Laparoscopic surgical technology refers to the technique of performing surgical procedures by creating artificial channels through incisions on the body surface, inserting instruments into the body cavity or space. This includes methods such as laparoscopy, thoracoscopy, arthroscopy, and nephroscopy. In 1910, Jacobaeus from Sweden first utilized laparoscopy to observe the human abdominal cavity and successfully applied it the same year in separating pleural adhesions in tuberculosis patients, marking the beginning of thoracoscopic surgery. In 1938, Veress from Hungary invented the spring-loaded safety Veress needle, which remains in use today. During the 1950s, British physicist Hopkins invented the rod lens system to reduce light transmission loss, significantly improving the clarity of laparoscopic images and advancing its application in the diagnosis and treatment of gynecological and gastrointestinal diseases. In the 1960s and 1970s, Semm from Germany performed numerous gynecological laparoscopic surgeries using his self-designed automatic insufflation device, cold light source, endoscopic thermal coagulation device, and many laparoscopic-specific instruments. In 1987, Mouret from France, while treating a gynecological condition, simultaneously removed a diseased gallbladder using laparoscopy. This marked the beginning of the era of minimally invasive surgery represented by laparoscopic procedures. Today, laparoscopic surgery is widely practiced across various surgical specialties.
Modern arthroscopic technology originates from cystoscopy. In the 1990s, arthroscopy witnessed revolutionary advancements in the diagnosis and treatment of joint disorders. Arthroscopy enables direct visualization during diagnostic procedures, offering accuracy superior to other diagnostic methods and thus gaining widespread adoption. The application of tubular systems for surgery under arthroscopic guidance allows for minimal trauma and high precision, significantly advancing arthroscopic surgery. With continuous improvements in equipment and techniques, the range of applications of this technology continues to expand, demonstrating advantages over conventional surgeries and leading to the establishment of arthroscopic surgery as a dedicated field.
Although thoracoscopic surgery emerged as early as 1910, traditional thoracoscopy was limited to diagnosing pleural diseases and releasing pleural adhesions due to restrictions in endoscopic instruments. Since the late 1980s, the development of endoscopic imaging systems and laparoscopic staplers and instruments has provided new momentum for thoracoscopic surgery. Currently, thoracoscopic surgical technology is widely utilized for the resection of lung, esophageal, and mediastinal tumors, as well as in various fields of cardiac surgery.
Percutaneous nephroscopic technology involves creating a surgical channel from the skin to the renal collecting system, introducing a nephroscope into the renal calyces, renal pelvis, or upper segment of the ureter to diagnose and treat upper urinary tract diseases. In 1976, Fernström and Johannson from Sweden were the first to report the use of percutaneous nephroscopy for stone removal, pioneering minimally invasive treatment for kidney stones. Following a series of technical and equipment refinements, percutaneous nephrolithotomy has now become the preferred approach for treating kidney stones.
Equipment, Instruments, and Basic Techniques for Laparoscopic Surgery
Although various endoscopes are utilized in clinical settings, they share basic components and operating principles. This section focuses primarily on laparoscopic equipment.
Laparoscopic Image Display and Storage System
This system includes components such as a laparoscopic lens, a high-definition miniature camera, an analog-to-digital converter, a high-resolution monitor, an automatic cold light source, and an image storage system.
Laparoscopic Lens
Utilizing Hopkins technology, the laparoscopic optical system transmits light through quartz glass rods and refracts through an air lens assembly to produce exceptionally clear and bright images with virtually no distortion. Laparoscopes are available in diameters of 10 mm, 5 mm, and 2.5 mm, with lens angles of 0° or 30°.
Miniature Camera and Analog-to-Digital Converter
The laparoscope is connected to a camera, and its image is converted from optical signals to electrical signals using a charge-coupled device (CCD). These signals are then digitized via an analog-to-digital converter.
Monitor
Current fully digital monitors display the image directly after line-by-line scanning, having undergone conversion from optical signals to digital signals via the CCD and analog-to-digital converter. These monitors achieve horizontal resolution of up to 4,096 pixels.
Cold Light Source
The cold light source is connected to the laparoscope via fiber optics to illuminate the surgical field. Light intensity can be controlled either automatically or manually. Light sources include xenon lamps, metal halide lamps, argon lamps, and metal arc lamps. Heat generated by these lamps is dissipated through strong internal ventilation fans and via conduction through the fiber optics, preventing burns to abdominal organs.
Recorder and Image Storage System
High-quality recorders include Beta recorders and S-VHS recorders, although lower-quality household VHS recorders can also be used. Professional image capture cards and corresponding software can be employed to capture and store surgical videos in real-time on a computer's hard drive.
CO2 Pneumoperitoneum System
The purpose of establishing a CO2 pneumoperitoneum is to provide sufficient workspace and visibility for surgical procedures, which is a necessary condition for avoiding unintentional injury to other organs. The entire system consists of a fully automatic high-flow insufflator, a carbon dioxide cylinder, a trocar with a protective sheath, and a spring-loaded Veress needle.
Surgical Equipment and Instruments
The equipment primarily includes high-frequency electrocautery devices, lasers, ultrasonic scalpels, laparoscopic ultrasound systems, and irrigation-suction devices. Surgical instruments include electrosurgical hooks, scissors, dissectors, graspers, forceps, intestinal clamps, suction tubes, needles, fan retractors, needle holders, clip appliers, and various endoscopic staplers and anastomosis devices.
Basic Techniques
Establishing Pneumoperitoneum
Closed Technique
A curved or longitudinal incision approximately 10 mm long is made at or below the umbilical margin, reaching the subcutaneous layer. The abdominal wall is lifted using towel clips or by hand, and the Veress needle is inserted through the incision either vertically or at an oblique angle toward the pelvic cavity. A double "give" sensation is felt as the needle passes through the fascia and peritoneum. Confirmation that the needle is in the abdominal cavity can be achieved using aspiration, negative pressure, or volume tests, following which carbon dioxide is introduced into the abdominal cavity until the preset intra-abdominal pressure of 12 mmHg is reached, completing the pneumoperitoneum.
Open Technique
A curved or longitudinal incision approximately 10 mm long is made at or below the umbilical margin, extending to the deep fascia. Under direct vision, the peritoneum is opened, and finger exploration confirms entry into the abdominal cavity and the absence of adhesions beneath the abdominal wall. A trocar is then placed, and the insufflation tubing is connected to establish the pneumoperitoneum.
Hemostasis in Laparoscopy
Electrocautery is the primary method for achieving hemostasis during laparoscopic surgery and includes both monopolar and bipolar techniques. Additional methods include titanium clips, Hem-o-lok clips, ultrasonic scalpels, automated staplers, closure devices, ligatures, and sutures.
Tissue Dissection and Cutting in Laparoscopy
Unlike open surgery, laparoscopic surgery does not allow for tactile assessment of tissue density. Tissue dissection and cutting are performed using surgical instruments and primarily include methods such as electrocautery cutting, sharp dissection with scissors, ultrasonic coagulation and cutting, blunt dissection with grasping forceps, and high-pressure water jet dissection.
Suturing in Laparoscopy
Suturing in laparoscopic surgery is a technically challenging procedure that surgeons are required to master and often involves training on simulators and hands-on practice. Traditional suturing techniques can be applied laparoscopically, and nearly all types of suturing needles and threads can be used in laparoscopic surgery.
Specimen Removal
Specimens that are smaller or slightly larger than the diameter of the trocar sheath can be retrieved using a specimen bag through the trocar. For larger specimens, the operation site may require a slight enlargement or the creation of a small additional incision for removal using a specimen bag.
Indications and Common Procedures in Laparoscopic Surgery
In its early years, laparoscopy was primarily used for abdominal exploration and diagnostics. With continuous technological advancements, the development of laparoscopic instruments, and the adoption of fully digital, large-screen, high-definition laparoscopic systems—particularly the introduction of 4K ultra-high-definition laparoscopes and intelligent energy systems such as electrocoagulation and vascular closure systems—the clinical application of laparoscopic techniques has become increasingly mature and widespread. These advancements have significantly enhanced the safety of laparoscopic surgery.
Currently, indications for laparoscopic diagnosis and treatment have broadened compared to earlier practices, while contraindications have become more limited, ushering this technique into a new era of minimally invasive surgery. Major indications now encompass nearly all benign diseases of the abdominal and pelvic cavities.
For malignant tumors, with the growing volume and quality of evidence in evidence-based medicine, surgical guidelines have been developed by professional associations for such procedures. The proportion of malignant tumor resections performed laparoscopically has increased annually, with laparoscopic radical colectomy and laparoscopic radical gastrectomy becoming increasingly common.
In addition, procedures such as laparoscopic pancreaticoduodenectomy (Whipple procedure), anatomical hemihepatectomy, liver donor harvesting, kidney donor harvesting, and vascular aneurysm resection or bypass have developed rapidly in recent years. Many large medical centers have now implemented these advanced procedures.
Complications of Laparoscopic Surgery
The minimal trauma of laparoscopic surgery does not necessarily imply minimal surgical risk. In addition to the complications that may occur in traditional open surgeries, laparoscopic procedures may also lead to unique complications specific to the laparoscopic technique.
Complications and Adverse Reactions Related to CO2 Pneumoperitoneum
CO2 gas is commonly used to establish pneumoperitoneum in laparoscopic surgery. The creation of a pneumoperitoneum inevitably impacts cardiopulmonary function to some extent. Effects include elevation of the diaphragm, reduced lung compliance, decreased effective ventilation, reduced cardiac output, venous stasis in the lower extremities, and decreased visceral blood flow. These changes may result in complications such as subcutaneous emphysema, pneumothorax, pneumopericardium, gas embolism, hypercapnia, and acidosis.
Complications Specific to Laparoscopic Surgery
Vascular Injury
Vascular injuries can occur during various types of laparoscopic surgeries. Aggressive trocar insertion is the primary cause of major retroperitoneal vascular damage. Although such injuries are rare, they carry a high mortality rate. Additional vascular injuries may occur during surgical manipulation.
Visceral Injury
Visceral injuries are relatively common during laparoscopic procedures. These injuries, if not detected during surgery, may lead to serious complications such as postoperative peritonitis, which may remain undiagnosed until severe consequences ensue. Visceral injuries can be classified into hollow organ injuries and solid organ injuries depending on the affected structures.
Abdominal Wall Complications
Abdominal wall complications in laparoscopic surgery are primarily related to trocar insertion and include trocar site bleeding, abdominal wall hematomas, trocar site infections, necrotizing fasciitis of the abdominal wall, and trocar site hernias.
Robot-Assisted Surgical Technology
With the continuous development of medical technology and artificial intelligence, robot-assisted surgical technology is attracting increasing attention in the field of surgery. Surgical robots, through mechanical arms, provide support for surgeons in terms of vision, auditory feedback, and tactile sensation during operations. Modern robotic surgical systems typically employ advanced sensor technology to enable predictive and intelligent control, assisting surgeons in performing more precise surgical procedures. The introduction of robotic surgical technology has ushered in a new era of minimally invasive surgery. Among these systems, the Da Vinci surgical robot from the United States is currently the most widely used and is now in its fourth generation. With the emergence and clinical application of domestically produced surgical robots, surgical costs are expected to decline significantly.
Components of a Surgical Robotic System
Surgeon Console
The console serves as the control center for the system and consists of a computer system, monitor, control handles, and output devices.
Bedside Robotic Arms System
This component includes two to three working arms and one camera arm. The camera arm is used to hold the laparoscope during the operation, while the working arms perform various surgical tasks.
3D Imaging System
The system contains image processing equipment integrated into the Da Vinci system and is equipped with monitors. It can also house auxiliary surgical equipment such as the CO2 insufflation system.
Advantages of Robotic Surgical Systems
Compared to conventional laparoscopy, robotic systems exhibit the following advantages:
- Visual Perspective: The 3D imaging system provides spatial positioning for finer operations and improves the precision of surgical manipulation.
- Ergonomics: Surgeons operate from a seated position at the main console, offering better comfort during procedures.
- Operative Precision: The system filters out hand tremors, allowing for more precise surgical movements and enabling delicate maneuvers.
- Flexibility: The system avoids instrument collisions and issues related to triangulation. It also supports functions like automated suturing, saving time and offering high flexibility.
- Tactile Feedback: Sensors measure the force of interaction between surgical instruments and tissues, enabling surgeons to perceive the magnitude and direction of contact forces.
- Remote Surgery: Supported by technologies such as high-speed internet, remote surgeries across geographical locations have been successfully performed.