A Light in the Dark
5 October 2023
From going in blind to the latest cutting-edge technology, our Curator explores the important developments in visualising the surgical field.
A key aspect which has constantly affected the ability of surgeons throughout surgical history is the ability to see inside the body. When the profession of surgery was in its infancy only external surgeries were performed, and normally as a last resort; amputation, growth removals, trephination, abscess draining and of course bloodletting. The reluctance to do internal surgery was due to three major factors; first, and perhaps the most important, was a lack of effective pain relief, secondly infection (the biggest killer of surgical patients before 1860), and lastly the inability to see inside the surgical site.
A Lithotrite made by Simpson, Edinburgh. 19th Century (Surgeons’ Hall Museum Collection)
The only exception to this rule was ‘cutting for the stone’ or lithotomy. This was a dangerous and painful procedure, but one that patients risked due to the excruciating and continual pain that a bladder stone itself could cause. The lithotomy was performed by opening the bladder via the perineum and removing the stone. The death rate from this procedure was very high, with some suggesting as much as one in four. An alternative treatment, lithotripsy, was created in the early 1800s, which involved a surgeon inserting a catheter into the bladder via the urethra and crushing the stone inside the bladder using an instrument called a lithotrite. This is arguably one of the earliest attempts at minimally invasive surgery, however this procedure was performed blind! The surgeon would ‘feel’ for the stone using an instrument called a sound and feel the instrument making impact with the hard stone. Once located, the stone could be grasped and drilled down into smaller pieces which could be passed naturally.
La Dentiste by Gerard Van Honthorst, 17th Century
These early surgical interventions indicate how important it is for the surgeon to be able to see inside the body. Even when open surgery became possible, thanks to anaesthesia and aseptic techniques, the problem of visualising the site remained. Light was a key obstacle - the difficulty of trying to view an open surgical site by candlelight can only be imagined today. Hospital operating rooms had large windows and were south facing to absorb as much light as possible, but this of course was dependent on weather and time. Instruments such as retractors helped to expose the surgical site and in return allow in more light, but it was the development of electricity and the light bulb that helped make open surgery more practical. Portable light from headlamps enabled surgeons to focus the light on where they needed to see, and future powerful overhead surgical lighting would finally allow surgeons to operate without restrictions.
These advances in externally sourced light were large steps forward. However, inventions starting in the early 19th century paved the way for the possibility of seeing inside the body without incision (using natural orifices). These early scopes led to the prospect of operating either without an open operating site or with a single port entry (minimally invasive or keyhole surgery).
The first attempt at using light and tube to view an internal organ was the Lichleiter, invented by Phillip Bozzini in 1806. This device used a viewing tube, candle and concave mirrors to reflect the light. This was followed by the first successful cystoscope by Nitze and Leiter in 1879, and although originally a diagnostic tool, it soon developed into use as a catheterising and irrigation tool. These changes were enabled by the invention of electricity and the light bulb. The downfall of this lighting technique was overheating.
The invention of fibre-optics in the 1950's overcame numerous restrictions when it came to seeing inside the human body. This discovery, alongside the rod-lens made by Harold Hopkins (1918-1994), drastically improved the quality of the image and led the way to minimally invasive surgery. The fibre-optics removed the heat component of earlier scopes, and the glass lens removed the small but bulky and poor-quality lenses, which allowed the scopes to be smaller in diameter and much more suited for surgical use. Basil Hirschowitz (1925-2013), a gastroenterologist, helped to expand this technology to make a flexible endoscope, particularly useful in gastroenterology.
Part of illuminating device for endoscope, called a Rod-Lens endoscope. Created in the 1960's by Harold Hopkins, and the same theory is still used today. (Surgeons’ Hall Museum Collection)
Minimally Invasive Surgery
Until this point, these various scopes had been used to enter natural orifices only. At the turn of the 20th century, the first laparoscopy occurred. Georg Kelling, a German surgeon, inflated the abdomen of a dog with air and through a small incision inserted a cystoscope for investigation. Whilst he claimed he also performed this procedure on human patients, it is Hans Christian Jacobaeus who is credited with performing the first human laparoscopy, the results being published in 1911.
Until the 1970's these types of operations were mainly used for diagnostic needs, yet they were nonetheless the first steps towards minimally invasive surgery. They formed the foundations that surgeons could - using small incisions, a port, a scope and adapted instruments - operate without the need for open procedures. Kurt Semm from Germany developed additional endoscopic tools, and as such was the first to perform laparoscopic surgery, an appendectomy in 1981. Despite initial fears and resistance, laparoscopic surgery continued to advance.
The next key development was in videoscopes in the 1980's, converting the image from the scope onto a display monitor. This would be a crucial step for minimally invasive surgery, allowing the surgeon to hold instruments in both hands, whilst viewing the surgical scene on a large screen rather than through a small eye piece. This would also assist in surgical training, with numerous surgeons being able to watch the video feed rather than crowding around the operating table, or indeed watch playback from past surgeries.
MINOP Endoscope. This minimally invasive system allows neurosurgeons to access deep seared regions of the brain without trauma to sensitive neurovascular structures. The endoscope allows illumination and inspection of angles in hidden parts of the surgical field with clear depictions of anatomical structure.
Closer to Home
In Scotland, the charge for minimally invasive surgery was led by RCSEd Fellow Professor Sir Alfred Cuschieri, who performed Britain’s first minimally invasive surgery at Ninewells Hospital, Dundee in 1987. He holds nearly sixty patents for surgical instruments, many of which were designed to advance minimally invasive procedures. He also helped to set up one of the first training units for this new skill in Dundee in 1992, which still stands as the Surgical Skills Centre at Dundee Institute for Healthcare Simulation, University of Dundee.
Minimally invasive surgery advanced throughout the 1990's, and more complicated procedures were successfully performed. The benefits included smaller incisions, reduced risk of infection, fewer complications, quicker recovery times and less scarring, making this type of procedure popular with patients. As the practice soared, new technology was invented in order to improve the restrictions presented by minimally invasive procedure.
The Museum’s Body Voyager galleries display some of the earliest surgical camera robotics. The benefits of these early robotics included eliminating the tremor on the part of the surgical assistant, who would previously be required to hold the camera in a fixed position for long periods of time. It also placed the control of the camera back into the more experienced hand of the surgeon, removing communication delays between the surgical team.
Aesop 300 on display in the Body Voyager Galleries. With thanks to Freehand 2010 Ltd
The oldest we have on display is the Aesop 300, an Automatic Endoscopic System for Optimal Positioning. Aesop 3000 was unusual in that it was voice operated. The robot had three settings: discontinuous, continuous, and pre-programed. In discontinuous mode command words such as ‘left’, right, ‘up’ or ‘down’ made the robot move in small steps, with commands repeated as necessary. Using the continuous setting, direction commands were preceded by the command ‘move’. The robot moved the camera in this direction until told ‘stop’. The pre-programmed mode allowed three locations of the operating field to be stored in the software. It was reported to be user friendly, but there were concerns that unclear commands and background noise could lead to errors and unwanted movements. Additionally, each user needed a voice card to be created beforehand to allow the system to recognise the individual’s voice commands.
EndoAssist on display in the Body Voyager Galleries. With thanks to Freehand 2010 Ltd
The EndoAssist surgical robot by Armstong Healthcare Ltd was introduced in the UK in the 1990's. As with other robotic camera holders, this was designed to allow the surgeon more direct control of the visual field. EndoAssist was controlled by the surgeon’s head movements through a headset which sent directional signals to the robot via an infrared receiver on the surgeon’s monitor. A directional arrow appears on the viewing monitor and the surgeon pushes down on a foot pedal to confirm and activate the movement in that direction, until the foot pedal is released. The robot could pan left and right, tilt up and down and, in addition, could also zoom in and out. To activate the zoom mechanism the surgeon would double tap the foot pedal. The EndoAssist robot had an additional safety feature, which limited the amount of force it could exert to prevent tissue damage.
Freehand 1.0 on display in the Body Voyager Galleries, With thanks to Freehand 2010 Ltd
One major issue with these early designs was the size of the robots. Surgical spaces are limited, and these large robots took up a great deal of space, as well as being cumbersome to move. The Freehand surgical system was developed as a smaller, more portable version of EndoAssist in the early 2000's. The Freehand system uses the same controls as EndoAssist, with the surgeon wearing a headset that detects movements of the head, but the whole unit is much smaller, lighter and more affordable than its predecessors. It is easily attached to the operating table so does not need to be repositioned if the table is moved. Like EndoAssist, the Freehand system has a safety feature that limits the amount of force it can exert to prevent damage to tissue.
Innovation and technology continue to address limitations, particularly in minimally invasive procedures. This includes increasing dexterity and visualisation, while reducing or eliminating hand tremor and tiredness. Robots now also offer the ability to provide 3D HD quality visualisation fully operated by the surgeon.
The da Vinci robotic surgical system, developed by Intuitive Surgical, has dominated the field since 2000. The system consists of 3 parts; the surgeon console, the patient cart and the vision cart. One of the arms of the patient cart holds the 3D high definition camera, connected via the vision cart, which shows a magnified live feed of the procedure to everyone in the operating theatre and directly to the surgical console. The other three arms hold interchangeable, wristed instruments that can perform delicate and precise movements with a far greater range of movement than the human hand. These movements and the camera are directly controlled by the surgeon at the console. The fact the surgeon can sit at the console eliminates tiredness and potential future back problems from overextending at the patient table for long procedures. Another benefit of the da Vinci is their work in introducing where possible a single-entry port, where all instruments and the camera are introduced in a single incision site.
Following the success of larger companies like Intuitive Surgical, there has been an explosion in the field of surgical robots in recent years. Many new companies are investing in research and development, with the aim of making surgical robots that are smaller, more portable and less expensive. One example is the Versius robot, developed by CMR Surgical in the UK. This has recently been given European approval for clinical use, and is now used in several hospitals including the Western General in Edinburgh. Similar in function to the Da Vinci system, this smaller robot is more portable and can be used in smaller, local hospitals without the need for a dedicated robotic suite.
da Vinci surgeon console on display in the Body Voyager Galleries
Today, open, minimally invasive, natural orifice and robotic procedures and techniques are available to the surgeon. This is due to the significant innovation in lighting and cameras throughout the centuries. To think it was only 230 years ago that surgeons were reliant on candlelight, 217 years since the first attempt at a scope and only 40 years ago that the first minimally invasive procedure took place in the UK, it will be interesting to see where the next few decades take surgical abilities.