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Moments in Surgical History |

From the Lumen to the Laparoscope

Irvin M. Modlin, MD, PhD; Mark Kidd, PhD; Kevin D. Lye, MD
Arch Surg. 2004;139(10):1110-1126. doi:10.1001/archsurg.139.10.1110.
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Published online

Throughout the ages, the issues that have defined the management of disease processes have been particularly exemplified in the gastrointestinal tract. The use of gas lamps and candles with reflectors by Bozzini, Segalas, Cruise, and Fisher (19th century) allowed for some ingress into both the upper and lower gastrointestinal tract. Von Mikulicz, Leiter, Nitze, Kelling, and Jacobaeus contributed to the development of rigid instruments that could be used endoscopically or laparoscopically. Endoscopic efforts were amplified and extended by Rosenheim, Sternberg, Wolf, and, finally, Schindler, who not only introduced novel lens systems but also for the most part overcame the problems of flexibility and illumination. Bernheim, Ruddock, Veress, and Palmer made significant technical and clinical contributions to abdominal cavity exploration. The subsequent application of Hopkins and Kapany's work on optics, and the development by Hirschowitz and Curtiss of the flexible fiber optic endoscope, enabled the design of instruments that would allow the appropriate illumination and vision of both the farthest reaches of the bowel as well as the interior of the abdomen. Thus, the same endoscopic instruments coupled with a surgical interest in diagnostic laparotomy allowed for the evolution of minimally invasive surgery along a similar timescale. The cycle whereby diagnostic laparotomy in the early part of the century was supplanted by endoscopy and laparoscopy has now attained full circle whereby laparoscopy has evolved from a diagnostic procedure into one with major therapeutic applications and is perceived as the state-of-the-art technique for a wide variety of operations, including appendectomy, cholecystectomy, hernia repair, fundoplication, splenectomy, colectomy, and gastrointestinal anastomoses.

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Figures

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Figure 1.

Phillip Bozzini of Frankfurt, Germany (right), introduced the first endoscope (Lichtleiter, left). Despite accurate blueprints and a fine design (background), his work was repudiated by the Vienna School of Medicine. His early demise (dysentery) at age 36 years hampered further progress in the development of endoscopy until the work of Pierre Segalas of Paris, France, and Adolph Kussmaul of Freiberg, Germany.

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Figure 2.

In 1868, Adolph Kussmaul (top left) was the first to attempt gastroscopy. The technique he used to introduce the rigid instrument was based on that practiced by sword swallowers (top right). The device (bottom) was based on that used previously by Antonin Desormeaux of Paris, France (1865), to study the bladder. A long, rigid speculum was introduced into the stomach, and the proximal tube component was attached as the light source. The latter was provided by an attached gasogene lamp. Unfortunately, the light was inadequate, and Kussmaul could not adequately discern detail.

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Figure 3.

The development of the open rigid tube by Johan von Mikulicz (top right) and Max Leiter led to the production of an efficient and effective esophagoscope (bottom left). The later addition by Leiter of his panendoscope was critical in resolving the issue of illumination. It provided a battery-operated universal light source for all endoscopes and was based on an Edison lamp that provided illumination by reflecting light from a diminutive electric bulb built into the handle. Resolution of the problem posed by inadequate illumination represented a major advance in endoscopy.

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Figure 4.

Chevalier Jackson (background, center) was an ear, nose, and throat surgeon from Philadelphia, Pa, who made numerous important contributions to endoscopy and the esophagus (left). Erudite, artistic, sophisticated, and a brilliant surgeon to boot, by 1930 his perspicacity enabled him to consider the concept of gastric juice as one of the causes of inflammation of the lower esophagus (text), which allowed him to strongly support the proposal that peptic esophagitis was a disease entity worthy of serious consideration.

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Figure 5.

The Lehrbuch und Atlas der Gastroskopie, published in 1923 by Rudolph Schindler (bottom right) while working at the Schwabing Hospital in Munich, Germany. This work became the mantra and the lodestone of gastroscopists for the next 2 decades.

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Figure 6.

Basil Hirschowitz endoscoping a patient (circa 1995). In 1959, Hirschowitz moved to Birmingham, Ala, as director of the Gastroenterology Unit, and much as Birmingham, England, had flourished under the intellectual influence of the Lunar Society (Priestley, Watt, Galton, Bolton, and Darwin), so the endoscopic cognoscenti flocked to his doors. In an epic Lancet article in 1961 that assessed the use of the ACMI 4990 (the model T of fiberoptic endoscopy), Hirschowitz claimed to the horror of the Schindlerian Luddites and other inflexible conservatives of the establishment that "the conventional gastroscope is obsolete on all counts." He was right.

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Figure 7.

In 1968, William S. McCune (1909-1998) (left), from George Washington University, Washington, DC, published his observations with endoscopic retrograde cannulation of the ampulla of Vater in the Annals of Surgery (background). This seminal publication opened the doors of new diagnostic and therapeutic possibilities to the pancreaticobiliary system. McCune performed his work using a modified Eder fiberduodenoscope (right), which possessed forward- and side-viewing lenses and a tract for the cannula and a balloon that brought the duodenal wall into focus when inflated.

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Figure 8.

Keiichi Kawai (left) of Japan and Meinhard Classen (right) of Germany independently and successfully developed the concept of the technique of papillotomy and instrumentation in 1973 and were both responsible for an extraordinary advance in biliary and pancreatic therapeutic intervention. Once the papilla could reliably be cannulated for diagnostic purposes, a variety of devices were implemented to broaden the therapeutic horizon. The sphincters of Oddi and Boyden were breached by papillotomies, balloons, baskets, stents, and coils as a new generation of endoscopists and instrument makers colluded to transluminally supplant the hepatobiliary surgeon.

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Figure 9.

In 1895, Howard Kelly (top left), professor of gynecology and obstetrics at The Johns Hopkins University, published in the Annals of Surgery the description and drawings of his instruments for proctosigmoidoscopy (top, bottom right, and left). Kelly was not the first to perform examinations of this sort, as the care of the nether region had been of considerable concern to humans since the distant times of the Egyptians. Thus, the Chester Beatty papyrus is devoted solely to anorectal disease, and the great physician Irj Or-en Akhty of the 10th dynasty is recorded as carrying the illustrious title of "Shepherd of the Anus." A variety of rigid instruments had been developed over the centuries, ranging from the hollow wooden pipes of African tribes to the diverse specula of Greece and Rome. Nevertheless, irrespective of material or design, inadequate lighting and flexibility proved to be critical obstacles to ingress beyond the rectosigmoid junction. In addition, the length and tortuosity of the colon further accentuated the limitations of rigid devices before the widespread introduction of fiberoptic technology in the early 1960s.

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Figure 10.

Although the island of Sardinia (left) had languished in relative obscurity since the departure of the Carthaginians, the innovative contributions in 1966 of Luciano Provenzale (top right) and Antonio Revignas of Cagliari University to the development of colonoscopy once again reminded the world of the power of the heirs of the Caesars. Using the 1955 technique of Blankenhorn for end-to-end intestinal intubation, with a small-caliber swallowed tube they positioned a pulley system of thin polyvinyl tubing arranged in tandem in the digestive tract and attached it to a lateral-viewing, nonsteerable Hirschowitz gastroscope. The application of a light pulling or pushing force enabled the gastroscope to progress endolumenally in a retrograde fashion along the length of the colon (center).

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Figure 11.

William Wolff (right) and Hiromi Shinya (left) (circa 1975) of Beth Israel Hospital, New York, NY (background), were not only instrumental in developing safe and effective colonoscopy but convincingly demonstrated that polypectomy was not only a feasible procedure but safe and effective. Although the concept of polypectomy was initially criticized, the publication of a series of carefully documented patient studies and reviews (top left) led to the widespread acceptance of therapeutic colonoscopy. There is little doubt that their contributions dramatically affected the issues of colon cancer surveillance and prophylaxis.

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Figure 12.

Dimitri Oskarovich Ott, a gynecologist from St Petersburg, Russia, is credited with undertaking the first laparoscopy, which he called ventroscopy, in 1901. Since 1891, he was known to use a normal incandescent light with a reflector while undertaking gynecologic procedures (background). The light was attached to his head, and a small, adjustable mirror was included that could be reset as the procedure evolved. In 1903, he published his account of the 600 operations he performed "per vaginam."

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Figure 13.

Georg Kelling of Dresden, Germany (top right), was the man who most effectively demonstrated the clinical applicability of laparoscopy. In 1901, at the 73rd German Naturalists and Physicians meeting, Kelling demonstrated its use on a live dog by inserting a Nitze cystoscope into the peritoneal cavity and demonstrating the pristine condition of the abdominal viscera. Although Kelling referred to his technique as coelioscopy in his January 1902 publication (top), it would subsequently be variously recognized as organoscopy or peritoneoscopy. By 1910, Kelling had devised a safe technique for inducing pneumoperitoneum, had produced modified instruments (center), and had successfully examined a series of humans. In the same year, Hans Christen Jacobaeus of Stockholm, Sweden (bottom left), published 2 cases of visceral exploration, one thoracic and one abdominal, and designated his technique as thoracolaparoscopy (Uber Laparo und Thorakoskopie) (bottom). The methods he used were less advanced than those of Kelling, who had described a separate needle with filtered air to produce the pneumoperitoneum, preferring to use the trocar for this purpose. Although Jacobaeus reported on 115 laparoscopies in 1912 and described cirrhosis, metastatic disease, and tuberculous peritonitis, he thereafter abandoned the procedure and devoted his attention to thorascopic lysis of tuberculous lung lesions. The logic of the latter procedure proposed that lysis would permit complete lung collapse after artificial pneumothorax induction and thereby would ensure healing.

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Figure 14.

Bertram Bernheim (bottom left) was born in Paducah, Ky, and attended The Johns Hopkins University (background) for undergraduate study and medical school. He obtained an AB degree in 1901 and graduated with an MD degree in 1905. In World War I, he served as an operating surgeon at The Johns Hopkins Hospital Base Unit Number 18 and held the rank of captain. He is recognized for performing the first laparoscopy in the United States (1911) (top) and, more importantly, for his pioneering work in blood transfusion and cardiovascular surgery and as a founder of the American College of Surgeons.

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Figure 15.

John C. Ruddock of Los Angeles, Calif (top), and Edward B. Benedict of Boston, Mass, were the major American proponents of laparoscopy or peritoneoscopy, as both preferred to call it. For his groundbreaking work, Ruddock used a McCarthy cystoscope that he had modified to include a redesigned trocar with biopsy instruments. He also introduced local anesthesia to facilitate the procedure. In 1937, he reported on his initial experiences with 500 patients (background), and by the time he retired, he had performed more than 2500 laparoscopies with much success and low morbidity.

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Figure 16.

Janos Veress (top left), a Hungarian physician, described a needle in 1938 (right) that was designed by him to prevent damage to the lungs or abdominal organs, either during removal of fluid from the thoracic or peritoneal cavity or during treatment of pneumothorax. The blunt-tipped cannula was connected to a spring and was slightly longer than the sharply pointed external needle (bottom). The cannula was held back by the skin and other solid tissue during insertion until the tip of the needle penetrated the pleura or peritoneum. The blunt end of the spring-loaded cannula then advanced automatically with, supposedly, no danger to internal organs. Veress successfully used this needle in more than 2000 procedures and concluded his original manuscript with the note that the instrument was beneficial to the healing process and that the smallest of injuries to lung tissue was preventable.

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Figure 17.

Two gynecologists, Kurt Semm (left) of Kiel, Germany, and Raoul Palmer (right) of Paris, France, were instrumental in the development of laparoscopy as a technique. Palmer used a rigid approach and invented preoperative exploratory coelioscopy in 1943, which allowed him to readily sample ovocytes and to perform electrocoagulation of the uterine horns, puncture of cysts, and adhesiolysis. In 1980, Semm, who was an inventor of devices and techniques sans egale, developing thermocoagulation and extracorporeal and intracorporeal endoscopic knotting to achieve endoscopic hemostasis, performed the first fully laparoscopic appendectomy. Part of the basis for this approach was Semm's concern with the problem of adhesions from a laparotomy. Most of his peers considered his fears exaggerated, and the laparoscopic technique itself was regarded as too dangerous to be accepted. In the background are instruments set out for laparoscopy.

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Figure 18.

The first laparoscopic cholecystectomy was conducted by Erich Muhe (top) of Erlangen, Germany, on September 12, 1985. This technique was then modified such that the operation could proceed via a trocar sleeve, and, thereafter, Kurt Semm designed an open laparoscope that benefited from the addition of a circular light. By 1987, Muhe had conducted almost 100 endoscopic gallbladder removals, but despite this output, his work was largely ignored. Phillipe Mouret (left) of Lyon, France, performed the first French laparoscopic appendectomy in 1983 and thereafter a gallstone removal in 1987. Neither of these observations were recognized as being important steps in the evolution of French laparoscopy, perhaps because of his principal role as a private surgeon and his choice not to publish. Parisian surgeon Francois Dubois (right), however, watched Mouret's operation, which had been memorialized on videotape, and finally undertook his own full laparoscopic cholecystectomy in 1988. It was not until the middle of the 1990s, however, that the surgical community was prepared to accept the pioneering roles of these men in the development of "minimally invasive surgery."

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Figure 19.

The pioneers of endoscopy and laparoscopy, from bottom left, clockwise: Hans Christen Jacobaeus, Bertram Bernheim, Janos Veress, John C. Ruddock, Raoul Palmer, Kurt Semm, Francois Dubois, Phillipe Mouret, Erich Muhe, and Georg Kelling. Each was a physician or surgeon of persistence undaunted by failure who used the technology available to them (endoscopes or laparoscopes, often built to specific design) to examine and treat problems in the abdomen. The more recent advent of robotics (top) is presenting a new generation of physicians and surgeons with the technology for the next endolaparoscopic step.

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