History Of Laparoscopy An Odyssey Of Innovations

Sergio G. Moreira, Jr. and Raul C. Ordorica

Division of Urology, University of South Florida, Tampa, Florida, U.S.A.

Sakti Das

Department of Urology, University of California Davis School of Medicine, Sacramento, California, U.S.A.

Urologists once only peered into the "new frontier" of laparoscopy. Today we are now embracing it and thriving within it, bringing its benefits to our patients. Even as we witness its growth and realize its potential, it is instructive to peer into the past.

"The principal mark of genius is not perfection but originality, the opening of new frontiers."

—Arthur Koestler

At the time of this writing, interest in laparoscopic urology continues to rise at an unprecedented rate. This interest is currently evident in both urologic practice and training. The wide range and availability of information has led the patient population to demand laparoscopic knowledge and skills from the urologic community. Thus, residency programs are increasingly emphasizing laparoscopic training, and graduates should have enhanced familiarity with laparoscopic technique once delegated to specialty training. Laparoscopic fellowship programs continue to thrive, producing tomorrow's academic leaders. Courses in advanced laparoscopic urology are available both nationally and internationally for established urologists.

Urologists once only peered into the "new frontier" of laparoscopy. Today we are now embracing it and thriving within it, bringing its benefits to our patients. Even as we witness its growth and realize its potential, it is instructive to peer into the past.

Laparoscopic surgery owes much of its history to the development of endoscopic technique in the beginning of the 19th century. Initial methods to examine body orifices were developed in 1805 by the German physician Phillip Bozzini (Fig. 1) (1), who constructed a thin silver funnel illuminated by reflected candlelight held within its stand (Fig. 2). After several modifications, the instrument was demonstrated at a scientific gathering in Frankfurt in July of 1806 and was indeed considered remarkable for the examination of the pharynx and nasal cavities. The "Lichtleiter" was purchased by order of the Emperor, and given to the Josephinum for testing its utility with unbiased studies. A set of tests on actual patients conducted by the faculties at the University of Vienna showed unfavorable results. The use of the instrument was considered an

unnatural act and there is no evidence that Bozzini had used the instrument again. Although the instrument would have proven cumbersome, inefficient, and painful for both the operator and the patient, it is considered the first major foray into endoscopy. The original Lichtleiter of Bozzini is now enshrined in the Josephinum in Vienna (2).

Throughout the mid 1800s, several scientists attempted to construct endoscope-like instruments. Pierre Segalas from France refined the urethroscope in 1826 adding an introduction cannula and mirrors for light reflection. Antonin Desormeaux, Segalas' fellow countryman, presented the first serviceable endoscope to the Academy of Paris in 1853 (Fig. 3) (1,3). He performed and reported several investigations of the urethra and bladder using such instrument, of which major development consisted of an illumination source of increased intensity obtained utilizing the reflected light from an alcohol lamp. A clear intellectual milestone had been reached, and Desormeaux was awarded a portion of the Argenteuil Prize for such an achievement (4).

The development of a light source that could be transported into the body cavity was the next, awaited major innovation. Using a platinum wire loop heated by an electric current, Julius Bruck, a dentist of Breslau, heralded the development of internal illumination in 1867 (5). Despite great success in the exploration of the oral cavity, Bruck's technique of water-cooled, diaphanoscopic bladder transillumination by a rectally placed coil was still dangerous, and rather ineffective. Apparently unaware of Bruck's earlier attempts, Max Nitze from Germany successfully applied this kind of illumination source to his cystoscope in the late 1800s (Fig. 4).

Compelled by the concept of an internal light source, Nitze succinctly stated: "in order to light up a room, one must carry a lamp into it" (5). Applying these concepts, Nitze and Diecke, an instrument maker in Dresden, were able to manufacture their first cystoscope in 1877 (6). This instrument was still rather bulky and unreliable. Teaming up with Joseph Leiter, a renowned instrument maker in Vienna, Nitze developed the necessary further improvements consisting of an electrically-heated platinum wire light source placed behind a quartz shield. The Nitze-Leiter cystoscope was presented in 1879 (Fig. 5).

Despite these advances, the heat generated within the bladder required a bulky water-cooling device, and the electrical apparatus that created the necessary current for the platinum wire was difficult to maintain (Fig. 6). Further progress awaited Thomas Edison's invention of the incandescent lamp in 1880. This landmark development provided increased illumination and alleviated the need for the water-cooling system. A larger part of the scope could be dedicated to the optical lens system, resulting in better visualization with improved light delivery (1). Multiple endoscopists, including David Newman (1883), Nitze (1887), Leiter (1887), and Dittel (1887) employed the incandescent bulb (6).

Refining the mignon lamp in 1898, Charles Preston provided a more dependable illumination source consisting of a bright light produced with low-amperage current (Fig. 7) (7). This became the standard light source for endoscopy until an adequate external systems of light delivery was developed 50 years later when Dimitri O. Ott, a famous Petrograd gynecologist, introduced "ventroscopy" for the inspection of the

FIGURE3 ■ Desormeaux's endoscope (ca. 1853).

FIGURE3 ■ Desormeaux's endoscope (ca. 1853).

Images History Laparoscopy
FIGURE5 ■ The Nitze-Leiter cytoscope (ca. 1879). FIGURE 6 ■ An early cytoscope.

abdominal cavity (8). He employed a head mirror to reflect light into a speculum introduced through a small anterior abdominal wall incision (9,10). Although technically primitive, the idea of closed diagnostic inspection of intraperitoneal contents was conceived. However, the concept of distending the peritoneal cavity with air to aid in visual inspection was not realized even though in 1870 Simons from Bonn had already reported safe air pumping into animal abdomen. Wegner from Berlin corroborated Simon's studies in 1877, and in 1882, Mosetit-Moorhof from Vienna successfully created pneumoperitoneum to treat tubercular peritonitis in a child (11). George Kelling from Germany (Fig. 8) had the pioneering idea of employing the Nitze cystoscope for the inspection of abdominal viscera. During the 73rd Congress of German Naturalists in 1901, he performed a so-called "celioscopy" on a dog. After insufflating the peritoneal cavity with air flowing through a needle, Kelling observed changes to the intra-abdominal organs at pneumoperitoneum pressures sufficient to stop intra-abdominal hemorrhage (i.e., up to 50-60 mmHg) (12). Kelling's advanced work was particularly notable for the use of a separate needle to produce the pneumoperi-toneum. However, he failed to publish in a timely fashion his work on humans, and the

FIGURE8 ■ George Kelling.

FIGURE 7 ■ Light source developed by preston in 1898 for the mignon lamp.

FIGURE8 ■ George Kelling.

FIGURE9 ■ Hans Christian Jacobaeus.

FIGURE9 ■ Hans Christian Jacobaeus.

technical refinements he developed. Hans Christian Jacobaeus of Sweden (an internist in Stockholm) published on both human laparoscopy and thoracoscopy in 1910, highlighting the low morbidity of such procedure despite the use of a single trocar to both produce the pneumoperitoneum and provide endoscopic access (Fig. 9) (13). By 1912, his reported series included a total of 115 patients (13—16). At Johns Hopkins University in 1911, Bernheim performed an organoscopy using a proctoscope to visually inspect the peritoneal cavity (Fig. 10) (17).

Minor variations in equipment and technique were described in subsequent reports from both Europe and the United States (18). In 1920, Orndoff devised a trocar with a pyramidal point and an automatic cannula valve to prevent the escape of gas from the pneumoperitoneum (19). He published his experience with laparoscopy performed using such devices and a roentgen screen. To prevent the leakage of gas, Stone from the United States described the fitting of the outer portion of the trocar with a rubber gasket in 1924 (20). At the same time, Zollikofer from Switzerland introduced the use of CO2 for insufflation and observed its ease of absorption (21). The primary medium was previously filtered air, with its intrinsic risk of air embolism. To minimize the risks related to initial abdominal puncture, Goetze from Germany developed an automatic insufflation needle in 1918 (22). Initially, the insufflating medium for this instrument was oxygen, a gas with lower incidence emboli formation when compared to air. However, it soon became obsolete with the advent of electrocautery. In 1938, Veress from Hungary further refined the automatic needle initially used for the creation of pneumothorax in the treatment of tuberculosis (Fig. 11) (23). The Veress needle is now routinely used to create pneumoperitoneum.

Besides for developing technical advances, many physicians are renowned and responsible for the instruction of laparoscopy as an accepted method. H. Kalk from Germany exemplified this as an outstanding proponent of "peritoneoscopy" throughout Europe (Fig. 12) (24-26). In fact, in addition to devising a 135°, fore oblique viewing system, his teachings led to the widespread adoption of his methods. With some 21 papers on the management of liver and gallbladder disease published between 1929 and 1959, he is referred to as the "Father of Modern Laparoscopy" (10), a title oftentimes shared with Kurt Semm (Fig. 13), a German gynecologist who developed many laparoscopic operative techniques and instruments including intracorporeal suturing techniques, a controlled insufflation apparatus, and safe endocautery devices. Semm first performed a laparoscopic appendectomy, which

FIGURE ll ■ Vepress's automatic needle (ca. 1938).

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FIGURE 12 ■ H. Kalk. FIGURE 13 ■ Kurt Semm.

was a considerable task, given the limited ability to convey the otherwise "closed" world of laparoscopy.

Although multiple devices had been designed for photographing laparoscopic detail, the majority of description was by illustration alone. These limitations continued until a single lens reflex camera for endophotography was introduced by Henning in 1931 (27). The first black and white and color photographic atlas was published by Kalk in 1935 (27). Later on Caroli, Ricordeau, and Foures from France first used an electronic flash intra-abdominally (28). Further major advances in visual reproduction awaited the development of improved light transmission, lens systems, cinephotography, and eventual video technology.

Meanwhile, laparoscopy made its initial forays into the interventional realm. Due to advances and modifications in high frequency unipolar electrocautery, in 1933, Fervers from Germany burned abdominal adhesions and performed excisional biopsy (29). In the United States, Ruddock further perfected his own peritoneoscope, pneumoperitoneum needle, trocar, and ancillary instruments for biopsy (30-34). He published his initial series of 200 cases in 1934, followed by his entire experience with more than 2500 cases. Laparoscopic tubal sterilization using electrocautery was first described in the porcine model by the Swiss Boesch in 1935 (35). Power and Barnes from the United States performed this on a patient in 1941; their report included an interim published discussion of the technique by Anderson (36,37). The American Donaldson used the Ruddock peritoneoscope to perform a uterine suspension in 1942 (38). Further progress in laparoscopic abdominal surgery had to await the better provisions for safe hemostasis achieved by improved electrocautery.

During World War II, culdoscopy, as described by Albert Decker in 1944, gained the attention of the American surgical community and became a standard gynecologic procedure in the United States for many years (39-41). Contemporarily, the French Raoul Palmer greatly furthered gynecologic laparoscopy throughout Europe (9,42). Interest was not rekindled in the United States until the publication, in 1967, of the first English laparoscopic textbook by the British gynecologist Steptoe, who was influenced by his European colleagues (43). The resurrection of American laparoscopy occurred through the dissemination of contemporary experience and by the accompanying advances in optics, light transmission, insufflators, and ancillary materials. These largely European developments broadened the field's utility and better ensured patient safety.

In 1952, the French Fourestier, Gladu, and Valmiere developed a method for light transmission along a quartz rod that greatly improved the quality of light produced, and removed the risk of electrical and heat injury plaguing previous systems (44). The same year Hopkins and Kapany from England first employed fiber optics similar to those used into the fiber optic gastroscope (45). Hopkins was also developed a quartz rod lens, which replaced prior lens systems of rigid endoscopes (46). Frangenheim incorporated many of these advances in laparoscopy, using diathermy for tubal sterilization in 1963, and fiber optics in 1965 (46). His extensive publications regarding anesthetic methods, pneumoperitoneum, tissue emphysema, air embolism, intestinal perforation, hemorrhage, burns, and cardiopulmonary problems furthered the course of safe laparoscopic procedure (47).

In the United States, Cohen, followed by Hulka, were at the forefront of laparoscopy through the late 1960s and early 1970s, disseminating and popularizing laparoscopy within the gynecologic community (47,48). After initially diagnostic application, the major indication was voluntary sterilization. These methods were so widespread, that Jordan M. Phillips founded the American Association of Gynecologic Laparoscopists in 1972 (48). Its second annual meeting was held in 1973 in conjunction with the First International Congress of Gynecologic Laparoscopy, and counted 600 attendees. At that time, approximately 500,000 laparoscopic procedures were performed annually in the United States, and laparoscopy became a requirement of residency training in obstetrics-gynecology programs by 1981 (48).

Meanwhile, substantial pioneering work by Kurt Semm advanced the safety and scope of laparoscopy (4,35,49-53). Automatic control systems were developed for induction and maintenance of the pneumoperitoneum using CO2. Through the 1970s, further Semm's work in conjunction with WISAP (Sauerlach, West Germany) led to the development of electronically controlled units. The development of the open trocar technique of Hasson expanded the indications for laparoscopy including patients with a history of prior laparotomy and adhesions, considered a contraindication to laparoscopy so far (46,54).

Semm takes great note regarding the lack of safe hemostasis as additional impediment in the advancement of laparoscopic surgery (35). The use of high frequency monopolar cautery within the abdominal cavity had been historically fraught with the serious sequelae of bowel injury. Indeed, the second most frequent cause for lawsuits against obstetrician-gynecologists in the early 1970s was for laparoscopic bowel burns (7). Therefore, a great deal of investigation was devoted to eliminate these dangers, particularly, with the growing popularity of laparoscopic tubal disruption. The electrical shielding of instruments and current reduction were introduced to obviate these problems, along with the subsequent development of the 100°C endocoagulator. Hemostatic methods also included the use of "endoloop" and suturing devices for large blood vessel control (4,50,53).

Laparoscopy, initially performed to diagnose liver and gallbladder diseases, was employed progressively less frequently as radiographic imaging developed and moved to the forefront. After performing the first laparoscopic cholecystectomy in Germany in 1985, Muhe suffered the indignities of collegial criticism and ostracism like Semm did before after performing the first laparoscopic appendicectomy. In 1987, Philippe Mouret, a French gynecologist, performed laparoscopic cholecystectomy during a routine pelvic procedure (45), and presented his experience during a meeting. The first clinical series of laparoscopic cholecystectomy were performed by Francois Dubois in France in 1988, and McKernan and Saye (1988) and Reddick (1989) in the United States (45,55). Reddick's and Dubois' documented the capability of laparoscopic cholecystectomy to duplicate open surgical principles (56). Based on these pioneering experiences, interest on laparoscopic cholecystectomy raised tremendously resulting in rapid widespread of the procedure to the point of almost replacing elective open cholecystectomy in many centers over a three-year period (45). While this may be startling when viewed as an isolated event, it is predictable when perceived within a broader framework.

The performance of complex intra-corporeal procedures in a safe and reliable manner required more than the simple development of advanced mechanical instrumentation. It was also the result of the coordinate efforts of many operators. During standard laparoscopic practice, only the primary could actually see the operative field, while the ability of the assistant to substantially participate was limited blind involvement. Additional eyepiece attachments were incorporated for learning purposes to allow the novice to gain the necessary skills to subsequently operate alone. Although closed circuit television was manufactured since 1959, portable systems were not available until 1970 (48). The term "portable" should be applied sparingly, because the initial cameras weighed some 10 pounds and were equipped with an attachable ceiling harness. Their size, image quality, and cost relegated them to the rare and cumbersome teaching aid. Only the advent of microchip technology allowed practical real-time video monitoring of the operative field. Widespread and extensive use of such technology throughout all areas of endoscopy marked the groundwork for major laparoscopic intervention. With the entire surgical team watching at the surgical field, more complex procedures could be undertaken.

Laparoscopy in urology paralleled, to a large extent, the changes in general surgery. Up to the late 1980s, urologic laparoscopy had limited applications. In 1976, Cortesi reported laparoscopic abdominal exploration in an 18-year old patient with bilateral abdominal testes (57). Since then, cumulative experience by multiple authors has substantiated laparoscopic management of cryptorchidism (58-61). Another anecdotal application was reported by Wickham, who, in 1979, performed laparoscopic ureterolithotomy by a retroperitoneal approach (62). Additional stone manipulation was performed by Eshghi, who, in 1985, laparo-scopically monitored the percutaneous transperitoneal removal of staghorn calculi from a pelvic kidney (63).

However, apart from its use in the pediatric population for cryptorchidism, uro-logic laparoscopy lacked a broad application when compared to the large population of patients with cholelithiasis treated laparoscopically by general surgeons. In fact, in many urologic procedures the benefits of laparoscopy were initially outweighed by the technically challenging anatomy that greatly limited access and compromised control. Varicocelectomy and bladder neck suspension were deemed feasible but showed little benefit over open surgery. Laparoscopic pelvic lymphadenectomy performed to overtake inaccuracy of imaging techniques for staging of patients with prostate carcinoma was deemed both feasible and effective (64). Laparoscopic pelvic lymphadenectomy in a porcine model was described by Howard Winfield in 1989 (65). Schuessler and associates first performed this procedure in a series of patients with prostate cancer. Nevertheless, interest in laparoscopic pelvic lymph node dissection dropped precipitously in mid 1990s due to advances in nonoperative staging of prostate cancer. After initial, isolated but encouraging reports, Janetschek et al. performed laparoscopic retroperitoneal lymph node dissection in an attempt to reduce the morbidity of open retroperitoneal lymph node dissection (66). Kavoussi and coworkers reported the feasibility of laparoscopic retroperitoneal lymph node dissection for patients with stage I non-seminomatous germ cell tumors. Efficacy was similar to traditional retroperitoneal lymph node dissection (67).

Renal procedures are the main target for urologic laparoscopic organ resection. Laparoscopic nephrectomy in a porcine model was first attempted via a retroperitoneal approach by Weinberg and Smith in 1988 (68). In 1991, after extensive laboratory trials including the development of the basic concepts of organ entrapment and tissue morcel-lation, Clayman and coworkers performed the first clinical laparoscopic nephrectomy. Subsequent continued results of transperitoneal laparoscopic nephrectomy have been reported by the same group (69-71). With increasing skills and experience, the total operative time of almost eight hours required to complete the initial case was reduced to four hours. Such procedures heralded a new era in laparoscopic urology that began to challenge and compete with conventional open surgery. However, many technical refinements were necessary to make laparoscopy an appealing alternative to open surgery. Using retroperitoneal balloon dissection to create an adequate retroperi-toneal space, Gaur obviated the initial difficulties with closed insufflation of the retroperitoneum (72). In addition to these advances, significant improvements in vascular control and soft tissue hemostasis are constantly evolving. As a result, more challenging laparoscopic renal procedures were progressively attempted and executed. Winfield and colleagues performed the first laparoscopic partial nephrectomy in 1993. Subsequent series of laparoscopic partial nephrectomy reported by many authors showed cancer control similar to open nephron-sparing procedures. Capitalizing on the relatively benign recovery from laparoscopic surgery, in 1994, Gill et al. demonstrated the feasibility of laparoscopic donor nephrectomy in the porcine model (73). The first clinical donor nephrectomy performed by Kavoussi and coworkers in 1995 (74). Over the next five years, the technique became more refined, and it has since spread worldwide. At many centers, laparoscopic donor nephrectomy is the now standard of care. The development of a handport providing direct hand assistance has increased accessibility to renal surgery. The ability to manipulate tissue has greatly increased the comfort zone for many urologists, broadening the indications for minimally invasive procedures. One of the critiques raised by laparoscopic purists regards the size of the incision required to place the handport. Undoubtedly, handassisted laparoscopy provides greater control and easier organ retrieval for the naive laparoscopic surgeon.

The next urologic milestone in laparoscopic organ resection was the management of prostate and bladder diseases. Laparoscopic radical prostatectomy was innovated and perfected in Paris by Guillonneau and Vallancien (2000) (75) as well as by Abbou et al.

(2000) (76). Although a steep learning curve was necessary to perform Laparoscopic radical prostatectomy in a time-sensitive manner, today several centers worldwide perform laparoscopic radical prostatectomies routinely with results similar to those of the open counterpart. Improved magnification and better identification of the anatomical structures are potential benefits, and decreased morbidity is anticipated. However, at the time of this writing, open prostatectomy remains the standard of care. Nevertheless, laparoscopic technology and experience on Laparoscopic radical prostatectomy, and their acceptance, continue to evolve.

Laparoscopy has been applied also to the technically demanding area of cystec-tomy. In 2000, Gill et al. reported their initial experience with bilateral pelvic lymphadenectomy, cystectomy, and ileal conduit urinary diversion in patients with muscle-invasive bladder cancer (77). The ability to complete this procedure intracorpo-really required a high level of reconstruction that has also been applied to other areas in urology. The same laparoscopic techniques for suturing and knot tying were efficaciously employed to perform, ureteral reimplantation, ureteroureterostomy, and pyeloplasty. In fact, in select centers laparoscopic pyeloplasty is becoming the standard of care for ureteropelvic junction obstruction.

The development of robot technology (da Vinci® Surgical Systema) is the epitome of surgical magnification and technical refinement (Fig. 14). Such expensive sophistication allows for intricate manipulation within a limited operative space.

It is becoming increasingly evident that laparoscopy has the potential to duplicate the principles of open urologic surgery for the management of several medical conditions involving the lymph nodes, kidney, adrenal gland, bladder, or ureter. However, although technical pioneers have demonstrated the feasibility of many demanding laparoscopic procedures, long-term results are awaited before these procedures would become routinely part of the urologic armamentarium. In order for evolution to occur and to continue, nuances must prove to be superior to the status quo. The hallmark of this current period of urologic laparoscopic history is the combination of technical achievement demonstrating what can be done, with the application of academic rigor to determine what should be done. In an increasing number of multi-institutional studies, laparoscopic procedures are compared with their open surgical counterparts. The evidence of comparable efficacy combined with improvements in postoperative pain, cosmesis, recovery, and length of hospital stay shows that laparoscopy belongs in the mainstream of urologic surgery.

FIGURE 14 ■ The da Vinci® Surgical System. Source: Courtesy of Intuitive Surgical, Inc.

FIGURE 14 ■ The da Vinci® Surgical System. Source: Courtesy of Intuitive Surgical, Inc.

aIntuitive Surgical, Inc., Sunnyvale, CA.

In this current era, feasibility and benefit of many urologic laparoscopic procedures have been proven on a large scale. As we enter the new millennium, the craft of open surgery may have an ever-decreasing role in the treatment of urologic diseases. This evolution will require the demonstration of benefit over existing standard practice, which then must be embraced by urology in order to be implemented. This evolution, initially charted by the relentless pioneers mentioned in this chapter along with countless others, will continue to be written as an odyssey of innovations in the hands of modern stalwarts.


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