Intra-abdominal color photography (photolaparoscopy)

Intra-Abdominal Color Photography (Photolaparoscopy)

Gt;STAV A. UHLmH, M.D., and EARL G. ~[ERRITF, M.D.

T HE t'L'R~'OSE of this paper is to describe the instruments and technics of photolaparoscopy and results achieved with up-to-date equip-

m e n t ,

In 1901, at a meeting of German physicians in Hamburg, Georg Kelling 14 demonstrated a new method of exploring the peritoneal cavity by inserting a cystoscope into the inflated abdomen of a dog. In Sweden Jacobaeus s named the procedure laparoscopy* and, between 1910 and 1914, published numerous papers on its clinical application. Special instruments, first devised by Kalk 9 of Berlin and by Ruddock > of Los Angeles, are in common use today.

Early attempts at photographic reproduct ion of laparoscopic findings were greatly enhanced by the invention of color film in the late thirties. By use of a ra ther complicated apparatus, Horan and Eddy, 7 in 1941, were able to obtain color transparencies measuring 4.5 ram. in diameter. In 1942 Kalk TM published intra-abdominal color photographs taken through a large-caliber thoracoscope. Although further development of methods and appliances was temporarily halted by World War II, great advances were made by investigators in Germany,< ~a. 2~ France,4. Italyfl (~ and Switzerland'-', a dur ing the past decade, hnpressed by excel- lent color reproductions in European medical journals and stimulated by the pioneer work done by Horan and Eddy at Harper Hospital 20 yr. ago, we resumed photolaparoscopy in 1959.

I N S T R U M E N T

Endophotography requires apparatus that combines a lens system of high quali ty with a powerful light source; several efficient photo-

From the Departments of Medicine and Surgery, Harper Hospital, Detroit, Mich. Color illustration of this study was supported in part b,v the Dr. William Spitzlcy

Research Fund, Harper Hospital. The authors wisb to thank Dr. Robert (2. Moehlig for permission to study the

patient of Case 9, and Mrs. Barbara C. Johnson, librarian, for her assistance in preparing the manuscript.

*This name prevails in all except the English-speaking parts of the world, in which the term peritoneoscopy, coined by Orndofflr in 1920, is preferred.

322 American Journal of Digestive Diseases

Phofolaparoscopy

l aparoscopes are ava i l ab le today. T h e e q u i p m e n t * used in this s tudy (Fig. 1) was des igned in G e r m a n y . I t comprises :

I. A 2 r a m . c a n n u l a f i t ted w i t h a need le to wh ich a syr inge or s p h y g m o m a n o m e t e r bulb can be attached, for induction of pneumo-

p e r i t o n e u m

2. A n 8-mm. c a n n u l a w i th t roca r and pressure valve, t h r o u g h wh ich the p h o t o l a p a r o s c o p e is passed af te r p e n e t r a t i o n of the a b d o m i n a l wa l t and r emova l of the t roca r

3. T h e p h o t o t a p a r o s c o p e tha t was evolved f rom the o r i g i n a l Ka lk l apa roscope in I95512 ( T h i s i n s t r u m e n t is cha rac t e r i zed by a p i v o t e d ocular , an exce l l en t wide -ang le lens system, a n d a d o u b l e f i l ament l a m p [Fig. 2] t ha t is a t t a c h e d to the d is ta l end of the i n s t r u m e n t by a screw moun t . T h e t h i n n e r f i l ament serves for p r e l i m i n a r y e x a m i n a t i o n a n d the heavie r f i lament p rov ides a d e q u a t e i l l u m i n a t i o n for p h o t o g r a p h y . )

4. T w o t r a n s f o r m e r s - - T r a n s f o r m e r I, a d j u s t a b l e f rom 1 to 10 v, w i th connec t ion to the th in f i l ament and T r a n s f o r m e r I I , w i th c o n n e c t i o n to camera and scope, wh ich synchronizes the heavy f i l ament wi th the

*Manufactured by Sass, Wolf g: Co., Berlin SW 61, Germany.

Fig. 1. Photolaparoscopic equipment. From left to right: photolaparoscope with connection to Transformer I, 35-ram. camera with attached Visoflex housing, cannula with pressure valve and trocar, air needle, and Transformers I and II. Arrow at the distal end of the photolaparoscope indicates main axis of vision; arrows at top (proximal) indicate connecting points for camera.

New Series, Vol. 6, No. 4, 1961 323

Uhlich & Merri÷:

Fig. 2. Equipment for guided liver biopsy. From left to right: distal end of photolaparoscope with double-filament lamp and optic window; flflgerating tip that can be passed through the outer biopsy needle for hemostasis; cannula, split needle and stilet of a Silverman-Boecker biopsy needle.

shutter and allows short light flashes during exposure by overloading the circuit with a charge of 24 v.

5. A 35-mm. camera equipped with a viewfinder of the reflex type. Various standard camera models* can be utilized and adequate adjust- ntent rings are available.

T E C H N I C

Laparoscopy basically has remained the same as when first practiced by Jacobaeus 50 yr. ago. It is performed under local anesthesia; all de- tails of technic, indications, and complications have been sufficiently discussed in current medical literature. 1, 9-1,~, ls-20, 2 2 This report is pri- marily concerned with the photographic aspects of the procedure.

Provided aseptic precautions are observed, any examining room that can be darkened completely is suitable for photolaparoscopy. An operating table is advantageous because it allows shifting of intra-abdominal organs by tilting the patient in different directions. In order to allay

*The transparencies reproduced in this paper were taken with a Leica M3 camera supplemented by a Leitz Endovisoflex housing.


Phofolaparoscopy

apprehension, a combination of meperidine, chlorpromazine, and pro- methazine is administered to the patient 30 rain. before the examination. This is important because increased cardiac and respiratory movements, naturally transmitted to abdominal organs, interfere with clear-cut photographic reproduction during the relatively long exposures that are necessary.

Sterility of the operating field is preserved by the following precautions. After systematic inspection of the abdominal cavity, the photolaparoscope remains in place; the shaft of the instrument, trocar sheath, and the area around the 1-cm. puncture wound are covered with a sterile towel. Connecting cord is attached to the photolaparoscope, and the camera is fixed to the ocular by a simple bayonet moun t (Fig. 1). Areas of interest are then centered through the Visoflex housing. Because of its pivoted ocular, the scope can be rotated freely without moving the camera. Th e exposure time, usually from 1/25 to 1/5 of a second, is set according to the distance of the light source from the object.

By working the double release, three actions are brought about in the following order: The mirror in the Visoflex housing is elevated, a surge of electrical current is sent through the heavy filament, and the shutter is released. As soon as satisfactory exposures have been obtained, scope, camera, and towel are removed, gloves are changed, and the ptmcture wound is closed by two skin clips.

CASE SUMMARIES AND RESULTS

Case t (Fig. 3-5)

A 61-yr.-old white man was admi t t ed wi th the chief compla in t of in te rmi t ten t abdominal pain of 5-yr. durat ion. Dur ing previous hospitalizations, cirrhosis of the liver had been suspected on the basis of chronic alcoholism, hepatomegaly, flocculation tests giving positive results, and repeated negative findings from X-ray examinations of the gastrointestinal tract. Photolaparoscopy was per formed in February 1960 to substantiate the diagnosis. A large red liver with rounded edge and smooth surface suggesting hepatit is , was found (Fig. 4). Simultaneous needle biopsy (Fig. 3) revealed chronic hepat i t is with no significant fibrosis.

Th e following case is a good example of the diagnostic problem "hepatomegaly of unknown origin."

Case 2 (Fig. 7)

A 66-yr.-old white woman with congestive hear t failure was admi t ted in December I959. On admission her liver was palpable 10 cm. below the r ight costal margin. No decrease in size was noted after full compensat ion of the cardiac condi t ion on digitalis. T h e medical history revealed that the pat ient had suffered f rom anicteric hepati t is in 1955, proved by liver funct ion tests and needle biopsy. Photolaparoscopy was performed in January 1960 to de te rmine the na ture of the hepatomegaly. T h e

New Series, Yol. 6, No. 4, 196i 325

Uhlich & Merriff

Fig. 3. (Case 1) Right lobe of a large, red liver. 1~ A biopsy needle can be followed in its course from the parietal peritoneum through the artificially induced air space into the liver,

Fig. 4. (Case 1) Round ligament appearing as a yellow band divides right from left lobe at the hepatic insertion. It is an important landmark for orientation and, in this patient, displays a variation in the form of a finger-like fat lobule projecting into the peritoneal cavity from above. In the foreground the antral part of the stomach bulges between the liver lobes.

Fig. 5. (Case 1) Close-up of the round ligament as it enters the porta hepatis, To the right the falciform ligament spreads as a bluish, translucent membrane.

Fig. 6. Fundns of well-filled gall bladder in good contrast with pink liver edge and yellow omentum. The small amount of blood seen around the gall bladder emerged from a biopsy site at the upper surface of the right liver lobe,

Fig. 7. (Case 2) Left liver lobe presenting the typical picture o£ postnecrotic "potato liver"13: irregular nodules of smooth surface divided by broad bands of whitish scar tissue.

Fig. 8. Enlarged spleen protruding between bowel loops and abdominal wall.

Fig. 9. (Case 3) Massive peritoneal adhesions at the site of previous cholecystectomy.

Fig. 10. (Case 4) Sharp edge and irregular fibrotic surface of left liver lobe, Be- cause of increased density the organ projects into the pneumoperitoneal space, expos- ing parts of the lower surface.

Fig. 11. (Case 3) Part of the anterior stomach wall with tortuous blood vessels. In portal hypertension various degrees of congestion and dilatation are observed.

Fig. 12. (Case 4) Ascending colon as it turns into the hepatic flexure, q-he parietal peritoneum is smooth and shiny and shows no signs of metastatic tmnor implantation. A small fat lobule protrudes from the abdominal walt.

Fig. 13. (Case 4) Whitish nodule of metastatic carcinoma in the upper surface of the left liver lobe, close to the falciform ligament. The biopsy site, 1 cm. to the right of the nodule, is hard to recognize since no blood emerged from the puncture wound.

Fig. 14. (Case 4) Survey view of mid-epigastrimn from the right: part of the stomach along the greater curvature (pink), gastrocolic ligament (yellow). and trans- verse colon (whitish).


\

o ~

f

]/

Phofolaparoscopy

laparoscopic picture (Fig. 7) was that of a coarse nodular-scar liver or "potato liver" and biopsy findings were typical of postnecrotic cirrhosis.

F igu re s 6 a n d 8 r e p r e s e n t l a p a r o s c o p i c f ind ings in 2 o t h e r p a t i e n t s

w i t h c i r rhos i s of the l iver .

Case 3 (f ig. 9 and l l )

A 69-yr.-old white man was admined complaining of epigastric pain and weakness. Pertinent facts in the medical history included chronic alcoholism, recurrent jaundice over the past 5 yr., cholecystectomy in 1954, and two recent episodes of hematemesis. Slight icterus, ascites, and pitting ankle-edema were present on admission, suggesting cirrhosis of the liver. A barium enema and an upper gastrointestinal X-ray study revealed no pathological findings. Photolaparoscopy was performed in December 1959 to substantiate the clinical diagnosis. Although the visual field was limited by peritoneal adhesions (Fig: 9), it was possible to observe the characteristic "hob- nail" surface of Laennec's cirrhosis. A network of dilated veins along the greater curvature of the stomach (Fig. 11) suggested portal ttypertension.

Case 4 (Fig. 10 and 12-i4)

A 73-}r.-old Negro woman was admined complaining chiefly of rapid weight loss over a 6-wk. period. Marked anemia and a firm nodular nrass in the right epigas- trium suggested malignancy. The proximal part of the stomach appeared narrowed in X-ray films, and a small filling defect of undetermined nature was noted in the cecal fun(his. Exploratory laparotomy was considered, but because of the patient's age and poor nutritional condition, laparoscopy was performed. A tunror with central umbilication was discovered in the liver (Fig. 13). (The advantages of needle biopsy under visual control became obvious. Isolated liver nretastases, naturally, are often missed by the "blind" biopsy technic.) On the basis of laparoscopic and histological findings the diagnosis of metastatic adenocarcinoma of the li~er, primary site probably in the pancreas or colon, was established.

D I S C U S S I O N

P h o t o g r a l ) h i c r e p r o d u c t i o n of e n d o s c o p i c f ind ings c o n t r i b u t e s to t he

accuracy of d iagnos is , r e p r e s e n t s a r e l i a b l e basis fo r f o l l o w - u p s tudies ,

a n d is of v a l u e in case d i scuss ion a n d t each ing . T h e d i s t o r t i o n of per-

spec t ive p e c u l i a r to a l l w i d e - a n g l e lenses a n d the lack of u n i f o r m i l l u m i -

n a t i o n of t he v i sua l f ield m a k e i t d i f f icu l t to j u d g e size, co lo r , a n d s h a p e

cor rec t ly f r o m a s ing le image . W i t h s o m e e x p e r i e n c e o n e can o v e r c o m e

this di f f icul ty by v i e w i n g o r g a n s a n d s t r u c t u r e s f r o m v a r y i n g ang les at

v a r i o u s d is tances . G o o d p h o t o g r a p h i c resu l t s can be o b t a i n e d w i t h c o l o r

f i lm of h i g h sens i t iv i ty . I t is i m p o r t a n t t h a t t he s a m e type of f i lm

m a t e r i a l a lways be used in o r d e r to m a k e o b j e c t i v e d e f i n i t i o n a n d com-

p a r i s o n of c o l o r shades . W i t h o u r l i g h t sou rce we p r e f e r to use d a y l i g h t -

type film. M u c h b r i l l i a n c e a n d fine d e t a i l of t he o r i g i n a l l l - m m , i m a g e

are lost d u r i n g a c o m p l i c a t e d p r i n t i n g process ; p r o j e c t i o n , t h e r e f o r e ,

New Ser~es, Vol. 6, No. 4, 1961 329

Uhllch & Merrlf÷

yields cons iderab ly be t te r end-results. We should like to emphasize that no special camera is needed, and that the described e q u i p m e n t , with m i n o r ad jus tmnts , can be ut i l ized [or in t ra thoracic , c u l d o s c o p i c , a nd proctoscopic p h o t o g r a p h y as well. T h e i l l u m i n a t i o n circui t works on low voltage a n d does no t increase the calcula ted risks of laparoscopy. T h e diagnost ic va lue of this p rocedure in selected pa t ien ts a nd the technical perfec t ion demons t r a t ed by i n t r a - a b d o m i n a l p h o u g r a p h y war- r an t a p lea for its wider u t i l iza t ion , pa r t i cu la r ly by gastroenterologists.

S U M M A R Y

T h e m e t h o d of exp lo r ing the a b d o m e n by endoscope, developed early in the cen tury by Ke l l ing and by Jacobaeus, today represents a va luable d iagnos t ic procedure. Objec t ive d o c u m e n t a t i o n of laparoscopic findings in a s imple and sale way has become possible by the use of mode rn e q u i p m e n t . Resul ts o b t a i n e d wi th a Sass&Volf photo taparoscope have been discussed and i l lus t ra ted by 12 color reproduc t ions of intra- a b d o m i n a l views.

Department of (,astroenterology Henry Ford Hospital

2799 lVest (;rand Boulevard Detroit 2. Mich.

R E F E R E N C E S

1. BENEDI(1. E, B, Endoscopy as Related to Diseases of the Bronchus, Esophagus, Stomach and Peritoneal Cavity. Williams g: Wilkins, Baltimore, 1951, Ch. 47, 48.

2. CAI,AX~F, A. Laparoscopic photography. Med. Biol. Illus., London, 6:148, 1956. 3. C.~LA~u.', A. I'ossihilitds actuelles de la I,aparoscopie. symposium Ciba 4:44, 1956.

1956, 4. CAROLL J., and FOURFS, A. Valeur diagnostique de la Laparophotographie.

J. Inter,rot. Coll. Surgeons 32:431, 1959. 5. FOI:RFS, A., RmORI)EAU MH.r., and CAROH, J. Technique de la Laparoscopie.

Presse todd. 62:929, 1954. 6. Hr.tx~vc. K. Die Farbphotographie der Bauchorgane wiihrend der Lal)aroskopie.

Med. Bild.Dienst "Roche" 2l:353, 1957. 7. HORAN, T. N., and EDDY, C. G. Intra-abdominal photography in color. Surg,

Gynec. & Obstet. 73:273, 1941. 8..]ACOI~A~:US, H. D. ()bet die M6glichkeit die Zystoskopie bet Untersuchungen

ser6ser ft6hlungen anzuwenden. Miinchen. Med. Wchnschr. 57:2090, 1910. 9. KM,K, H., Erfahrungen mit der Laparoskopie, zugleich mit Beschreibung eines

neuen Instrumentes. Ztschr. klin. Med. 11l:303, 1929. 10. KAL|':.. H. Fortschritte der Laparoskopie. Deutsche reed. Wchnschr. 68:677, 1942. 11. KAt.K, It., und BRUEHL, XV. Leitfaden der Laparoskopie nnd Gastro skopie,

Thieme, Stuttgart, 1951. 12. KALK, It. Bemerkungen zur Technik tier Laparoskopie mad Beschreibung neuer

Instrumente. Med. Clin. 50:696, t955. 13. KALK, H. Biopsy findings during and after hepatic coma and after acute necrosis

of the liver. Gastroenterology 36:214, 1959.


Photolaparoscopy

14. KELLI>,f;, (J. ('~ber ¢)sophagoskopie, (;astroskopie trod Koelioskopie. ,ltii~chen reed. Wchnschr. 49:21, 1902.

15. LE~x'r, H. Die Beobachtung der Leberoberflache mit dem l 'hotolaparoskop. Deutsche reed. Wchnschr. 84:24, 1958.

16. MENCH1NI, (}., and B~-:NDA, N. Un nuovo (;omplesso per Lapaofotografia a Colori. Atti Conf. Int. Epatol. Perugia, 1957.

17. ORNDOFF, B, It. T h e peri toneoscope in diagnosis of diseases of the abdomen. Nebraska M, ]. 5:124, 1920.

18. RVDDOCK, J, C. Peritoneoscopy. II'est J. Surg. 42:392, 1934. 19. RUDDOCK, J, C. T h e applicat ion and evaluation of per i toneoscopy--Review of

2,500 Cases. Cali/ornia Med. 71:110, 1949. 20. RUDDOCK, J. C, Peritoncoscopy: A critical clinical review. S. Clin. North America

37:1249, 1957, 21. WJ~ml.:I., I1. C!ber Endophotographie , speziell bei der Laparoskopie. Photogr.

Wisse~.~ch. 5:15, 1956. 22. ZOEC~LI.:R, S. J. Peritoneoscopy: a revaluation. Gastroenterology 34:969, 1958.

New Series, Vol. 6, No. 4, 1961 331

Documents

Intra-abdominal color photography (photolaparoscopy)