Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Almost 190 years later, on 9 February 1996, after his annual symposium on laparoscopic surgery in the Sint-Lucas Hospital in Assebroek, a suburb of Bruges, Belgian surgeon Luc Van der Heijden is sitting a little nervously at a small table at the front of the auditorium. For this official occasion, he has changed out of his operating clothes and put on a smart suit. Television cameras are focused on him and technicians are trying to make contact with the Sint-Antonius Hospital in Nieuwegein, 150 kilometres away in the Netherlands. The communication link has been made possible by relatively new technology, the Integrated Services Digital Network (ISDN). Dutch surgeon Peter Go appears on the screen. The image is a little shaky and the sound is tinny as he explains that his patient is already anaesthetised and ready on the operating table. He has a groin hernia, which is going to be repaired by laparoscopic (keyhole) surgery. The camera in the patient’s abdomen will not be held by human hands, however, but by a robot – and Van der Heijden is going to operate it from Belgium. While the members of Go’s operation team in the Netherlands stand with their arms folded in front of them, with the press of a button in Belgium the camera moves up and down and from left to right in the man’s abdomen.

  Although the laparoscopic hernia repair was eventually completed by the Dutch surgeon Go, this remote operation of the camera was the world’s first experiment with telesurgery. Now, twenty years later, complex operations – such as removal of the rectum, the adrenal glands, parts of the large intestine, or a gastric bypass – are performed laparoscopically as standard procedure. That means they can be performed more quickly (usually within one or two hours) more safely and more easily than was the case with a conventional, open operation. How did we get to this stage?

  You don’t get far with an instrument that requires lighting a candle, and in 1879 Viennese instrument-maker Josef Leiter and urologist Maximilian Nitze solved the problem once and for all by moving the light source from outside the body, to inside the bodily cavity itself. Leiter and Nitze developed a cystoscope, an instrument that enabled them to look inside the bladder through the urethra with the use of a glowing wire (this was almost six months before Thomas Alva Edison would invent the light bulb) to produce light, which was cooled with water. The cystoscope made Leiter world famous. He persuaded the assistant of the greatest surgeon in the world, Theodor Billroth in Vienna, to help him develop the ultimate endoscope: a gastroscope, an instrument to look inside the stomach. Leiter and the assistant, Johan von Mikulicz, constructed a tube with a water-cooled light on the end. As the patient had to swallow the long tube in its entirety, von Mikulicz performed the first gastroscopy on a circus sword-swallower in 1880. Von Mikulicz would use the gastroscope to examine the stomachs of hundreds of patients, sometimes together with his pupil Georg Kelling.

  An examination with Von Mikulicz’s rigid tube must have been a terrible experience for the patient. He would be laid on the table on his back, with his head hanging over the edge. Then the metal tube, which was a good 60 centimetres long, would be pushed through his open mouth, down his oesophagus and into his stomach. The stomach was then made visible by pumping it up with air and switching on the light. If the patient lay still, did not panic or choke, the doctor would have enough time to inspect part of the stomach. Not much, but more than anyone had ever dreamed of until then.

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  Towers and trocars

  A laparoscopic operation relies entirely on technology. It requires four devices, which are mostly stacked on top of each other on a movable trolley known as a laparoscopy tower. At the top is the screen, and below the camera unit, to which the handheld digital camera head is connected, is the insufflator, which inflates the abdomen to a constant pressure with carbon dioxide, and the light source. Three cables run from the tower to the operation: the cable from the camera, a fibre-optic cable for the light, and a tube for the carbon dioxide gas. The camera and the light cable are connected to the laparoscope, a tubular instrument about 10 millimetres in diameter and 30–40 centimetres long, with a lens system for the image and light. To gain access to the inflated abdominal cavity, devices called trocars are inserted through the abdominal wall. These are tubes between 5 and 12 millimetres in diameter with an airtight valve, through which the laparoscope, clamps and other instruments can be placed in the abdomen. Electricity is used for cutting and cauterising in the abdomen. That is why the gas in the abdomen may not contain any oxygen and all the instruments and trocars are electrically insulated. The trocars and the laparoscopic instruments are minute and mechanically complex, and as they are easily damaged and difficult to clean, many are disposable and are discarded after each laparoscopy. That makes laparoscopic surgery expensive, but that is paid back by the fact that patients spend less time in hospital.

  * * *

  The next milestone was actually a by-product of a different idea. Experiments inflating the abdominal cavity with air had been carried out for many years in a process known as insufflation; it was tried as a treatment for tuberculosis in a time when experimentation was all that could be done to combat wasting diseases, and it was even alleged to have been successful in some cases. Either way, it had become clear that inflating the abdomen with air could do little harm. Von Mikulicz, too, had experimented with insufflation and had used the same air pump for his gastroscope. His assistant Georg Kelling had come up with the idea of raising the air pressure in the abdominal cavity higher to stop internal haemorrhaging in the abdomen, and had experimented with this treatment on dogs.

  First, Kelling generated a rupture of the liver in the test animal. Then he inflated the abdominal cavity and waited. But the dogs kept dying. He did not understand why the idea would not work and wanted to know exactly what happened in the abdominal cavity. So he inserted a Nitze-Leiter cystoscope through the wall of the inflated abdomen to see it with his own eyes. What it showed was that the air pressure did not press the rupture in the liver closed at all. As he watched the dog bleed to death, he realised he had invented something new.

  On 23 September 1901, Kelling repeated the experiment in front of an audience at the 73rd Congress of the Naturalist Scientist’s Medical Conference in Hamburg, but now without rupturing the liver. He inflated the abdominal cavity of a healthy dog with air, inserted a cystoscope through the abdominal wall and keyhole surgery was born.

  It is difficult to imagine that laparoscopy, which is now irrevocably part of modern surgery, was once completely the domain of non-surgical internists. When Kelling performed that first laparoscopy experiment in 1901, there were few options for supplementary tests to support a diagnosis. Blood tests were still at an embryonic stage, X-rays did not show much of value when it came to the abdomen, and microscopic study was only possible after a patient had died. Laparoscopy was therefore a welcome new method that facilitated significant progress in medicine but which, as yet, had little to do with surgery, and was instead used to examine the liver and other organs close up to determine how far a disease had spread. And the procedure was not without teething problems: in 1923, an abdomen inflated with oxygen briefly caught fire, fortunately doing little damage to the patient. Since then, carbon dioxide – which cannot explode – has been used.

  It was not surgeons who took the next step – from diagnostic laparoscopy (looking inside the abdomen to see what there is to see) to therapeutic laparoscopy (looking inside the abdomen to do something) – but gynaecologists, because it is not only the liver that can be inspected with a laparoscope through the navel: there is also a perfect view of the womb and ovaries. All you have to do is tilt the operating table with the head downwards, so the intestines shift position from the lower to the upper abdomen. And because, unlike internists, gynaecologists were accustomed to performing operations, it only required a small step for them to conduct minor operations with the aid of a laparoscope. They started with laparoscopic sterilisation, which entailed tying off both fallopian tubes, and then went further, lancing cysts on the ovaries and removing ectopic pregnancies. As they go
t better at it, they performed increasingly complex procedures. German gynaecologist Kurt Semm removed uterine fibroids and was eventually able to remove a whole womb laparoscopically. In 1966, he marketed the first automatic insufflator, the CO2-Pneu-Automatik, which inflated the abdomen with carbon dioxide and kept it at a safe constant pressure. Semm also developed the first laparo- trainer, a model in a box with which gynaecologists could learn how to perform laparoscopic operations.

  In the Netherlands on 2 December 1975, Henk de Kok, a surgeon who learned laparoscopy from his brother Jef, a gynaecologist, performed the world’s first laparoscopically assisted appendectomy at the hospital in the Dutch town of Gorinchem. With the laparoscope in one hand, he located the appendix and, with the other, he determined the location on the abdomen where he could make a minuscule incision through which he could extract the appendix, watching all the time through the laparoscope. His fellow surgeons thought the whole procedure scandalous.

  Laparoscopy had never enjoyed much popularity among surgeons. Because you always had to hold the laparoscope with one hand, you only had one hand free to perform the procedure. Surgical applications of laparoscopy only really became possible with the advent of a completely new technology. In 1969, George Smith and Willard Boyle invented the charge-coupled device, better known as the CCD chip, which enables images to be digitalised and processed. The first CCD camera came on the market in 1982 and, within a few years, the latest models were small enough for a surgeon’s assistant to hold the camera while the surgeon stood upright, watching the screen. Still, many surgeons were not convinced. The first video-assisted laparoscopic cholecystectomy – the removal of a gall bladder with a video camera and a television screen – was performed by Phillipe Mouret in Lyon in 1987. Mouret was in fact a gynaecologist, but the successful operation set many a surgeon’s hands itching and, within a few years, laparoscopy had spread like wildfire.

  The cholecystectomy became the most commonly performed laparoscopic operation in the world. It only requires three or four tiny incisions, altogether no bigger than four centimetres, while the incision for a classic gall bladder removal was longer than 15 centimetres. The public noticed the difference immediately, as the innovation was big news in the media. Patients experienced much less pain and no longer had to spend a week in hospital, but could go home the next day. It was the start of a trend that unleashed a genuine revolution. Minimal invasive surgery – performing the maximum surgical intervention with the smallest possible operational technique – became the magic word in twenty-first century surgical practice. It sounds so logical, but it was only possible as a result of complex high-tech developments.

  Now, there is not a single organ in the abdomen that cannot be operated on laparoscopically. In 2001, French professor Jacques Marescaux built on Van der Heijden and Go’s feat by performing a trans-Atlantic operation which – with an obvious sense of spectacle – he called Operation Lindberg. From New York, he controlled a robot in Strasbourg, performing a laparoscopic cholecystectomy on a female patient nearly 4,000 miles away. More recently, without making an incision, Marescaux removed a gall bladder endoscopically through an opening in the vagina. Yet, despite surgeons’ best efforts to showcase surgery as an innovative discipline, it is radiologists and cardiologists who have made the most spectacular progress in minimal invasive techniques in recent years. They can now replace a heart valve through a puncture in the groin, stop a bleeding spleen, remove a stone in the bile duct through the liver and treat a rupturing aortic aneurysm as if it is the easiest thing in the world, without the need for an operation at all.

  As for non-surgical physicians, they stopped using diagnostic laparoscopy around the same time that surgical laparoscopy with a video camera began, but not because surgeons took it over from them. Other technologies had been developed, including ultrasound scans and computed tomography (CT) scanning, which give a much clearer image of the liver than laparoscopy.

  Georg Kelling, the man who discovered laparoscopy, died at his home in 1945 during the bombing of Dresden. His body was never found.

  18

  Castration

  The History of a Very Simple Operation: Adam, Eve and Farinelli

  THE ANCIENT GREEK creation legend includes one of the most frequently performed surgical procedures in the history of humankind. Primal couple Uranus and Gaia, representing the sky and the earth, have children who are giants and Uranus, afraid that he will be usurped by one of his sons, casts them all into the underworld. But Uranus’s fears prove true as, with the help of his mother, the Titan Cronos escapes, castrates his father and takes over the reins of power. For ten days, Uranus’s genitals fall towards earth, finally plunging into the sea and giving birth to the goddess Aphrodite. Cronos is just as fearful of losing power as his father and devours all his own children, with the exception of Zeus, who escapes and later returns to kill his father. The three largest planets in our solar system are named after these three great gods: Uranus, Saturn (the Roman equivalent of Cronos) and Jupiter (the Roman equivalent of Zeus).

  Castration also occurs in another creation legend – though in reverse form. The Egyptian god Osiris is cut into fourteen pieces by his angry brother Seth and spread all over the world. Isis, Osiris’s wife, searches for the pieces and finds thirteen of them, which are then surgically reassembled. Isis becomes the Egyptian patroness of surgeons and Osiris is once again god enough to father a son by her, Horus. This is quite an accomplishment, since the missing fourteenth part of Osiris is his genitals. Horus eventually becomes the god of the sky and kills Seth.

  It is not only the Egyptian creation legend that closely resembles the myth of Uranus and Cronos; the creation story in the Old Testament also has many similarities. As in the Greek version, the biblical story starts with the creation of a male and a female: Adam and a woman referred to in some interpretations as Lilith are created from the dust of the earth. In both legends, the man then undergoes an operation: Adam is anaesthetised and a rib is removed, while Uranus is castrated. From each of the removed body parts, a new woman is created – Aphrodite in the Greek version and Eve in the Bible. What is interesting about the biblical story, from a surgical perspective, is that the body part extracted from Adam is not, as with the Greeks and the Egyptians, the easy-to-remove genitals. Removing a rib was far too complex an operation for that time, in fact inconceivable, given the surgical dissection it requires. Furthermore, the Bible also tells us that the operation left a scar on Adam’s body, yet, there is no scar on the side of a man’s chest, and men have the same number of ribs as women: twenty-four.

  But men are indeed born with scars. Two, to be precise, as biologist Scott Gilbert and biblical scholar Ziony Zevit pointed out in a fascinating article in 2001. The navel is a scar left over after the umbilical cord is discarded. The second scar is the perineal raphe, a vertical line exactly in the middle of the scrotum and the base of the penis, which is a remnant of the embryonic development of the male urethra. Nearly all other mammals have a bone beneath this line, known as the baculum, but men are among the few that do not. This is interesting because the Hebrew word tzela, used in the Bible, does mean ‘rib’ but also a support joist or buttress. With a little imagination tzela could refer to a different long, rigid bone, perhaps the baculum. Could this penis bone – that men do not have – be the ‘rib’ that was removed from Adam? Was it a castration after all, the resection of Adam’s ‘supporting buttress’?

  As castration was apparently nothing out of the ordinary for the authors of these old myths, the operation must have very early origins. That is quite possible, since it is not a particularly complex procedure: you can easily cut, chop or strike off someone’s genitals with even the simplest of tools – two rocks, for example. The castration of Cronos was recorded by Hesiod in the eighth century BC, but the story was already part of a much older tradition, and indeed there are references to castration in the Old Testament that state that men whose testicles have been crushed or cut out cannot ent
er heaven.

  Initially, castration was a dangerous operation that served to punish or subjugate. In China and other parts of the Far East, it was applied as an alternative to execution for prisoners of war. The techniques were very cruel: in some cases the genitals were smeared with faeces and then bitten off by a dog. But even with less unhygienic methods, by simply cutting or chopping off everything hanging between the victim’s legs, the chances of bleeding to death or developing gas gangrene were so high that the outcome differed little from a regular death sentence.

  Yet, since at least 2,500 years ago, there must have been ways of castrating men without such a great risk, since not all of them underwent the operation as a form of punishment and it was often of great importance that it was successful. Persian kings received annual ‘tax’ payments from their provinces in the form of a set number of castrated young men from the most prominent families in the country. On the Greek island of Chios, a man called Panionios made his fortune performing castrations, a profession that was scandalous by Greek standards. This self-proclaimed surgeon would buy the most attractive slaves at the local market, castrate them and sell them at a high price on the mainland in Asia Minor. We do not know how he performed the operation, but he was clearly so successful at it that he could live well from the trade. One of his victims ended up as a eunuch at the Persian court, where he worked his way up to become a confidant of King Xerxes, which allowed him the opportunity to take revenge on the surgeon who robbed him of his manhood. He returned to Chios, where he forced Panionios to castrate his own four sons, who then had to return the favour on their father.