Endoscopy

Endoscopy is the use of a thin, lengthy, flexible scope that can be inserted into the body for the diagnosis and treatment of various conditions. Until the last third of the twentieth century, one of the limiting factors in the treatment of internal injuries or diseases was the need to perform open surgery on the patient. That meant putting him under anesthesia, carrying out the operation, sewing up the incision, and allowing the patient to recuperate from the procedure for several days in the hospital. In some instances, such as trauma, the need for open surgery only added to the time involved for the patient to be treated.

Surgeons for many years had attempted various means to penetrate the interior of the body without the need for a major incision.

The use of x rays allowed observation of bones and, with some use of enhancement, certain organs and the blood vessels. Although this procedure gave ample information about bone fractures and at times even bone cancer, x rays gave evidence of a tumor or other disease process without telling the physician what actually was the cause of the condition. Knowing the tumor or disease was present did not remove the necessity of surgical diagnosis. Clearly, a method was needed to look into the body to observe a pathologic condition as it existed rather than as a shadow on an x-ray plate.

As early as 1918, a physician named Takagi was attempting to use the technology of the day to examine the interior of joints. He used a cystoscope, an instrument used to examine the interior of the urinary bladder, but immediately came upon major problems. The cystoscope was a rigid tube with a light on it that was inserted in the urethra to examine the urinary bladder. Because it was rigid the instrument was not maneuverable or flexible enough to be guided around various anatomic structures. The light on the cystoscope was at the far end and could be broken off easily inside the patient. Also the heat of the lamp, small as it was, soon heated the joint space to an unacceptable level, far too quickly for the doctor to carry out a thorough examination.

Technology available by the late 1970s, however, solved these problems and allowed a specialty to begin that today is widespread and beneficial. The space age brought on the science of fiber optics, long strands of glass that could carry light and electricity over long distances, around corners, in a small bundle compared to copper wires. Using fiber optics, the light source for the endoscope could be housed in the handle end of the scope so that the light itself never entered the body. Fiber optics also allowed the instrument to be flexible so that the doctor could steer the end into whatever area he wanted. The efficiency of fiber optics in carrying light and images meant that the diameter of the endoscope could be reduced considerably compared with the few scopes then available.

At first, the endoscope was called the arthroscope and used only to visualize the internal anatomy of joints such as the knee. Soon the scope was fitted with instruments such as scalpels and scissors to carry out surgery, a vacuum line to suck out any floating material that might interfere with the function of the joint, and a television camera so the physician, instead of peering through a small opening in the scope, could watch his progress on a larger television screen.

With these and other refinements the endoscope now can be used to penetrate nearly any area of the body, provide the physician with information on the condition of the area being examined, and provide the means for the physician to carry out surgical procedures through a tiny incision. The patient usually is in and out of the treatment facility the same day and the recovery from such minor surgery is rapid.

Like any other surgery, endoscopy is carried out in a sterile environment. The patient is positioned and appropriate anesthetic is administered. Often the area to be examined is filled with saline to expand the interior space and lift the overlying tissues from the area being examined. Saline is a mild salt solution. Through a small incision the tip of the endoscope is inserted into the joint space. The end of the endoscope being held by the surgeon has a "joy stick," a lever that protrudes and that can be used to guide the tip of the endoscope from one area into another. A second endoscope may be needed to assist with surgery, provide more light, maintain the saline environment, or for any of a number of other reasons. Using the lever the physician moves the tip of the endoscope with the TV camera from one area to another, examining the structures within the joint as he goes.

The use of the endoscope to penetrate joints is called arthroscopy. It is an especially useful procedure in sports medicine where athletes often suffer knee injuries as the result of running, jumping, or being tackled. The ligaments that hold the lower leg bone, the tibia, to the upper leg bone, the femur, can be ruptured if the knee is twisted or hit from the side. Arthroscopy allows the surgeon to examine the details of the injury, determine whether a more radical procedure is needed, and if not, to repair the torn ligaments and remove any loose material from the joint using the arthroscope. The athlete will require a few weeks of physical therapy to regain full strength, but the actual surgery can be completed in only a short time and he will be out of the hospital the same day he enters.

The laparoscope or peritoneoscope (so named because it penetrates the peritoneum, the lining of the abdominal cavity) is used to examine the interior of the abdomen. The tip of the scope with the TV camera attached can be guided around, above, and underneath the organs of the abdomen to determine the source of bleeding, the site of a tumor, or the probable cause of an illness. In the case of gallstones, which form in the gallbladder near the liver, the gallbladder can be removed using the surgical attachments. Suturing the stump of the gallbladder can also be accomplished using the attachments.

To examine the inner surface of the lower digestive tract the scope used is the sigmoidoscope. It can be passed into the colon to examine the walls of the intestine for possible cancer or other abnormal structures.

Obviously, the physician using the endoscope must be highly knowledgeable about anatomy. Human anatomy as it appears through the lens of the scope is considerably different from its appearance on the page of a book or during open surgery. The physician must be able to recognize structures, which may appear distorted through the lens of the endoscope, to determine the location of the tip of the endoscope and to know where to maneuver the scope next. Training is carried out under the guidance of a physician who has extensive experience with the endoscope.