Laparoscopy and the General Surgeon

Gynecologic Surgery for the General Surgeon 0039-6109/91 $0.00 + .20 Laparoscopy and the General Surgeon Thomas A. Gaskin, MD, FACS,* James H. Isobe, MD, FACS,t John L. Mathews, DMD, MD, FACS,:I: Susan B. Winchester, MD,§ and R. Jay Smith, MDII Laparoscopy, and the general surgeon TEXT BOOK OF SURGERy23 INDEX Lactotropin, 643 Lambl' excrescences, 2409 ~? page _ . Laparotomy, for intra-abdominal injury, 308-309 The advent of laparoscopic cholecystectomy has catapulted closed abdominal surgery and laparoscopy to the attention of general surgeons everywhere. Laparoscopic cholecystectomy has had a secondary effect of arousing interest in other video-controlled procedures. The rapid growth and development of video-controlled "closed" procedures promises to have as dramatic an effect on the practice of surgery as have other principal developments such as blood transfusion, antibiotics, cardiopulmonary bypass, and total parenteral nutrition. The rapid growth and development of laparoscopic surgery have also raised a number of complex issues, problems, and opportunities. Laparoscopy and laparoscopic surgery are not new," they are new only *Chief of Surgery, Baptist Medical Center Princeton; Clinical Assistant Professor of Surgery, The University of Alabama at Birmingham Medical Center; and Southern Area Chairman, Cancer Liaison Program, Birmingham, Alabama tClinical Instructor, Department of Surgery, The University of Alabama at Birmingham; and Attending Surgeon, Baptist Medical Center Princeton, Birmingham, Alabama :f:Principle Investigator for Alabama Lithotripsy; and Attending Surgeon, Baptist Medical Center Princeton, Birmingham, Alabama §Attending Surgeon, Baptist Medical Center Princeton and St. Vincent's Hospital, Birmingham, Alabama [Assistant Associate Director of Surgical Education, Baptist Medical Center; and Attending Surgeon, Baptist Medical Center Princeton, Birmingham, Alabama Surgical Clinics of North America-Vol. 71, No.5, October 1991 1085 1086 THOMAS A. GASKIN ET AL. to the general surgical community. The lack of attention given to laparoscopy by general surgeons since its development in the early part of this century is largely attributable to its role as a diagnostic tool rather than a therapeutic one. A relatively small number of general surgeons1, 8, 9, 18, 30 around the world have attested to the usefulness oflaparoscopy for the general surgeon. For the most part, gynecologists developed the instrumentation and operating principles and techniques of operative laparoscopy, 9, 15, 18, 23 and because gynecology is less and less a part of the general surgeon's training and practice, few general surgeons developed and retained an interest in laparoscopy. Beginning in 1982,1 the American Board of Gynecology required training in laparoscopy for gynecology residents; few general surgical programs offered any substantial exposure to laparoscopy during this period. An exception is the general surgical residency program at The Baptist Medical Centers, which, at its Princeton Hospital, has provided surgical residents with exposure to laparoscopy for more than a decade. One of those residents (coauthor JLM) had the experience of performing laparoscopic cholecystectomy on a patient on whom, 10 years earlier, he had participated in diagnostic laparoscopy. It is the intent of this article to offer a perspective on laparoscopy based on a long experience and interest in a community-based general surgical practice. We will examine milestones in the development of laparoscopic surgery, the uses of diagnostic laparoscopy for the general surgeon, and therapeutic laparoscopy (closed abdominal surgery). Issues in training, credentialing, resource utilization, payment, and review will also be examined. Rapid developments in laparoscopic surgery will dictate frequent revisions and updates of this information. MILESTONES IN LAPAROSCOPY Few advances in medicine are the result of a single breakthrough but instead represent the accumulated result of many smaller advances. Examination of these advancements provides insight into the basic principles of current technique and indicates directions for future development (Table 1). The urge for deeper visualization of the human body beyond physical examination has been present since ancient times. While there were some developments in earlier periods, the achievements were few because of crude instruments, limited access, and primitive technology. Milestones in laparoscopy began with a few developments during the latter part of the 19th century and accelerated with advances made since the turn of this century. The first attempt at endoscopy was by Bozzini in 1805. He was censured by the medical faculty of Vienna for being too inquisitive in attempting to observe the interior of the urethra in a living patient with a simple tube and candlelight. The father of endoscopy, Desormeaux, invented the first effective endoscope in 1843. This was an impetus for the development of the otoscope by Brunton, the urethroscope by Langlebert, and the cystoscope by Nitze. In 1901, George Kelling, a Dresden professor, reported his initial celio scopic examination of a living dog to a medical meeting in LAPAROSCOPY AND THE GENERAL SURGEON 1087 Table 1. Milestones in Laparoscopy 1805 1843 1901 1910 1911 1918 1920 1928 1929 1934 1938 1940 1947 1952 1953 1965 1967 1968 1969 1971 Bozzini examined urethra with tube and candlelight Desormeaux invented first effective endoscope Kelling performed celioscopy on living dog Jacobeus performed first laparoscopy on human Bernheim first in US to view peritoneal cavity using proctoscope Getze developed automatic spring needle Ordnoff developed pyramidal point on trocar Bovie developed electrosurgical cauterization unit Kalk devised foroblique lens; second puncture for controlled liver biopsy Ruddock reported on 900 peritoneoscopy procedures Veress developed modified spring needle to induce pneumothorax TeLinde described culdoscopy Palmer introduced endouterine cannula Fourestier, Gladu, and Vulmiere developed quartz rod and external light source Thomsen took color photographs of cul-de-sac Wolf Company developed electronic flash Hopkins lens system Cohen and Fear rekindled laparoscopy in US Lumina optic system Phillips founded American Association of Gynecologic Laparoscopists Excerpted from Phillips J (ed): Laparoscopy. Baltimore, Williams & Wilkins, 1977, pp 616; with permission. Hamburg. He initiated pneumoperitoneum with air filtered through sterile cotton and used a cystoscope to view the viscera. In 1910, H.C. Jacobeus of Stockholm was the first to apply this new method to humans, and his publication discussed the inspection of three body cavities: peritoneal (laparoscopy), pleural, and pericardial. 12 In the US, Bertram M. Bernheim in 1911 was the first to view the peritoneal cavity, using a half-inch proctoscope with ordinary lighting. The advancements that followed Bernheim's can be discussed under these headings: optics, lighting, photography; access to the abdominal cavity; and technique and instrumentation. Optics, Lighting, and Photography In 1929, H. Kalk, the founder of the German school of laparoscopy, devised a new lens system that permitted oblique (135-degree) viewing. In 1934, American internist John C. Ruddock reported on 900 peritoneoscopy cases utilizing an endoscope with improved optics and an operative channel. Between 1960 and 1967, British physicist Harold H. Hopkins found better light transmission with a modification of the lens chain design. Whereas the previous system (up to 1960) had small glass lenses separated by large air spaces, the Hopkins system used large quartz, rod-shaped lenses interspersed for short distances with air. Subsequently, coating of the lens surfaces with magnesium fluoride, which is deposited on the glass surface by evaporation in a vacuum, was found to minimize the light reflection problem and to reduce light loss." The early source of endoscopic lighting was the incandescent bulb, developed by Edison in 1880. The bulb converted 97% of electrical energy into heat and the remainder into visible light. As a result, the tip of the endoscope became extremely hot, making endoscopy of the lower abdomen 1088 THOMAS A. GASKIN ET AL. likely to cause burns. The idea of conducting light by means of transparent fibers was patented in 1928. Fourestier, Gladu, and Vulmiere in 1952 developed a method of transmitting an intense light from a source outside the abdominal cavity along a quartz rod to the distal end of the endoscope. 26 Subsequent application of flexible fiberoptic instruments began in 1957 with the gastroendoscope. The fiberoptic cable consists of an inner core of glass with a relatively high refractive index and a fused sheathing of lowindex glass known as cladding. The hot light source enters one end of the fiberoptic cable and is repeatedly and totally reflected internally from the lateral surfaces until it emerges at the opposite end as cold light. The normal light loss within the system at coupling points results in the transmission of 26% of the original light. Since 1965, all endoscopes have utilized this cold light system, and in the 1970s high-intensity halogen light sources enhanced endoscopic photography. The German gynecologist Thomsen in 1953 was the first to take color photographs of the cul-de-sac utilizing a flash at the tip of the endoscope. 12 Came in 1954 adapted this technique for electronic flash, which functioned under the 24-V maximum permitted for use in the human body. Because initial attempts at photography resulted in an occasional twitching of the patient, the Storz Company placed the flash source within an insulated device adjacent to the eyepiece. This resulted in heating up of the eyepiece, making it uncomfortable after a sequence of pictures was taken. The Wolf Company subsequently used the fiberoptic cable to transmit the electronic flash to the lens in the mid-1960s, thus satisfying one of the basic requirements of modern endoscopic photography. Laparoscopic cinematography was developed in the late 1960s. Utilization of a xenon vapor light source, color film with appropriate speed, and finally the development of the Lumina optic system in 1969 allowed enhancement of full-screen color movies. The Lumina optic had narrow diameters with optics at the tip, allowing a 160-degree angle of foroblique vision surrounded by glass fibers for the transmission of cold light. ACCESS TO THE ABDOMINAL CAVITY The first attempts at laparoscopy in humans were initiated without a pneumoperitoneum. In 1918, Goetze developed the automatic spring needle for safe puncture and gas insufflation of the abdomen. Hungarian Janos Veress in 1938 described a modification of the spring needle for inducing pneumothorax in the treatment of tuberculosis. This is the needle commonly used today for initiation of pneumoperitoneum. In 1959, Friedrich C. Menken suggested the horizontal insertion of the Veress needle at the umbilicus after lifting the abdominal wall. Utilizing this technique, he reported no complications in his first 3000 cases. American radiologist B. H. Ordnoff in 1920 developed the pyramidal point on the trocar, making access to the abdominal cavity easier. He also developed an automatic trocar-sheath valve that prevented the escape of gas. In 1924, Zollikofer from Switzerland was the first to use carbon dioxide for insufflation because of its quick absorption. German gynecologist and engineer Kurt Semm in 1977 presented the CO 2 Pneu-Automatic Insufflator, which was a result of experiments and studies started in 1954. 12 LAPAROSCOPY AND THE GENERAL SURGEON 1089 Technique and Instrumentation In 1928, an electrosurgical unit designed by W. T. Bovie was utilized by Harvey Cushing in intracranial operations for the control of bleeding. This revolutionary technique was modified and insulated appropriately so that in 1962, Palmer used electrocoagulation for tubal sterilization." In 1929, H. Kalk introduced the technique of a second puncture for controlled liver biopsy. . Because some gynecologists found the abdominal wall route inadequate for visualization of the pelvic organs obscured by the small bowel, Richard W. TeLinde in 1940 described culdoscopy utilizing a dorsal lithotomy position. In 1944, Albert Decker, a New York gynecologist, introduced the knee-chest position for culdoscopy, and this was the technique commonly utilized in the US for the next 30 years. In Europe, gynecologic laparoscopy via the abdominal route flourished and by 1965 was a well-established diagnostic and therapeutic procedure. The impetus came from the father of modern gynecologic coelioscopy, the Frenchman Palmer, who developed the endouterine cannula in 1947, along with a number of other instruments. In 1967, Patrick Steptoe, an English gynecologist, published Laparoscopy in Gynaecology and described the necessary instrumentation and techniques, especially in sterilization. Phillips in 1971 founded the American Association of Gynecologic Laparoscopists. The worldwide adoption of laparoscopic sterilization resulted in increasing complications, described in the first annual report of the Complications Committee in 1972. In yet another move to decrease complications, Harrith M. Hasson developed a cannula for open laparoscopy in 1974. In 1987, Phillippe Mauriat of Lyon, France, performed the first laparoscopic cholecystectomy. In June 1988, McKernan and Saye performed the first laparoscopic cholecystectomy in the US utilizing the argon laser. Considerable interest regarding this procedure was evident by the Second World Congress of Endoscopic Surgery held in Atlanta, Georgia, in March 1990. Dr. Dubois of Paris reported on a series of approximately 350 patients undergoing laparoscopic cholecystectomy, and Eddie Reddick of Nashville, Tennessee, presented a similar paper on about 200 such patients. The cumulative results of these developments in light source, optics and photography, insufflation, and energy sources and instruments have allowed the surgeon to perform laparoscopic operations with relative safety and ease. It was not always so. DIAGNOSTIC LAPAROSCOPY Diagnostic laparoscopy provides direct observation of many, but not all, intra-abdominal structures and surfaces, as well as a few retroperitoneal ones. The abdominal wall and diaphragmatic peritoneal surfaces can be seen over most of their areas. The insuffiation of the abdomen makes abdominal wall defects and hernias readily apparent. The magnification provided by the laparoscope often makes tiny peritoneal implants visible that might be overlooked under nonassisted vision. Such lesions are easily biopsied. Much of the hepatic peritoneal surface is visible. The surface characteristics of the liver serve to classify hepatic parenchymal disorders. 1090 THOMAS A. GASKIN ET AL. Visually directed biopsy of the liver assures that the lesion in question is the lesion sampled. The other iI1tra-abdominal viscera can be examined to a greater or lesser degree depending on body habitus, location of the subject organ, and the expertise and patience of the examiner. The examination of the female reproductive system is not within the scope of this review. Retroperitoneal structures such as lymph nodes, masses, and undescended testicles can also be identified and examined. Some intraperitoneal devices are appropriately inspected and manipulated by laparoscopic technique-ventriculoperitoneal shunts and peritoneal dialysis catheters, but NOT peritoneal venous shunts because of the risk of air embolism. Table 2 outlines the diagnostic uses that have been described by various authors.l": 7, 9, 13, 14, 20, 22, 25, 27, 29, 30, 33 many of which have been of use to us over the past 15 years. Computed tomography (CT) of the abdomen and improvements in ultrasonic diagnostic techniques have dramatically reduced the frequency of open abdominal exploration for the diagnosis of abdominal pain, for the diagnosis and staging of intra-abdominal malignancy or its recurrence, and for the assessment of injury secondary to blunt trauma. However, laparoscopy has the ability to provide important diagnostic information quickly and accurately when imaging techniques fail to yield all the information Table 2. Some Diagnostic Uses of Laparoscopy Abdominal Wall Hernia Adhesions Urachal abnormalities Omphalomesenteric duct abnormalities Metastases Trauma Liver and Biliary Tree Hepatocellular disorders Benign and malignant tumors Gallbladder disease Trauma Ascites Malignancy Esophagus and stomach Pancreas Lymphoma Lymph nodes: pelvis, portal, celiac Ovary, uterus, fallopian tubes Inflammatory Cholecystitis Appendicitis Salpingitis Meckel's diverticulum Diverticulitis Miscellaneous Undescended testicle Malfunctioning intraperitoneal devices Miscellaneous trauma Ischemic bowel LAPAROSCOPY AND THE GENERAL SURGEON 1091 needed. There remains the inability to examine all surfaces, to explore the retroperitoneum, or to obtain tactile information. This is partially offset by the ability to obtain photographic documentation, especially with magnification, thus offering the opportunity for consultation and review. There are prospective comparisons of the efficacy of laparoscopy in the evaluation of trauma, upper gastrointestinal malignancy, and the acute abdomen. Berci and Cuschieri'' have reported a series of 55 patients who sustained blunt abdominal trauma and who were randomized to peritoneal lavage or minilaparoscopy (bedside laparoscopy with a pediatric endoscope). The predictive value of minilaparoscopy was 92% contrasted with 72% for peritoneal lavage. Said another way, the advantages of minilaparoscopy over other current techniques are that it can identify those patients with positive peritoneal lavage who do not require operative treatment and those patients with minimal findings on peritoneal lavage who do require operative treatment. The study can be done rapidly by the surgical team without the need to transport the patient to the radiology department. Watt et al 24 prospectively compared ultrasound and CT in cancer of the esophagus and gastric cardia. Laparoscopy was more accurate in the diagnosis of hepatic, nodal, and peritoneal metastases. Patterson-Brown et apo assigned 321 patients with abdominal pain to one of four groups: A, requires an urgent operation; B, does not require an urgent operation; C, uncertain as to need for urgent operation (including all women with possible appendicitis); and D, ineligible for laparoscopy. Laparoscopy was performed in patients in group C. The results of this approach were then compared with computer-aided decisions based on diagnostic probabilities. Those investigators found a marginal but definite advantage for selective laparoscopy. These studies are cited because they compared the results of laparoscopy with concurrent techniques in a prospective series. As surgeons become more adept at laparoscopy and enthusiasm for its use increases, we must, as a discipline, follow the examples of Berci, Cuschieri, Watt, and Patterson-Brown and their coworkers. THERAPEUTIC INTERVENTIONAL LAPAROSCOPY Jules Verne said "what one man can conceive another man can achieve. n It appears that this is becoming the case in laparoscopy and general surgery today. The laparoscope is stimulating not only technology in the area of optics, lasers, and instrumentation but also the minds of enterprising surgeons. There is no question that laparoscopy will become an integral part of the general surgeon's armamentarium. Interventional laparoscopy was introduced into this country in a formal way at the First World Congress of Endoscopy Surgery of The Society of American Gastrointestinal Surgeons (SAGES) in Louisville, Kentucky, in 1988. Presentations were made concerning the European experience in laparoscopic cholecystectomy and lysis of adhesions. Other possible uses that were mentioned included appendectomy, inguinal hernia repair, and vagotomy. These topics were exciting but secondary to others presented at that meeting. At the SAGES Second World Congress in Atlanta in March 1990, the interventional techniques 1092 THOMAS A. GASKIN ET AL. with the laparoscope were at the forefront. The program was entitled "Unlimited Frontiers." It was Reddick and McKernan who in this country developed these unlimited frontiers into reality and popularized the instrument, the laparoscope, in cholecystectomy and got the attention of general surgeons. At this writing, there have been five published series of laparoscopic cholecystectomy (Fitzgibbons R Jr, Schmid S, Santoscoy R, et al, manuscript submitted)." 10,22,34 A total of 505 patients are presented in these five series. There have been no deaths. The elective hospital stay was approximately 1.5 days. The complication rate in the three most recent series has been around 5%. Many of these complications, such as bleeding and bowel leakage, are now managed laparoscopically rather than with subsequent open laparotomy. Ductal injury is serious, and the incidence in laparoscopic cholecystectomy is not known, but in the early experience might well be greater than that for standard cholecystectomy, which is estimated as 1/400. 17 In spite of this, the majority of the 500,000 cholecystectomies performed in the country yearly probably will soon be performed with the laparoscope. At present, in our institution, 88% of cholecystectomies are performed in this manner. Our experience to date totals more than 250 cases in both acute and chronic cholecystitis. Another diverticulum of the gastrointestinal tract well treated in this manner is the appendix. At the Second World congress of SAGES, Goetz presented more than 500 cases of appendicitis treated laparoscopically in a community hospital in Germany over a number of years. The data were impressive, and the complications were no different than those of open appendectomy. Length of stay is somewhat similar to that of routine appendectomy and may reflect the usual perioperative mild ileus. In our experience, the laparoscope is being used more often now in the evaluation of the acute abdomen. Not only can the appendix be well evaluated, but also the adnexa, as well as other organs of general surgical interest such as the ileum, gallbladder, and liver. The laparoscopic technique varies from center to center. The mesoappendix is managed with clips or with bipolar as well as monopolar cautery. The appendix is Endolooped as well as stapled with the new instrument just now available. The French pull the appendix through the abdominal wall, tie it manually near its base, and then allow it to retract. The technique is variable but is being perfected. It is usually performed with three punctures. Inguinal hernia is also being treated laparoscopically at several centers. This approach appears to be more applicable to indirect hernia and is being managed by a ring closure accomplished either with a stapler or with intraabdominal suturing. The direct hernia appears more challenging and requires the placement of mesh and an intra-abdominal suture technique that to date is cumbersome and time consuming. There were no published series as of December 1990, probably a reflection of the short duration of experience. Prospective study will be required to establish whether the laparoscopic approach is competitive with the large number of published series using standard approaches with recurrence rates less than 1%. Chronic abdominal pain, in the absence of objective radiographic or endoscopic findings and in the presence of a history of abdominal surgery, LAPAROSCOPY AND THE GENERAL SURGEON 1093 is frequently evaluated by the general surgeon. Jacques Perissat, who is Professor of Surgery and Chief of Digestive Surgery Service at the University of Bordeaux, France, at The SAGES World Congress presented a vast experience of lyses of adhesions intra-abdominally for treatment of chronic abdominal pain. Complications were near-negligible, and there were no bowel injuries. There are many other areas in which the laparoscope is being used, and the surgeon's imagination appears to be the only limiting factor. We have personally used it in chronic peptic ulcer disease with outlet obstruction, performing a laparoscopic pyloromyotomy together with transoral endoscopic balloon dilatation. We have manipulated Tenckoff catheters and placed them back in the proper position after insufflating through the catheter with carbon dioxide. The literature shows other interventional techniques, such as the laparoscopic placement of a jejunostomy feeding catheter. 19 Perhaps the most exciting area of development arises from the thought that anything that can be placed in a bag, such as a solid organ (the kidney, spleen), can be removed through the laparoscope. Ralph V. Clayman, who is in the Department of Urologic Surgery at Washington University School of Medicine and who is publishing his technique in both the Journal of Endourology* and the New England Journal of Medicine, has performed laparoscopic nephrectomy in three patients. His technique involves not only laparoscopic dissection of the organ but also placement of the organ in a bag intra-abdominally. With the use of a tissue morcellator, the organ is removed through the laparoscope. Thus, any organ, even a segment of bowel, that can be placed in the bag could subsequently be removed from the abdomen without the open technique. Another area in which technology will advance the efforts of general surgeons will be the development of better needles and sutures, as well as instruments to be used intra-abdominally for bowel anastomoses. The gynecologists have been using Keith needles in the pelvis with good success. However, curved needles are being developed, which should facilitate intra-abdominal use. Still other areas are being investigated and include vagotomy for chronic peptic ulcer disease. Apparently, again, the Europeans are in the forefront, and their procedures include posterior truncal vagotomy and an anterior serosal myotomy. It appears that many are benefiting from these new interventional techniques. This includes a broad spectrum of people from the patient to the enterprising pig farmer who "rents" the animal to a training course and has it returned after its gallbladder has been removed by a neophyte laparoscopic surgeon. The issues in this area in the 1990s will be legion; however, they include application of this technology only in appropriate instances supported by sound surgical research and efforts to eliminate complications, which seemingly occur early in the learning curve of the surgeon. *For an initial report, see Clayman RV, Kavoussi LR, Long SR, et al: Laparoscopic nephrectomy: Initial report of pelviscopic organ ablation in the pig. J Endourol 4:247, 1990. 1094 THOMAS A. GASKIN ET AL. ISSUES AND CHALLENGES "The Laparoscopic Revolution-Walk Carefully Before We Run," an editorial by Professor A. Cuschieri," sets the precedent of referring to closed abdominal surgery as a revolution. If one takes that to mean rapid disorganized change, it is an appropriate term. The revolution will put pressure on the surgical community to adapt quickly and effectively. The issues and challenges can be classified as those related to development, training, credentialing, resource allocation, payment, and quality assurance and review. Development The Wall Street [ournai" correctly noted that laparoscopic surgery is not being developed in the traditional way by study in academic laboratories (with notable exceptions). 1, 30, 33 In keeping with Professor Cuschieri's description of "revolution," it has taken to the "streets." Laparoscopy is being developed in communities by enterprising surgeons supported by medical equipment companies. The question posed by Elmslie": ", . . surgeons 20 years ago were slow to recognize the future of gastrointestinal endoscopy. Will we have more vision when it comes to the question of CAS [closed abdominal surgery]?" is still germane. With exceptions, as evidenced by the bibliography, the community development oflaparoscopic surgery, has arisen by default and has been spurred on by the tremendous public demand. The challenge is to reinstitutionalize future developments in much the same way that political revolutions do. The question remains whether this will take place in academic centers or elsewhere. Training The SAGES 24 responded to the need for standards in training by publishing guidelines in May 1990. The authors of that report recognized both that surgical residency programs would not keep pace with the initial stampede of demand by those already in practice and also that there were surgeons with prior and continuing experience in diagnostic laparoscopy. As of January 1991, brochures for training programs are still largely from nonuniversity institutions. Some (not all) of these have an established curriculum, an experienced and stable faculty, and credible animallaboratories." The challenges are to continue such programs, set and monitor standards, and provide for the introduction of new techniques and skills. Credentialing Hospital boards and staffs need considerable variation in credentialing criteria. In general, however, there are reasonable standards of training for general surgery set by the Accreditation Council for Graduate Medical Education and the American Board of Surgery, but they do not include laparoscopic surgery to date. If there are not standards for training, if we cannot look to the American Board of Surgery or the Accreditation Council for Graduate Medical Education for identification of the criteria for qualification, how can hospital credentialing committees develop consistent standards and criteria for the granting of privileges? There are few general LAPAROSCOPY AND THE GENERAL SURGEON 1095 surgeons who have been taught laparoscopic surgery in an approved residency program. Most will have been exposed to the technique in a 2or 3-day course with an animal laboratory. Many general surgeons, having completed such a course, will ask for assistance and supervision from those with existing privileges in laparoscopic surgery, be they general surgeons or gynecologists, until they can demonstrate acquisition of those skills satisfactorily. The hospital credentials committee will be challenged to develop and enforce standards individually because of the rapidity with which the field has developed. In addition, it is probable that the credentials committee will not have someone with personal experience in the technique. The principle remains that individual hospital staffs and boards have considerable leeway in establishing requirements for credentialing. This variation is appropriate and necessary. The requirement of preceptorship has been adopted by many hospitals to satisfy the need for demonstration of proficiency. Resource Allocation Perhaps the biggest restraint on a more widespread adoption of laparoscopic cholecystectomy was the failure of the medical instrument industry to recognize and satisfy the demand for instrumentation. Long waiting lists and requirements that "complete" sets be purchased have been common.i" Hospital management and department chairs can expect a continued "arms race" as successive generations of equipment become available. Fortunately, hospital management already has considerable experience because of the development of diagnostic imaging. Nonetheless, the intense demand will require analysis of what can reasonably be expected in terms of patient volume and to establish the appropriate priority of the purchases vis-a-vis other capital requirements. Payment One would have thought that the principles of payment established by the gynecologic uses of laparoscopy would have prevented most of the disputes about payment for laparoscopic cholecystectomy and other general surgicallaparoscopic procedures. Unfortunately, that has not been the case. Some insurance companies assumed the untenable position that laparoscopic cholecystectomy was an experimental procedure. Clearly, laparoscopy was a proved technique for intra-abdominal surgery and cholecystectomy an established treatment of the diseased gallbladder. Equally extreme was the contention that laparoscopic cholecystectomy was a whole new operation (but not experimental) and justified substantial additional payment. Inconsistent and extreme positions by providers and carriers alike have not been a credit to either group. Quality Assurance Most advances in surgery relate to new applications of existing skills. Laparoscopy entails the learning of new skills. Once those skills have been mastered, evolution of new applications can resume as it has historically. By its nature, laparoscopic surgery has some inherent risks. There is a greater dependency on advanced technical instruments and the operators 1096 THOMAS A. GASKIN ET AL. of those instruments. More skill is required by all those involved in the operation: surgeon, assistant surgeon, camera operator, scrub nurse, circulating nurse, radiology technician, equipment nurse (laser, insufflation equipment, video), anesthetist, and even the scheduling clerk, who must coordinate the reservation of the room, the personnel, and the specialized equipment. Operating with two-dimensional images and without tactile and proprioceptive orientation is familiar ground to few. It has been predicted, with good reason, that the widespread introduction of these new techniques over a relatively short period of time will result in a number of misadventures. 2, 3, 31 Cholecystectomy is not a complication-free operation regardless of experience and technique. Use of a technique that requires different and, we maintain, greater skill plus a greater need for teamwork will produce a greater number of complications. Peer-reviewed reports of the frequency and nature of complications are not expected for several years. The challenge for quality assurance organization-hospital based and otherwise-will be to discriminate between complications that arise from the inherent limitations of the technique and those that arise from its inappropriate use or application. In our preoperative discussions, we have used the analogy of a "reverse lottery." Instead of a lot of people losing a little and a few gaining a great deal, a lot of people will gain substantially (in decreased pain and rapid recovery) and a few will lose a great deal by sustaining a major complication. The relative riskbenefit of open versus closed operations must have future definition for each application. In the interim, review organizations will be struggling with trying to judge the results (as they apply to individual patients and surgeons) of two different approaches to the same task with a different frequency of complications. They will be doing so without published or historic standards. Credentials committees will sympathize with them. SUMMARY 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 gynecology. The unanticipated demand by the public has placed unprecedented pressure on our systems for training, credentialing, developing, supplying, and evaluating changes in surgical technique. The diagnostic value of laparoscopy has been documented by a handful of general surgeons over the past several decades and is likely to become a more widely accepted technique. The potential of future developments in video-controlled operations is immense. REFERENCES 1. Berci G, Cuschieri A: Practical Laparoscopy. London, Bailliere Tindall, 1986 2. Cuschieri A: The laparoscopic revolution: Walk carefully before we run. J R ColI Surg Edinburgh 34:295, 1989 3. Cuschieri A, Berci G, McSherry C: Laparoscopic cholecystectomy. Am J Surg 159:273, 1990 LAPAROSCOPY AND THE GENERAL SURGEON 1097 4. Cuschieri A, Hennessy T, Stephens R, et al: Diagnosis of significant abdominal trauma after road traffic accidents: Preliminary results of a multicentre clinical trial comparing minilaparoscopy with peritoneal lavage. 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