History

Since ancient times, medical men have desired to inspect human body cavities and passages to understand their complexity and to treat their diseases. Easily accessible body cavities, such as the mouth, rectum or even the vagina, were already inspected in ancient times with the help of speculums.

Accounts of catheters and rectal speculums have been handed down from Hippocrates II. The Greek, born on the island of Kos and known for the Hippocratic oath, inserted tampons calabash. However, the Greeks did not dare to use a speculum to view the rectum or inspect the vagina.

Erasistos, born in 320 BC in Keos, was the first to describe anatomically correct curved catheters. Oreibasis, born in 325 BC in Pergamon, invented the indwelling catheter at Rome in the times of Julius Caesar. He also dilated the urethra with a goose quill swathed in swollen parchment.

The origin of endoscopy can be traced back to a reference in the Babylonian Talmud. The treatise describes a lead funnel with a curved mouth furnished with a wooden outlet (Mechul). Both parts were inserted in the vagina to show by retraction for the first time to human eyes, the cervical os as an internal organ, to diagnose uterine bleeding and differentiate it from vaginal bleeding.

A triple armed vaginal mirror and a rectal speculum were excavated in Pompei. The Syrian gynecologist, Archigenes from Apameia, who practised in Rome from 95 BC to 117 BC, wrote a treatise on uterine bleedings. He used a cervical mirror for inspection and commented on various forms of gynecologic palpatory examinations as well as external and internal inspection.

The Arab, Abul al-Qasim Khalaf ibn al-Abbas Al Zahrawi is regarded as the Middle Ages’ most eminent surgeon. He is also known as Alsaha-Ravius or Albucasis of Cordoba (936-1009); he used a glass mirror to reflect light to view the inside of the vagina. He described his speculum as “two rods, one lying on the top of the other, which are introduced into the cervix (he probably meant vagina) to expand it with the help of screws”.

The first endoscopic light source can be traced back to Giulio Cesare Aranzi (1530-1589). This Venezuelan used camera obscura (1587) to focus a ray of light to view the nasal cavity. He held a water-filled spherical bottle in front of a hole in a shutter in a darkened room and projected that focused light to view the nasal cavity. He recommended an artificial light source on rainy days.

The French gynecologist and surgeon, George Arnaud de Rosil (1698-1774) gave new significance to the vaginal speculum. Arnaud was the first to use an endoscopic examination lamp making use of a covered lantern. The light source was a night lamp that was placed in a box painted silver from inside. Similar to camera obscura, light focused through a convex lens could be used to illuminate the vagina that was opened with a speculum.

Philipp Bozzini (1773-1809) who marks the turning point from the old to new medicine must unquestionably be mentioned for his contributions to the development of modern endoscopy. He studied in Mainz and Jena where he became acquainted with Christoph Wilhelm Hufeland who published the “Journal of Practical Pharmaceutics and Art of Wound Healing”. In 1804, he published the first description of his instruments in a small Frankfurt newspaper. The equipment had optical part with the illumination device and mechanical part that adapted itself to the anatomy of the body orifice. In 1806, he published a detailed account of his light guide.

In 1807, the Weimar National Industrial Comptoir published the monograph, “The Light Guide or the Account of a Simple Device to Illuminate Internal Cavities and Passages of Living Animals”. Bozzini himself made the sketches and even engraved them in copper.

Bozzini constructed an instrument for the vagina, rectum and oral cavity including the throat. One could see and even operate on a modest scale with it. Even though the light source was too weak and the visual field too small, all further attempts at cystoscopy in the next 70 years were exclusively based his illumination principle using an extracorporeal light source to reflect the light. His principle of using an artificial light source to reflect light toward the object to be examined and redirect light to the eye of the observer substantially influenced the international discussion on the development of endoscopes.

Antonin Jean Desormeaux (1815-1894) constructed the first portable endoscope, and presented this historic development on November 29, 1843, for which he received a part of the Argenteuil prize from the Academie Imperiale de Medecine. He was the first to clinically use Bozzini’s light guide for which many regard him the “Father of Endoscopy”. His instrument was a system of mirrors and lenses with an open flame as light source. Skin burns were the most frequent complication. The light guide was essentially used in patients with urological illnesses.

The most important development of endoscopic abdominal surgery is connected with photography and television. Theodor S. Stein (1868) started it in Frankfurt. In 1874, he introduced his “photo-endoscope”.

Gynecology was the so to say initiator of the development of operative endoscopy. Apart from Desormeaux, Aubinais and Pantaleoni must also be mentioned for their attempts to inspect the uterine cavity, i.e. today’s hysteroscopy. The technical development of endoscopy to perfection was left to cystoscopy. The plausible cause is: the Mignon filament (Edison) at the tip of the cystoscope by Nitze and Leiter posed no danger of burns because the urine in the urinary bladder ensured appropriate cooling.

In 1881, Johann Mikulicz (1850 -1905) and Leiter adopted the principle of rigid the optic system developed by Max Nitze, and successfully constructed the first clinically usable gastroscope. Mikulicz carried out several clinical examinations at Billroth’s Surgical Clinic in Vienna.

Between 1890 and 1900, George Kelling (1866-1945) of Dresden worked on the anatomy and physiology of the stomach “to determine the size of the stomach”. He gained experience in oral air insufflation, and worked on the pressure ratio of the gastrointestinal tract and the abdominal cavity. Simultaneously, he worked on improving the techniques of examination of the gastrointestinal tract, which resulted in application for a patent.

His know-how of gastric and esophageal endoscopy, and knowledge of air insufflation were the foundation of future attempts to carry out therapeutic and diagnostic examinations in closed body cavities. The brilliant idea of connecting his air insufflation apparatus to the Fiedler trocar and Nitze cystoscope led to the birth of laparoscopy.

On September 23, 1901, he gave the historic lecture on “Tour of the Oesophagus and Stomach by Flexible Instruments” at the 73rd meeting of the Society of German Natural Scientists and Physicians in Hamburg. He exemplified the principle of his new method, the ´coelioscopy´, based on the principle of abdominal instead of oral insufflation and utilizing the Nitze cystoscope for visualization, to show the abdomen of a dog.

“I question myself, how the organs will react to the air introduced inside? To find out, I have developed a method to introduce the endoscope in the closed abdominal cavity (coelioscopy).” (Kelling 1901).

After an interval of a century and considering the status of endoscopy today, one can evaluate Kelling’s endoscopic work as follows:

In 1911, an internist, Hans Christian Jacobaeus (1879-1937) from Stockholm, introduced the term, “laparothoracoscopy”. He was the first to view the thorax and abdominal cavity by endoscopy, and recommended the endoscopic technique to view other body cavities. In contrast to Kelling, he inserted the trocar directly without creating pneumoperitoneum. Like Kelling, he began by breaking down adhesions under thoracoscopic vision.

Bertram M. Bernheim (1880-1958) of the Johns Hopkins Hospital introduced endoscopic surgery into the USA in 1911. He called the procedure “organoscopy”. His instrument consisted of a half-inch proctoscope and a simple light.

Heinz Kalk (1895-1973), a gastroenterologist from Berlin, known as the founder of the German School of Laparoscopy, developed a 135° lens system and double trocar. He used laparoscopy as a diagnostic method in diseases of liver and gallbladder. In the publication of his experiences in 1939, he reported over 2,000 liver punctures under local anesthesia with no fatalities. He broke down adhesions by laparoscopy.

Constant improvements in the laparoscopic methodology smoothed the way for its wider operative use. Important steps in the process were: the use of harmless carbon-dioxide (CO2) for pneumoperitoneum by Zollikofer in Switzerland (1924), the coagulation of adhesions by Fervers in Germany (1933) and the intra-abdominal use of monopolar current by Ruddock in USA (1934).

Boesch, from Swiss Aarau, reported in his paper on laparoscopy about “the wonderful perspective of female genital organs and about the exposure of hidden organs, e.g. the ovaries with an elevator (palpation probe)”. He noted further: “with the laparoscope, we have found a way to carry out tubal sterilization for the given indication without laparotomy. With a suitably insulated coagulation clamp, the tubes can be coagulated at multiple places in 3-5 minutes under endoscopic vision”. In 1941, Frank H. Power and Allen C. Barnes developed the same technique in the USA; however, they used a peritoneoscope for tubal sterilization.

The insufflation of the abdominal cavity by instruments was problematic for a long time. Kelling carried it out with the Fiedler trocar, which had a blunt “mandrin” to avoid injuries; in 1918 Otto Goetze (1886-1957), who coined the term “pneumoperitoneum”, produced a similar instrument with a spring mechanism for air insufflation for contrast radiograms.

In the year 1938, the Hungarian, Janos Veress (1903-1979) developed a special cannula with spring mechanism with the aim to create pneumothorax, and consequently, to treat tuberculosis which was prevalent at that time. With only minor modifications, the Veress needle is still used today to create pneumoperitoneum for laparoscopy. Its special mechanism prevents injury to the internal organs during needle insertion through the anterior abdominal wall.

In the 60s of the 20th century, gynecologists began with the first small operative interventions. However, the French gynecologist, Raoul Palmer had already carried out laparoscopy in the Trendelenburg position in 1944. In this position, the intestines were displaced out of the pelvis and consequently could be better assessed during the operation. Additionally, he required continuous gas insufflation, which was controlled automatically. He also carried out the first laparoscopic sterilization in Paris.

The piercing of the umbilicus for the laparoscope by Raoul Palmer in 1946 was a groundbreaking procedure in gynecology. Like Kelling, he called the endoscopic diagnostic procedure coelioscopy, and developed several methods to insert endoscope. Abdominal access involved many technical difficulties because of the mainly blind insertion technique through the anterior abdominal wall.

Decker, an American, introduced the laparoscope transvaginally through the vaginal fornix. He called this procedure “Douglasscopy or Culdoscopy”. Douglasscopy from a diagnostic perspective was insufficient. This technique, which was initially prevalent in America, later lost its importance. In 1998, it was the team of Brosens and Gordts who brought about a renaissance of this procedure as transvaginal hydrolaparoscopy for the diagnosis of sterility.

Hans Frangenheim (1920-2001) and Kurt Semm (1927-2003) are uniqueliy connected with the development of laparoscopy in Germany after the Second World War.

In 1950, Hans Frangenheim began his training in gynecology with Anselmino in Wuppertal, and in 1951, he came in contact with laparoscopy for the first time. He was called to the medical clinic in Cologne where a lower abdominal tumor was diagnosed during hepatoscopy and further line of treatment had to be decided. Looking back, he wrote:

“I sensed there that a new aid had presented itself for the field of gynecology and I began to look into the literature. A remark made by Kalk in a textbook impressed me the most. He said that he was certain that gynecology would open a big field of indications for laparoscopy”.

After Frangenheim´s appointment in October 1955 to the post of Assistant Medical Director of the National Gynecological Hospital at Wuppertal, he attended lectures by Palmer in Paris, and realized that laparoscopy was clearly superior to culdoscopy, which was still practiced in Germany. Frangenheim began to concentrate his efforts on regulating uncontrolled gas insufflation, developing new instruments and the photographic documentation of endoscopic findings. He had a difficult time with German endoscopy firms. Finally, with modified anaesthesia equipment from Draeger, he succeeded in reducing the gas pressure from the customary 50mm Hg to 15 mm Hg, and in restricting the carbon dioxide gas flow to maximum of 5 L/min. He even defined indications for the diagnostic laparoscopy in extrauterine pregnancy, chronic lower abdominal pain, sterility and ovarian tumors.

His monographs: “Laparoscopy and Culdoscopy in Gynecology”, “Laparoscopy in Gynecology, Surgery and Paediatrics”, “Diagnostic and Operative Laparoscopy in Gynecology- Atlas with Colour Illustrations” as well as countless publications and lectures contributed to the further spread of the method.

In 1966, he was appointed Medical Superintendent of the Gynecological Clinic in Constance. Under his presidency the 2nd European Congress of Endoscopy was held in Constance and from that event laparoscopy received further impetus. In 1982, he received the first order of the Federal Republic of Germany for his outstanding work. On the occasion of the 80th birthday, Semm praised him for his contribution with these words: “Today, the name Frangenheim is inseparably associated with the gynecologic laparoscopic methods. His achievements for Germany and for the world are epoch making and will go down in the annals of history”.

The Kiel University Department of Obstetrics and Gynecology under Semm (1927-2003) is regarded as the birthplace of modern endoscopic surgery. Semm, collaborating with Richard Fikentscher (1903-1993), developed a new universal insufflation machine, for the diagnosis of tubal patency, i.e. blowing through the fallopian tubes according to Rubin. Befitting his knowledge of tubal insufflation, Semm developed an apparatus called “CO Pneumo” for insufflating CO2 gas during laparoscopy to minimize operative risks of endoscopy. The instrument was in use from 1964 onwards at the Second University Clinic for Obstetrics and Gynecology in Munich, and created pneumoperitoneum automatically. The cold light (extracorporeal light that shone across a bundle of fiberglass) was simultaneously developed. Together, they eliminated intestinal burns and gas embolism that were the main dangers of gynecological laparoscopy. In spite of progress the world over, gynecological diagnostic laparoscopy was universally rejected. For this reason, Semm selected the word “pelviscopy” to demonstrate that a new technique had been developed. Starting from 1965 this new method spread quickly within Germany, mainly as a diagnostic procedure of female infertility. In 1976, Semm developed an electronic version of the “CO2 Pneumo” with the Quadro test for operative pelviscopy.

After Semm demonstrated the “Co2 Pneumo” at the Congress of the American Fertility Association in Washington in 1969, Cohen published a book on this procedure in 1970. In the USA, the acceptance of this new pelviscopic procedure in gynecology was phenomenal. Even though the method was used a million times, it was employed in 95% of the cases only for tubal sterilization, unlike in Europe, where Boesch had already accomplished this 35 years before. Ignorance of the laws of physics, while using high frequency energy in closed body cavities, was the cause of many grave accidents through burns to the internal organs, such as intestines and ureter. Such incidents once more deeply incriminated this method.

Fascinated by the idea that pelviscopy can be used not only for sterilization, but also for other operative purposes, Semm introduced in his new regimen for hemostasis in New Orleans in 1974. The use of high frequency current for creating destructive heat was not required in endocoagulation. The human body did not come in contact with the electrical energy. Optimal controlled hemostasis took place at 110°C. Between 1970 and 1980, the high frequency current in the monopolar- and bipolar techniques using inadequately safeguarded equipment led to uncontrollable burns. Today, in clinical endoscopic practice, it is ensured that electro energy used under vision does not lead to burns. Modern coagulation and cutting equipment, which work with monopolar and bipolar currents, have control mechanisms that minimize the risk of unintentional burns. Bipolar and monopolar instruments have a controlled and restricted coagulation zone.

Semm, who produced his own instruments as he was a skilled instrument maker himself, built an automatic CO2 insufflator in 1963, introduced thermocoagulation in 1973 and was the first to use the Roeder loop to stop arterial bleeding. For laparoscopy, he developed special suction irrigation equipment and an electronic insufflator. The methods of hemostasis (endosuture with intra- and extracorporeal knots) developed by Semm and his range of instruments made more difficult interventions possible. However, many physicians, gynecologists as well as surgeons, criticized him for his vehement use of the so-called “keyhole surgery” They were of the opinion that due to the modern anesthetic techniques, big operations by laparotomy posed no problems and Semm exaggerated the problems with subsequent adhesions. Some treated the news of the new spectrum of operations (oophorectomy or the removal of complete uterine appendages, treatment of tubal pregnancy) with disbelief, and concluded that Semm started his operations as a laparoscopy and then ended it as conventional operation by laparotomy.

Semm was exposed to the most intense hostility of the German gynecologists (and endoscopic surgeons), when he carried out the first laparoscopic appendectomy in 1983.The surgeons especially saw no need to abandon the established operative method, and to replace it with technically more difficult one. Semm’s first attempt at publishing this method met with rejection. The fact that a gynecologist wanted to show the surgeons, how an operation should be carried out was simply unthinkable at that time. He had crossed the limit that was till then considered as sacrosanct. However, Semm knew that endoscopic surgery had enormous potential not only in gynecology, but especially in surgery and therefore continued unperturbed toward the goal of reducing the surgical trauma for patients. Two German surgeons, Friedrich Gotz and Arnold Pier, followed his intent and provided a wider base for laparoscopic appendectomy. By the early 90s, they had carried out hundreds of appendectomies in this way and perfected the technique, which is now used in cases of acute appendicitis.

In 1977, Semm developed a 10mm morcellator for pelviscopy purposes. However, in today’s operative pelviscopy where even fist-size myomata are removed from the uterus with little blood loss, this instrument is not very effective. In 1988, the manually operated serrated-edged macro-marcellator (SEMM) of 15 - 20 mm diameter was introduced. This instrument can reduce a myoma of about 5cm in size to small pieces within a few minutes. The posterior colpotomy for removal of myoma or even a small abdominal incision is no longer required. Since the introduction of horizontal morcellation, morcellators have been motorized, and they are available in 10 - 24 mm diameters.

As in laparotomy, intra-abdominal irrigation equipment is also necessary in laparoscopy also to guarantee a good view. The acqua-purator of 1974 gave way to the CO2 aqua-purator in 1990.Today, the aqua-purator Biotherm has removed many problems of hypothermia-even in operations of longer duration. In 1994, insufflation of preheated CO2 was introduced to preserve isothermia.

In September 1985, a surgeon from Böblingen, Erich Mühe, (1938 – 2005), performed laparoscopic cholecystectomy for the first time in the world using Semm’s instruments. In 1986, he reported 97 successful laparoscopic operations. In the year 1989, Reich et al. described the first laparoscopic assisted vaginal hysterectomy. In 1991, Mouret carried out the first cholecystectomy by video laparoscopy.

In the 70s and 80s, most surgeons simply ignored the development of laparoscopic operations because of the introduction of new medicines, the impressive results of intensive care and the innovations in anesthesia that facilitated extensive surgeries. The basic concept that a big problem (disease) requires a big solution (abdominal incision) was so deeply rooted in surgeon’s thinking that there was no place for “keyhole surgery”. That is why, the surgical fraternity refused to accept and modify gynecological instruments for their use.

However, contrary to the general development some surgeons accepted the challenge and accelerated the introduction of laparoscopic techniques in surgery. A group of German surgeons was particularly active in this process, and in December 1976, they started the Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonographie (CAES) in Hamburg. In the USA, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) was set up 5 years later. In the following years, both organizations laid the foundation for the introduction of endoscopy into clinical practice.

Prompted by Dr. Bernd Manegold, a surgeon from Manheim and one of the founders of the CAES, the first edition of the scientific journal “Surgical Endoscopy” was published in 1987 under the direction of many leading endoscopists. The following year “the First World Congress for Surgical Endoscopy” was successfully held in Berlin with 500 experts from all over the world. This finally led to the acceptance of endoscopy in surgery.

In 1983, the British urologist John EA Wickham (born in 1927) used the concept “minimally invasive surgery” for the first time. The concept attracted attention in 1987 after he published his visions of extensive endoscopic treatment in the famous “British Medical Journal”. In spite of the criticism, this concept mirrored the general trend of the 80s as the minimally invasive techniques greatly fascinated doctors and patients alike.

This development was further accelerated by crucial technological innovations. The introduction of new light sources (Palmer 1953), the Hopkins optics (1960) and the cold light source had already improved the illumination in endoscopic operations in the 60s. The video technique was also important. The new video camera was much smaller and, therefore, easier to manage than its predecessor and the videocassettes also were simpler for everyday use than the 8mm or 16mm film. In the 80s, more surgeons used video cameras, but even the latest and smallest of the cameras together with the endoscope proved unwieldy, because they altered the balance and made precision work difficult. Electronic minicameras brought the breakthrough: a 4 mm optoelectronic transducer, charge coupled device (CCD) converted the view from inside the body cavity to electronic impulses and transferred them to the monitor. The combination of optic trocar and video camera opened new possibilities for the surgeons, because now with both the hands free, they could operate ambidextrously and simultaneously follow on the monitor, what was happening along with the entire team.

The years that followed were moulded by a lively exchange and reciprocal stimulation. In 1987, the video laparoscopic cholecystectomy in Lyon by Philipe Mouret (born in 1937) and his presentation of the procedure at the SAGES meeting in Louisville triggered a down right boom in France, and also encouraged surgeons in the entire world to tread this path further.

When Semm presented his laparoscopic appendectomy in Baltimore in 1988, JB Mckernan and WB Saye took it up and in June 1988, they reported the first laparoscopic cholecystectomy in the USA using Semm’s instruments, and combining the procedure with laser technology. As a result many later successful endoscopists visited both the protagonists in Nashville to learn the new technique. At the same time, Sung Tao Ko from Chicago upheld the laparoscopic appendectomy by Semm and brought Semm´s instruments to America.

The news about these sensational methods reached even the media in the USA. During a TV talk show, it was made public with the help of gallbladder operation. After that the Nashville surgeons received hundreds of calls not only from patients, but also from doctors.

As in October 1989, Douglas O Olsen and Eddie Joe Reddick casually announced their training courses for laparoscopic cholecystectomy at the Congress of the American College of Surgeons, they were booked out within a very short time and new courses had to be planned. Many American observers felt that laparoscopy had pervaded the entire surgical fraternity in USA. In the following weeks, a wave of enthusiasm for this new technique spread through the nation, and training courses sprung like mushrooms. The industry was confronted with an abundance of orders so that the waiting period rose up to six months. In the beginning, the leading endoscopists tried to channel the development and to warn about the risks of injudicious use, but they soon realized that it was not possible. No one had thought before 1989 that one of the most established operative method in surgery, cholecystectomy, would change so radically within just a few months. Even the surgeons, who had substantially contributed to this development, were surprised by the speed. Literally thousands of surgeons had to retrain themselves. The training courses were out booked for months, and the shortage of instruments was an unheard of phenomenon in Western medicine. In the following years with the spread of laparoscopy and increasing experience, new operative methods quickly developed in many operative specialities.

The production of endoscopic instruments showed an upswing, and the interaction and interest of the most varied medical specialities –not only surgery, urology and gynecology - increased. Today, the interest of the industry, doctors and patients worldwide is reflected in a common endeavor, to improve surgery in many aspects through modern technology. This is reflected in further developments in the use of digital picture control, robotic instruments, computers and telesurgery. The numerous medical specialist bodies that have emerged and that deal increasingly with the oncological fields also reflect these efforts. In 1965, the German Society for Gynecologic Endoscopy and in 1971, the American Society of Gynecologic Laparoscopy were founded. In 1986, the World Society for Gynecologic Surgery, in 1990 the European Society for Gynecologic Endoscopy (ESGE) and in 1991 the International Society for Gynecologic Endoscopy (ISGE) came into being with yearly or two-yearly meetings.

The development of hysteroscopy and falloposcopy must also be mentioned here. After Lindermann (1971) and Semm (1974) established the CO2 hysteroscopy, the real breakthrough in operative hysteroscopy came after 1980, basically as fluid hysteroscopy. Today, hysteroscopy is a routine procedure, and one cannot imagine diagnostic and therapeutic interventions without it.

From today’s point of view, the ideal entry for viewing the tubal lumen is by hysteroscopy, through a transcervical and transuterine catheter with 0.8 mm thick telescope on flexible falloposcope.

Publications on gynecologic endoscopic surgical work in the 80s concentrated primarily on sterilizations, conservative operations on the adnexa and the enucleation of myoma. From 1989 onward there was a growing number of reports on adhesiolysis, appendectomy, lymphadenectomy and laparoscopy assisted vaginal hysterectomy in different variations. In surgery, besides gallbladder resection, fundoplication and hernia operations, extensive splenectomies, bowel resections and great advances in surgical oncology and the neurosurgery are now described. In orthopedics, the operations on knee have improved further. In urology, there are reports on nephrectomies and robotic prostatic resections. In gynecology, robotic optic holders and instruments are employed.

The worldwide evolution to improve endoscopic surgery has begun; its end is still not in sight. The aim of this surgery is to achieve at least the same, if not better results than with conventional operative techniques.

In conclusion, it must be stressed that the history of laparoscopy and its introduction into surgical practice is a story of many researchers who for many years battled against prevailing opinion and partly against rejection of their brainchild of performing “gentle operations”. Many of the pioneers were ignored, called dreamers or regarded as crazy. It was only through their persistence, tenacity and strong personalities that they could stand firm in the face of adversities.

The history of laparoscopy is a unique mixture of various trends in different fields, spurred by the activities of the specialist societies and their journals and influenced by the world congresses. The influence of industry, which has kept pace and actively supported this development for years, should not be forgotten. Without suitable technology, this dissemination would not have been possible.