History of Minimally Invasive Surgery

The early history of laparoscopy is unknown to many surgeons, but endoscopy was first described by Hippocrates in Greece (460-375 BC). He made reference to a rectal speculum.

The first simple speculum for gynecological endoscopy dates from about the same time. Roman medicine also produced instruments with which they could inspect internal organs. In Pompeii's ruins (70 AD), a three-bladed vaginal speculum was found; this instrument was similar to the modern vaginal speculum. Thus, the interest for physicians to look into the "internal organs" has existed since the early days of medicine.

The credit for modern endoscopy belongs to Philipp Bozzini (1773-1809). He developed a light conductor which he called "Lichtleiter" to avoid the problems of inadequate illumination. This early endoscope directed light into the internal cavities of the body and redirected to the eye of the observer. The medical community of Vienna ultimately inhibited the fate of this invention because of professional rivalries and politics. But Bozzini's invention established the principles that guided the development of endoscopy, and it inspired others to forge ahead in this new field.

John D. Fisher (1798-1850) in Boston described an endoscope initially to inspect the vagina, but later he modified it to examine the bladder and urethra. In 1853, Antoine Jean Desormeaux, a French surgeon, first introduced the "Lichtleiter" of Bozzini to a patient. For many he is considered the "Father of Endoscopy." This instrument had a system of mirrors and lens, with a lamp flame as the light source; the endoscope burned a mixture of alcohol and turpentine. Burns, as might be imagined, were the major complication of these procedures. Desormeaux had initially contemplated using electricity, but abandoned that idea. The Lichtleiter was mainly used for urologic cases. Many developments, which occurred independently but almost simultaneously, produced breakthroughs for endoscopy and laparoscopy that were the bases for modern instruments. In this period was the invention of incandescent light.

Maximilian Nitze (1848-1906) modified Edison's light bulb invention and created the first electrical light bulb as the source of illumination. Like the Lichtleiter from Bozzini, this instrument was only used for urologic procedures. In 1883, Newman of Glasgow described using a miniaturized version of the incandescent bulb in a cystoscope.

The year 1901 was an important one in the history of laparoscopy. George Kelling, a surgeon from Dresden, coined the term "coelioskope" to describe the technique that used a cystoscope to examine the abdominal cavity of dogs. Kelling also used filtered air through sterile cotton to create a pneumoperitoneum, with the goal of stopping intra-abdominal bleeding (ectopic Pregnancy, bleeding ulcers, pancreatitis), but these studies did not find any response or supporters. Kelling noted that the abdominal cavity could store more than 2.5 liters of blood. He also considered intra-abdominal adhesions a contraindication for the procedure. He promised a more detailed report later, which did not appear.

During late 1910 and early 1911, H.C. Jacobaeus, from Stockholm, used the term "laparothorakoskopie" for the first time. He published his report on laparoscopy and thoracoscopy in humans in Münchener Medizinische Wochenschrift. He also suggested employing similar techniques to examine body cavities endoscopically. A response by Kelling appeared two months later in the same journal, disputing Jacobaeus' claim to be the first to perform the procedure in humans, stating that he had successfully used celioscopy in two humans between 1901-1910. Unfortunately, Kelling had made a mistake: he did not publish his work. Interestingly, in Jacobaeus' paper in 1911, he viewed thoracoscopy as a more promising procedure than laparoscopy.

Bertram M. Berheim, an assistant surgeon at Johns Hopkins, performed the first laparoscopy in the United States in 1911, before he learned of the work of Kelling and Jacobaeus. He named the procedure "organoscopy." The instrument was a proctoscope of a half-inch diameter, and he used ordinary light for illumination.

Otto Goetze developed an automatic pneumoperitoneum needle characterized for its safe introduction to the peritoneal cavity for use in diagnostic radiology. He suggested in his article that the needle could be used in laparoscopy.

B.H. Orndoff, an internist from Chicago, reported the first large series of peritoneoscopies (42 cases) in the United States in 1920. One of his innovations was a sharp pyramidal trocar point.

Heinz Kalk, a German gastroenterologist, is considered the founder of the German School of Laparoscopy. In 1929, Kalk developed a 135-degree lens system and a dual trocar approach. He used laparoscopy as a method of diagnosis for liver and gallbladder disease. In 1934 an American internist, John C. Ruddock, described laparoscopy as a good diagnostic method, many times superior to laparotomy. His instrument consisted of a built-in forceps with electrocoagulation capacity.

In 1938, Janos Veress of Hungary developed the spring-loaded needle for draining ascites and evacuating fluid and air from the chest. Its main purpose was to perform therapeutic pneumothorax to treat patients suffering from tuberculosis. He used it in over 2000 cases. He did not suggest that it be used for laparoscopy. Its current modifications make the "Veress" needle a perfect tool to achieve pneumoperitoneum during laparoscopic surgery. In 1944, Raoul Palmer of Paris performed gynecological examinations using laparoscopy and placing the patients in the Trendelenburg position so air could fill the pelvis. He also stressed the importance of continuous intra-abdominal pressure monitoring during a laparoscopic procedure.

Harold H. Hopkins was responsible for the two most important inventions in endoscopy after World War II: the rod-lens system and fiberoptics.

During the 1960s, Kurt Semm, a German gynecologist, invented the automatic insufflator. His experience with this new device was published in 1966. He played a major role in the development of laparoscopy. He called his procedure "Pelviscopy." He performed an appendectomy during a gynecological procedure and opened a large door for a new surgery, although he was almost removed from the Germany Physician Society because of that procedure. Although Semm was not recognized in his own land, on the other side of the Atlantic, both American physicians and instrument makers valued the Semm insufflator for its simple application, clinical value, and safety. Semm made and designed many new instruments.

H.M. Hasson, a gynecologist from the Grant Hospital of Chicago, Augustana Hospital and Columbus-Cuneo Medical Center, published in the American Journal of Obstetrics and Gynecology on July 15, 1971 his paper named: "A modified instrument and method for laparoscopy." He developed a technique performing laparoscopy through a miniature laparotomy incision.

In England, in 1980, Patrick Steptoe started to perform laparoscopic procedures in the operating room under sterile conditions.

In 1981, rules and requirements to perform laparoscopy were adopted by many hospitals and surgical societies. The American Board of Obstetrics and Gynecology made laparoscopy training a required component of residency training.

The first solid state camera was introduced in 1982. This was the start of "video-laparoscopy." Nothing had caused more revolution and had led to so many other developments during the past ten years than the first laparoscopy cholecystectomy on a human in 1987. Phillipe Mouret performed the first video-laparoscopic cholecystectomy in Lyons, France. Within a year, Dubois (Paris), Perissat (Bordeaux), Nathanson and Cuschieri (Scotland), McKernan and Saye (Marietta, Georgia), and Reddick and Olsen (Nashville, Tennessee), had performed laparoscopic cholecystectomy at their respective institutions on both sides of the Atlantic.

Since that year, many contributions of hundreds of surgeons have brought a new approach to surgery to the benefit of our patients.