Internationales Symposium 1997
Summary of the International Symposium, September 4 -6, 1997 in Bochum, Germany
Without doubt operative endoscopy was a revolution in surgical techniques. As a result of an increasingly sophisticated progress nowadays we operate older patients with indications that require advanced surgery with longer operation times and therefore enable those patients also to benefit from the minimal-invasive approach. In this cases metabolic and haemodynamic modifications of the pneumoperitoneum through carbon dioxide, which can possibly lead to complications, have gained in importance. Morphological studies showed in experimental models, that carbon dioxide has possibly an increasing effect on spillage of cancer cells.
The gasless laparoscopy technique seems to be a new modality to avoid some of the problems of carbon dioxide. Under the auspieces of the European and German Societies for Gynaecological Endoscopy (ESGE and AGE) and the American Asociation for Gynecologic Laparoscopists (AAGL) the first International Symposium on Gasless Laparoscopy in Gynaecology was held at the University of Bochum in Germany. The worldwide interest for this method was underlined by about 100 doctors from more than 25 nations, especially from developing countries. The scientific level of the meeting was a very high one, especially because of the huge amount of experimental work that was presented by motivated speakers. Under our honorary presidents Alan Gordon (UK), Kurt Semm (D), the presidents Liselotte Mettler (D) and Harry Reich (USA) we spend two and an half days searching for the development of new techniques and also realizing that laparoscopy is not more only a "video" topic but a real scientific discussion. The cooperation with other subspecialities as anaesthesiologists, general surgeons and neuro surgeons had also improved our knowledge of the problems of carbon dioxide.
As a brief summery of this congress further investigations of the problems due to carbondioxide especially during long operations and in older patient is needed. A decrease of the body temperature at about 1-3 °C and a decrease of the intra-abdominal temperature near to 32 °C can cause postoperative pain. The increase of the intra-abdominal pressure can cause a compression of the diaphragm with consecutive hypoventilation. A compression of the vena cava can lead to a reduction of cardiac output and a high central venous pressure to an increase of the peripheral resistance. The absorption and intravasation of carbon dioxide can cause an increase of arterial pO2, a metabolic acidosis, a hypercarbia and a hypoxemia. Domenico D'Ugo (an anaesthesiologist from Rome, Italy) summarized this metabolic modifications of carbon dioxide in the following paradox: "The need of using carbondioxide insufflation is virtually the only cause for excluding high risk patients, who certainly are the patients who would really benefit from minimal invasive procedures". Operating on patients with cardiac insufficiency, pulmonary obstruction or pregnancy can be a new a challange and a real indication for gasless laparoscopy. On the other hand the need for special endoscopic instruments, suture material, suturing devices, coagulation and cutting devices as HF, LASER, APC, CUSA or Sonic scalpell and at least the utilization of an huge amount of disposables lets the costs of endoscopic surgery sometimes grow into astronomic rates. By utilizing conventinal instruments and preparation techniques the gasless technique can help to save money and to reduce operation time. Peter Maher (AUS) pointed out that mechanical wall elevation allows also a portless access through abdominal wall incisions to structures which may require digital manipulations to allow diagnosis. The concept of gasless laparoscopy avoids also problems with gas loss, suction or specimen removal out of the abdominal cavity and allows a new aera of laparo-vaginal surgery.
The experimental models concerning the modifications of the peritoneum have been investigated by about 10 working grous worldwide. Joachim Volz (D), Vittorio Paolucci (D) and their co-workers pointed out that the acidotic modulation of the peritoneal surface can be one of the reasons for increased tumor growth after CO2 laparoscopy in animal models. Experimental trials have been presented about the effect of different gases on tumor progression, the tumor implantation in a nude mouse model, on in-vito human cell growth in a simulated pneumoperitoneum and about tumor seeding after laparoscopic surgery. Daniel Dargent (F) pointed out that due to the results of the experimental trials the endoscopic operations on complex ovarian cyst is a manadotory indication for the gasless technique. Michel Canis (F) stressed on the need of more experimental and clinical studies in order to prove the results that were found. It was concluded that laparoscopic oncological surgery should at this time only be performed under controlled precautions.
We have now about 11 devices for gasless laparoscopy since Kurt Semm (D) have introduced a simple "gasless" device, the Abdominal Cavity Expander (ACE). It seems that reusable devices will be the future market. Prototype models show a very good exposure of the abdominal cavity even in the upper abdomen. Simple mechanical as well as mechanic-electrical devices were constructed in some industrial research centers which will be on the market in the near future.
A new edition of the book on "Gasless Laparoscopy in General Surgery and Gynaecology" is going to be prepared and will include the work of this congress. At this time I would like to emphasize the fact that we should continue developing new techniques and indications for minimal access surgery. In case of "Gasless Technique" I'm sure that this method will bring a new modality to the repertoir of endoscopic surgical procedures. Endoscopic surgery with the phases of enthusiasm, criticism and realism is now bringing the real benefits of minimal invasive surgery to all our patients.
I would like to thank all who made this congress so successful!
Daniel Kruschinski, MD
Ruhr-University of Bochum, Germany