Endoscopy is a technique whereby a surgeon views the interiors of body. Endo means inside and Scopy means seeing. Essentially, an endoscopist inserts a telescope inside the body through small holes. This telescope picks up the image from inside, magnifies it and passes it onto the eye of endoscopist or to the camera head as the case may be. As is apparent, endoscopes are used to perform Minimally Invasive Surgeries.

Minimally Invasive SurgeryConventionally, all surgeries are performed by open technique. As per open technique, the surgeon exposes the anatomy to be operated by incision. This means that if the surgeon wants to operate on the Gall Bladder of a patient, he/she makes a big incision in the patients abdomen, exposes all the viscera and then performs the desired surgery. The exposing of the affected as well as normal organs invites hoards of micro-organisms, even in a sterile Operation theatre, making the wound vulnerable to infection. Besides, this technique also implies heavy blood loss and long, painful stay for the patient at hospital untill the wound heals. This in turn means that the surgery is expensive for patients as well as the medical fraternity. For the patient because of the complications mentioned above and for the medical fraternity because this means low turnover of patients. To combat these obvious drawbacks of open technique, a new technique was developed in the nineteenth century that enables the surgeon to access the anatomy-of-interest by making small holes in the vicinity of affected site, viewing the affected organ through one of the holes and operating through the others. Though diagnostic endoscopy began that early, operative endoscopy finds its birth in the early part of twentieth century. The usage of video imaging has come in as late as 1985. But, of late, the technique is gaining importance and acceptance at rapid pace because of its obvious advantages over the open technique. More and more surgeons are opting for MIS wherever possible. Endosys has been at the forefront of Endoscopy in general and Arthroscopy in particular. Endoscopy is a very general term. It is visualising the insides of the body. Under the head Endoscopy, there are different types of Scopy such as Laparoscopy, Hysteroscopy, Arthroscopy, Sinuscopy, etc. that are in relation to specific organs/parts of the body where they are performed. Laparoscopy is the MIS of abdomen while Hysteroscopy is the MIS of Uterus & Arthroscopy is the MIS of joints. It should be appreciated that though Endoscopy of different organs of the body has different names, it still is Endoscopy. Hence, the basic system for diagnostic studies still remains the same. This basic diagnostic system is covered in the following unit. But Endoscopy is seldom done only for diagnosis. It is, most of the times, done for operating purposes and the surgical instrumentation involved is different for each of the organs.

Diagnostic Endoscopy As mentioned earlier, Endoscopy makes use of a telescope to view the interiors of the body, thus eliminating the need to open the organ by incisions. A telescope is made up of tip, shaft and eye-piece. The shaft is made up of rod lenses that pick up and focus the image onto the eye-piece of the telescope. This shaft and its optic assembly is of varying diameter for different applications. But image formation requires illumination of the anatomy. Without the organ’s interiors being lit up, nothing can be seen. For this reason, Endoscopy requires a light source that would illuminate the organs. Thus, a surgeon has to have a telescope to insert inside the body and a light source to illuminate the organ. The telescope is inserted through small holes. Normally, the organs inside the body are densely packed and the surgeon finds it difficult to differentiate them unless they are separated from each other. The separation is also required so as to help the surgeon to operate only on the affected organs and not on the normal ones. Hence, to enable the separation, distention of the body cavity is required. This is either achieved by passing gas or liquid. Either of the medium keeps the cavity inflated throughout the procedure. In small cavities, this distention is achieved using fluid and in large cavities, gas is used. Fluid also helps in cleaning up of the debris formed due to surgical procedures. Thus, besides the telescope and light source, Endoscopy also requires gas or fluid medium to distend the body cavity under study. For diagnostic Endoscopy, the above-mentioned equipment is the bare minimum requirement. As is evident, the surgeon views the affected and/or normal organs through the scope. Such a scope that allows the surgeon to place his/her eye in front of the eye-piece and view the organs is called Direct-View Scope. Direct-View scopes are enough to see inside the body but are very tiresome for the surgeon because he/she has to constantly look through the eye-piece. To make it easier for surgeons, video systems have been developed that pick up the images from eye-piece of telescope, process the images and project them onto a monitor for viewing. These video systems are commonly called as camera systems. Though camera system is not strictly required, it has gained the position of indispensable equipment as it allows the surgeon to do a lot more with the image than only view it. Detailed advantages of a camera system are specified in the unit dedicated to camera system.

Arthroscopy Arthroscopy is Endoscopy of joints. The joints covered by Arthroscopy are Knee, Shoulder, Wrist, Ankle, Elbow, Hip, etc. Of these, the joint that is most commonly treated using Arthroscopy is Knee. Relatively a simple joint, Knee is also one of the most prone for injuries. Because of high incidence of injuries and its relative simplicity, Knee joint has assumed the position of default joint for Arthroscopy. Knee Arthroscopy for diagnostic purposes involves minimum two holes. These holes are called Portals in medical terminology. The primary portal is the Anterolateral portal. This portal is made not more than 1cm lateral to the Patellar Tendon and 1cm superior to the lateral joint line. This portal is taken without any direct visual aid. For making the portal, surgeons use surgical blade and make a small incision at the desired position. This small incision is later made deeper to penetrate the capsule and to reach inside the joint proper. This is called the principal portal because it allows visualisation of the entire joint through one portal only. This portal is made before any other portals. All the other portals are then made under direct visualisation using the telescope through this portal. The position for the anterolateral portal is decided as mentioned above so as to protect the fat pad and the anterior part (horn) of the lateral meniscus from getting penetrated and thus damaged. Also, the portal is made with the joint in 90deg flexion. Besides the Anterolateral portal, there are other standard portals such as Anteromedial, Superolateral and Posteromedial. While performing the procedure, the second in line is the Anteromedial portal that is made after making the Anterolateral portal. Note that the Anterolateral portal carries the Arthroscope. With the joint visualised from within, the Anteromedial portal is made. To ensure the protection of fat pad and anterior horn of the medial meniscus, a 18 gauge needle is used that is penetrated from a point that is 1cm medial to the edge of Patellar Tendon and 1cm superior to the medial joint line. This needle is advanced in the anterior-posterior direction untill it is confirmed visually (on the monitor) that it is in the right position. On ensuring the correct placement, Anteromedial portal is made. This portal is used primarily for inserting the instruments used in Arthroscopic surgeries. All the other portals are made subsequently. During diagnostic Arthroscopy, this portal is used to insert the probe that is used to clear the line of vision for the scope and palpate/feel soft tissues like menisci. Generally only one more portal is made and that is the Superolateral portal that is useful for drainage of the irrigation fluid. An outflow cannula is inserted through this portal for allowing complete drainage of the fluid. Many of our Indian surgeons do not even make this portal. It should be noted that the Arthroscope is inserted in the primary portal after starting the infusion of fluid and the outflow is through the cannula itself, thus eliminating the need of Superolateral portal.

Typically, the diagnosis of knee involves a circular route consisting of seven points. This route is called the Seven Point Tour of the Knee. The seven points of the tour are as follows:

Patellofemoral joint or the posterior aspect of Patella or Patellar tracking

Lateral Gutter

Overall view of the lateral meniscus

Medial Gutter

Detailed view of the lateral meniscus

Detailed view of the medial meniscus

Though not followed religiously, this is a rough pattern of the way a surgeon assesses the knee. While demonstrating our scope or any equipment on a leg model, we have to adhere to this tour. Repeated following of this tour also aids in remembering and understanding the orientation during Arthroscopy. It is very easy for a novice to lose the orientation inside the joint because of the 30deg direction of view (the most commonly used scope in Arthroscopy is 4mm in diameter and 30deg direction of view). More about the use of direction of view will be discussed in the unit dealing with Arthroscope and its accessories.

While crossing over to the medial compartment from the lateral compartment of the knee, Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL) are assessed in the Intercondylar Notch. Also, during the tour, the condyles are assessed for osteochondral or purely chondral defects. While performing the diagnosis, it is essential to have a hook probe as many a times, the tears in menisci and tension of the ACL are examined using the probe. Some of these defects may not be visible without palpating the fore-mentioned tissues. To palpate these soft tissues while performing Arthroscopy is afforded by the probe.