1892 made a remarkable achievement in pathophysiological basis of gall stone formation by his contribution of research cholelithiasis, in which he stated that gallstones were formed mainly in the gallbladder and that stasis was a factor in their formation and that in addition, the nidus for gallstone formation might originate from sloughing of epithelial cells or other debris and by this Bernard Naunyn overcame obstacles in the aetiology of gall stones and recognised Escherichia coli and Salmonella typhi causing cholecystitis and cholangitis as the causative factors

Graham and Cole were the first to tell the contrast radiological study of the gall bladder and all of his attempts throughout his career have resulted in a great success by the development of oral cholecystography in 1924. But trial and error is the essence of scientific research and intra venous cholecystography was developed in 1935 and direct puncture of biliary tract was then tried and this research has resulted in the development of a technique called Percutaneous Transhepatic Cholangiography.

As other peak scientists were doing different researches and developments, Okuda in 1968 excels because of his curiosity about insight of common bile duct and his research resulted in the development of a 6-8 inches fine needle with this the Percutaneous Transhepatic Cholangiography become more easy and less complicated.

In hope of better examination of the common bile duct Mclier in 1941 developed rigid choledochoscope, but efforts of Shore did not stop with construction of a rigid scope that also utilised his vision and ideas for examining the common bile duct and in 1965 he invented a flexible choledochoscope

It takes special people to launch any new thing, like Hans Kehr is known for their contributions by inventing the facility to drain common bile duct by inventing a T tube that is helpful for surgeon to give the best results in spite of facing complication during surgery.

Although surgical removal of the gallbladder has been the gold standard of treatment of cholelithiasis for more than hundred years, its dominant position has been challenged by development of several new non-operative modalities ⁴.

HISTORICAL BACKGROUND OF LAPAROSCOPY

"To cut is to cure," "The greater the surgeon, the bigger the incision," and "Wound heals from side to side and not top to the bottom" are just few of the aphorisms that residents have been exposed to during training. Despite these sayings it is well accepted that surgery causes morbidity and mortality. Pruitt has stated "Surgery…is a controlled injury of variable magnitude…" ⁵. The extent of which depends on the surgical incisions. Because they have not appreciated the morbidity of incisions, surgeons have avoided "minimal access procedures," which they consider something less than surgery. They have been slow to follow gasteroenterologists, pulmonologists and radiologists into the field of minimal access procedures. With the introduction of laparoscopic cholecystectomy, the importance of minimal access surgery has suddenly impacted on surgeons and pushed the surgeons into new era ⁶.

The image of laparoscopic cholecystectomy surgery is tied to surgeons’ and opticians, through their untiring efforts over the decades laparoscopy was established.

The earliest inspection of body cavity was performed by Hippocrates (460-375 BC). Babylonian scholars have furthered the knowledge of endoscopy and developed a siphopherot, a metal tube of lead in 500 AD

The importance of performing an internal examination of the many compartments of the human body has been recognised for many centuries. Abu-L-Qasim (936-1013) the most famous Arabic writer on surgery is credited with being the first to use reflected light to inspect an internal organ, the cervix which he has recorded in his encyclopaedic Altrasrif which greatly influenced medieval European medicine. Other investigators subsequently developed instruments subsequently developed instruments to examine the nasal recesses and the urinary bladder with the aid of artificial light and mirrors.

Both surgical endoscopy and gallbladder surgery had their beginnings in the 1800s. "Modern" surgical endoscopes were first developed in the early 1800s. Endoscopy as we know it today was not developed until the problem of thermal tissue injury caused by the illuminating source was solved. The first endoscope that incorporated an optical viewing component used a glowing platinum wire at one end as the light source. Later, clinical investigators used endoscopes with incandescent light bulbs at the tip of the instrument. The usefulness of photography to record the endoscopic findings was recognised early, and by 1874 ⁷.

Dr Georg Kelling (born 1866) a German physician by his hard work, and enthusiasm, described in Hamburg the examination of the stomach and oesophagus in human and also the use of cystoscope to visualise the viscera of a dog.

In 1901 Kelling reported using a cystoscope to inspect the peritoneal cavity of a dog after insufflation with air. He then coined the term “celioscopy” to describe this technique. The first report of using this procedure in man was by Swedish physician Jacobaeus in 1910. It is not surprising, therefore, that cystoscopy, which was developed in the nineteenth century, preceded other forms of endoscopy because of the coolant effect of water on the distal light source. These early procedures, however, were entirely diagnostic in nature; the exposure obtained and the instruments available did now allow operative intervention. The early pioneer introduced their trocars and cystoscope directly into the peritoneal cavity. Stein had modified existing cameras to record images of bladder pathology.

 

DIAGNOSTIC LAPAROSCOPY:

In 1910 Jacobaeus first coined the term of “LAPAROSCOPY”. The thought processes behind was to obtain details of the body cavities and to see more important striking appearance of the body and to see what goes on inside without practically opening it. It emerged as an effective diagnostic and therapeutic tool in surgery ⁸.

Further developments in the early years of the century included the adoption of the Trendelenburg's position by Nordentoft in Copenhagen (1912) the use of carbondioxide for the insufflation by Zollikoffer in Switzerland (1924) and introduction by Veress in Budapest (1938) of the modern spring loaded needle which he devised to introduce the pneumothorax in the treatment of pulmonary tuberculosis.

OPERATIVE LAPAROSCOPY:

The earliest attempts at therapeutic laparoscopy were by general surgeons who performed adhesiolysis. These include Fervers (1933) who used oxygen as the distension medium and experienced great concern at the audible explosion and flashes of light. John Ruddock (1934) described an optical system with biopsy forceps and coagulation.

The major development in instrumentation since bipolar electrocoagulation and endocoagulation has been the introduction of a variety of forms of laser and their application to laparoscopic surgery ⁹. Carbon dioxide laser, which is transmitted along the solid lens system, was the first to be used extensively and was introduced to Europe by Maurice Bruhat of Claremont Ferrand and to the USA by James Daniell of Nashville in 1982. Since than laser is transmitted along flexible fibre optic cable have increased in popularity and include Nd:YAG, KTP and Argon laser. All of these physical modalities from the basis of modern laparoscopic surgery. Endoscopic surgery is rapidly becoming popular alternative to traditional operative procedures for a variety of diseases. Laparoscopic biliary tract surgery, laparoscopic appendicectomy, laparoscopic gynaecological procedures, thoracoscopic treatment of pneumothorax and persistent pleural effusions, as well as arthroscopic examination and treatment of joint spaces have all become accepted minimally invasive endoscopic procedures. Laparoscopic cholecystectomy has belatedly awakened the general surgical community to the concept of closed abdominal surgery. Current techniques have largely been developed by our colleagues in gynaecology ¹⁰. Public awareness that endoscopic surgery is associated with diminished pain and cosmetic disfigurement as well as quicker resumption of normal activities has accelerated its acceptance by the surgeons. This is exemplified by introduction of laparoscopic cholecystectomy, which attracted only minor curiosity when first performed in 1987 in France by Mouret. Laparoscopic cholecystectomy was carried out in United States during the latter part of 1988 by McKernan and Saye and shortly thereafter by Reddick and Oslen. The procedure was then widely disseminated during 1989 and 1990 and superseded open cholecystectomy with rapidity that has never seen before ¹¹.This widespread application of laparoscopic cholecystectomy occurred before reports began to appear in the literature in 1991 ¹². Interest in this procedure has grown almost exponentially, largely fuelled by patient’s demand. Diagnostic laparoscopy has been safely done under local anaesthesia ¹³.

The first laparoscopic cholecystectomy was performed in Pakistan in 1991 ¹⁴. “The future of laparoscopic surgery should be directed towards identifying limitations, eliminating source of operating errors, improvement in skill and experience and improving existing technology and also to make it economical and justifiable” ¹⁵. Education is required for prevailing attitudes towards improving standards of laparoscopic cholecystectomy ¹⁶. Interest in laparoscopic cholecystectomy has grown almost exponentially, largely fuelled by patient’s demands. This was largely due to the reason that the patients were informed of the considerable benefits of minimally invasive surgery without any indication of the possible complications ¹⁷ The initial reports of laparoscopic cholecystectomy came from surgeons and centres that were pivotal to the development and maturation of the procedure. Although the initial complication rate described by these authors were acceptable compared with open cholecystectomy, anecdotal and mainly unpublished account of serious complications and deaths began to circulate ¹⁸. Subsequently the indications have been expanded (and contraindications have decreased) and as many as 95% of patients with cholelithiasis may now be candidates for this procedure due to quality enhancement ¹⁹.

“Ultrasound, luxury of past, a necessity of present.” In 1942 Dussik and Deniver pointed out the benefits of using the ultrasound for the diagnosis of the biliary disease. It is now use peroperatively which adds our vision in see choledocholithiasis.

We are proud of our past and make a promise to the future in surgery. This spirit—on display in laparoscopic cholecystectomy—will lead us into the next century.