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Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure

The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure Author Liselotte Mettler

Department of Obstetrics Abstract: and Gynaecology, Endoscopic surgery spans the wings from 1901 (Georg Kelling) till the cutting edge years with Raoul Palmer, Kurt University Hospitals Semm , Hans Frangenheim , Hans Lindemann and Jordan Schleswig-Holstein, Philipps in 1985 in gynecology , It did experience further multispecialitxy progress from 1985 – 2017 with higher Arnold-Heller-Str. 3, dexterity, precision , loss of anxiety, micro and robotic House 24, 24105 Kiel, surgery, single , multiple ports and robotic technology. The evolution has just begun and will lead to a bright future. The Campus Kiel, Germany, influence of industry, which has kept pace and actively Email: supported this development for years, is the driving force besides the heroes of doctors and engineers that bring up new [email protected] ideas. Without suitable technology, this dissemination would

not have been possible. Endoscopic development and its future does depend on new inventions, on the audacity of leading heroes, their input into this field but also on their management of life to continue to survive and on a healthy and successful cooperation with the medical technical industry and the governments of our countries which grant us the freedom of research and development for the best of all our patients. In 1967 I attended a Medical meeting in Munich, Germany, and heard a lecture of Kurt Semm on Laparoscopic Surgery, it fascinated me. Kurt Semm became the chairman of the Kiel University Department of Obstetrics and Gynecology in 1970. This was were I graduated from medical school. At that time working in the jungles of Peru in General Surgery at the Amazone Hospital Albert Schweitzer I applied for a residency position in Gynecology and Obstetrics at Kiel university. He wrote me back that I can start any time, mentioning that a “jungle girl” should know what she wants and he did not need to see any application papers. That makes up my 50 years with Endoscopic Surgery (1967-2017)

1. History In 1911 internist Hans Christian Jacobaeus (1879-1937) from Stockholm introduced the Historically on the twenty-third of September term, ‘laparothoracoscopy’ [5]. He was first to 1901, Georg Kelling gave the historic lecture view thorax and abdominal cavity by on ‘Tour of the oesophagus and stomach by endoscopy and recommended endoscopic flexible instruments’ to natural history technique to view other body cavities. In scientists and doctors’ seventy-third meeting contrast to Kelling, he inserted the trocar in Hamburg. He also introduced his new directly without creating pneumoperitoneum. procedure that he called ‘Coelioscopy’ [1]. Jacobaeus began like Kelling by breaking Kelling had used his oral air insufflation down the adhesions under thoracoscopic apparatus for the intra-abdominal insufflation vision. together with a Nitze-cystoscope for Heinz Kalk (1895-1973), a gastroenterologist illumination to see the abdomen of a dog, in from Berlin, known as the founder of German animal experiment for the time. school for laparoscopy, developed a 135 o lens system and double trocar [6]. He used laparoscopy as a diagnostic method in “I question myself, how the organs will react diseases of liver and gallbladder. In the to the air introduced inside? To find out, I publication of his experiences in 1939, he have developed a method to introduce the reported over 2000 liver punctures under local endoscope in the closed abdominal cavity anesthesia with no fatalities. He broke down (Coelioscopy) (Kelling 1901). adhesions by laparoscopy. After an interval of a century and considering The insufflation of abdominal cavity by the status of endoscopy today, one can instruments was problematic for a long time. evaluate Kelling’s endoscopic work of as Kelling carried it out with the Fiedler trocar, follows: which had a blunt “mandrin” to avoid injuries;  Contradicting the spirit of times, Kelling Otto Goetze (1886-1957) who coined the term had favored the endoscopic procedure to “pneumoperitoneum”, in 1918 produced a exploratory laparotomy [2] similar instrument with spring mechanism for air insufflation for contrast radiograms [7].  With far sight Kelling challenged the stage wise treatment of malignancy and In the year 1938, the Hungarian, Janos Veress for this purpose sent repeated reminders (1903-1979) developed a special cannula with for the primary use of endoscopic spring mechanism –with the aim to create procedure [3]. pneumothorax and consequently to treat tuberculosis which was prevalent at that time  In 1901, Kelling advised –clearly [8]. With little modifications the Veress foreseeing the problems in training young needle is used still today to create doctors, to practice endoscopic procedures pneumoperitoneum for laparoscopy. Its on cadavers. A hundred years ago, special mechanism prevents injury to the dummies were not available to the pioneer internal organs during needle insertion of endoscopy through the anterior abdominal wall.  Kelling, a visionary, had predicted use of In the 19 sixties gynecologists first began endoscopic interventions particularly, small operative interventions. However, the laparoscopy as day care procedures (1901) French gynecologist Raoul Palmer had [4]. already carried out laparoscopy in the Trendelenburg position in 1944. In this 3 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure position the intestines were displaced out of even defined indications for the diagnostic the pelvis and consequently could be better laparoscopy in extrauterine pregnancy, assessed during the operation. Additionally, chronic lower abdominal pain, sterility and he required continuous gas insufflation, which ovarian tumours. was controlled automatically. Palmer also His monographs, ‘Laparoscopy and carried out the first laparoscopic sterilization Culdoscopy in Gynecology’[10], in Paris. ‘Laparoscopy in gynecology, surgery and The piercing of the umbilicus for the paediatrics’ [11], ‘Diagnostic and operative laparoscope by Raoul Palmer in 1946 was a laparoscopy in gynecology- atlas with color groundbreaking procedure in gynecology. illustrations’ [12] as well as countless Like Kelling, he called the endoscopic publications and lectures contributed to diagnostic procedure ‘Coelioscopy’ and further spread of the method. As clinic developed several methods to insert director in Konstanz he organized a European endoscope. The abdominal access involved congress on endoscopy in Konstanz. On the many technical difficulties because of mainly occasion of his eightieth birthday Semm blind insertion technique through the anterior praised Frangenheim for his contribution with abdominal wall [9]. these words: ‘today the name, Frangenheim is In 1950 Hans Frangenheim (1920 – 2001) inseparably associated with the gynecologic (Fig. 1) began his training in gynecology in laparoscopic methods. His achievements for Wuppertal, Germany with Anselmino and in Germany and for the world are epoch making 1951 came in contact with laparoscopy for the and will go down in the annals of history’ first time. He was called to the medical clinic [13]. in Cologne where a lower abdominal tumor Kurt Karl Stephan Semm (1927-2003) (Fig. 2) was diagnosed during hepatoscopy and further is regarded in Germany as the real father of line of treatment had to be decided. Looking operative laparoscopy, which he started to back he wrote: evolutionize from 1970 – 1995 as chairman of ‘I sensed there, that a new aid had presented the department of Obstetrics & Gynecology at itself for the field of gynecology and so began the University Clinics Kiel, Germany. Already to look into literature. A remark made by Kalk working under Richard Fikentscher (1903 – in a textbook had impressed me the most, 1993) in Munich he developed a new which said, it is certain that gynecology would universal abdominal insufflation equipment [14, 15]. He developed a pressure controlled open a big field of indications for laparoscopy’. apparatus called “CO2 Pneumo” for insufflating CO2 gas during laparoscopy to From Wuppertal we visited the Paris lectural minimize operative risks of endoscopy [16]. Raoul Palmer. For the development of This machine was already used from 1964 laparoscopy he concentrated on regulating onwards at the second university clinic for uncontrolled gas insufflation, developing new women in Munich and created the instruments and photographic documentation pneumoperitoneum automatically [16]. The of endoscopic findings. He had difficult time cold light (extracorporeal light that shone with German endoscopy firms. Finally, with across a bundle of fibreglass) was modified anesthesia equipment from Draeger, simultaneously developed. Together, they he succeeded in reducing the gas pressure eliminated intestinal burns and gas embolus from the customary 50mm Hg to 15 mm Hg. that were the main dangers of gynecological and restricting the carbon-di-oxide gas flow to laparoscopy. In spite of all the progress, world maximum of 5 liters per minute. Frangenheim 4 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure over the gynecological diagnostic laparoscopy high frequency current in the mono and was universally rejected. bipolar techniques using inadequately covered At this time Semm was able to convince the apparatus led to uncontrollable burns, today, German Insurance Companies to accept in clinical endoscopic practice also, it is infertility treatment as a medical treatment. ensured that the electro energy used under Laparoscopy was only considered as a vision does not lead to burns. The modern diagnostic procedure. In order to be able to coagulation and cutting equipment which bill for an operative procedure, Kurt Semm work on mono and bipolar current have created the word “Pelviscopy” for any control mechanisms that minimize the risk of procedure performed in the minor pelvis right unintentional burns. Bi and monopolar after taking the chairmanship in Kiel. He instruments have a controlled, restricted completed the work already started in Munich coagulation zone [20]. since 1965. This new method spread quickly Semm, who produced his own instruments, as within Germany as a diagnostic procedure of he was a skilled instrument maker himself, female infertility. In 1967 Semm developed an built an automatic CO2 insufflator in 1963, electronic version called CO2 – “Pneu introduced thermo coagulation in 1973 and Automatic” with the quadrotest for operative used for the first time the Roeder loop to stop Pelviscopy [17]. arterial bleeding. For the laparoscopy he developed special suction irrigation After Semm demonstrated the “Co2-Pneumo” at the congress of the American Fertility equipment and an electronic insufflator. Association in Washington in 1969, Cohen Difficult interventions were possible because published a book on this procedure in 1970. In of the methods of hemostasis (endosuture with USA, the acceptance of this new method of intra and extra corporeal knots) developed by Semm and his range of instruments. However, pelviscopic procedures in gynecology was phenomenal. Even though the method was many physicians, gynecologists as well as used a million times, it was employed in 95% surgeons criticized Semm for his vehement of the cases only for tubal sterilization, unlike use of the so-called “key hole” surgery. They in Europe [18], where Boesch already were of the opinion that due to the modern accomplished this 35 years before [19]. The anaesthetic techniques, big operations by ignorance about the laws of physics while laparotomy posed no problems and Semm had using the high frequency energy in closed exaggerated the problems with subsequent body cavities was the cause of many grave adhesions. Some treated the news of the new accidents causing burns to the internal organs spectrum of operations (oophorectomy or the like intestines and ureter. Such incidents once removal of complete uterine appendages, more deeply incriminated this method. treatment of tubal pregnancy) with disbelief and concluded that Semm has started his Fascinated by the idea, that pelviscopy can be operation as laparoscopy and then ended it as used not only for sterilization but also for conventional operation by laparotomy. other operative purposes, Semm introduced in his new regimen for hemostasis in New Semm was exposed to the most intense Orleans in 1974. The use of high frequency hostility of the German gynecologists (and current for creating destructive heat was not endoscopic surgeons) when he carried out the required in endocoagulation. The human body first laparoscopic appendectomy in 1983 did not come in contact with the electrical [21].The surgeons especially saw no need to energy. Optimal controlled hemostasis takes abandon the established operative method and place at 110 oC. Between 1970 - 1980, the to replace it with technically more difficult one. Semm’s first attempt at publishing his 5 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure method therefore met with rejection. The fact In September 1985 a surgeon from Böblingen, that a gynecologist wanted to show the Erich Mühe, (1938 – 2005) performed surgeons, how an operation should be carried laparoscopic cholecystectomy for the first out was simply unthinkable at that time. time in the world using Semm’s instruments Semm had crossed the limit that was till then [25]. In 1986, Mühe reported 97 successful considered as sacrosanct. But he knew that laparoscopic operations [26]. In the year 1989, endoscopic surgery had enormous potential Reich et al. described the first laparoscopic not only in gynecology but especially in assisted vaginal hysterectomy [27]. Erich surgery and therefore continued with his Mühe could not publish it as the German endeavors in laparoscopy, unperturbed general surgeons dismissed him from his job. towards the goal, of reducing the surgical Later 7 years after his first laparoscopic trauma to the patients. Two German surgeons, cholecystectomy, the German Surgical Friedrich Gotz and Arnold Pier followed Society recognized the significance of Mühe's Semms’s intent and provided a wider base to work by awarding him the GSS Anniversary laparoscopic appendectomy [22]. In the early Award. Then in 1999, the SAGES officially nineties they had already carried out hundreds recognized Mühe's LC and he presented “The of appendectomies in this way and perfected First Laparoscopic Cholecystectomy: the technique, which they could now use even Overcoming the Roadblocks on the Road to in acute appendicitis [23]. the Future” in San Antonio, TX in 1999. In 1976 a 10mm morcellator (Semm 1976) Worldwide the French General Surgeon, was produced for pelviscopy purposes. Philippe Mouret from Lyon, considered as the However, in today’s operative pelviscopy first cholecystectomy surgeon performed by where even fist size myomata are removed laparoscopy. from the uterus with little blood loss, this instrument is not very effective. So in 1988, In 1983, the British urologist John E. A. the manually operated SEMM (Serrated Wickham (born in 1927) used the concept Edged Macro Morcellator) of 15to 20 mm “minimally invasive surgery” for the first diameter was introduced. The instrument time. The concept attracted attention in 1987 could reduce a myoma of about 5cm size to after Wickham published his visions of small pieces within few minutes. The extensive endoscopic treatment in the famous posterior colpotomy for removal of myoma or British Medical Journal [28]. In spite of the even a small abdominal incision was not strong criticism it mirrored the general trend required any more [24]. Since the introduction of the 80s as the minimally invasive of horizontal morcellation, the morcellators techniques had greatly fascinated the doctors are motorized and are available in 10 mm to and their patients. 24 mm diameters. This development was further accelerated by Just like laparotomy, intra-abdominal crucial technological innovations. The irrigation equipment is necessary in introduction of new light sources (Palmer laparoscopy also to guarantee good view. The 1953), the Hopkins-optics (1960) and the cold acquapurator of 1974 gave way to CO2- light source had already improved the aquapurator in 1990.Today the aquapurator illumination in endoscopic operations in the biotherm has removed many problems of 60s [29]. The video technique was also hypothermia-even in operations of longer important. The new video camera was much duration. In 1994, insufflation of preheated smaller and therefore easier to manage than its CO2, was introduced to preserve isothermia. predecessor and the videocassettes also were 6 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure simpler for everyday use than the 8mm or Appendectomy was rejected as an 16mm film. In the 80s more surgeons used unacceptable technology. The news about video cameras, but even the latest and these sensational methods reached even the smallest of the camera together with media in USA. During a TV talk show it was endoscope proved unwieldy because it altered made public with the help of gall bladder the balance and made precision work difficult. operation. After that the Nashville surgeons Electronic minicamera brought the received hundreds of calls not only from the breakthrough: a 4 mm optoelectronic patients but also from doctors. transducer (CCD) converted the view from The production of endoscopic instruments in inside the body cavity to electronic impulses the industry showed an upswing and the and transferred them to the monitor. The interaction and interest of the various medical combination of optic trocar and video camera specialties –surgery, urology and gynecology, opened new possibilities for the surgeons increased. Today the interest of the industry, because now with both the hands free, they doctors and patients worldwide is reflected in could operate ambidextrously and a common endeavor, betterment of surgery in simultaneously follow on the monitor what many aspects through modern technology. was happening along with the entire team. That is reflected in further developments in Another milestone of the realization of the use of digital picture control, robotic appendectomy by laparoscopy, which Kurt instruments, computers and tele surgery. The Semm started in patients that showed besides numerous specialties which have emerged and their gynecological problems sub-acute which deal increasingly with the oncological appendicitis, was the acceptance by U.S. fields also reflect these efforts. That is why in general surgeons. Although we performed 1965 the German Society for Gynecologic laparoscopic appendectomies since 1981 and Endoscopy and in 1971 the American Society numerous German general surgeons had for Gynecologic Endoscopy were founded. visited Kiel for that purpose, only when The World Society for gynecologic surgery Semm presented his laparoscopic (1986), the European Society for Gynecologic appendectomy in Baltimore in 1988, J.B. Endoscopy (ESGE, 1990), the Asian Society Mckernan and W.B. Saye took it up and in of Gynecological Endoscopy, the International June 1988 they reported the first laparoscopic Society for Gynecologic Endoscopy and the cholecystectomy and appendectomy in USA International Society of gynecological using Semm’s instruments and combining the Endoscopy (ISGE, 1991) came into being procedure with laser technology. As a result with yearly or two-yearly meetings. many successful endoscopists visited both the The development of hysteroscopy and protagonists in Nashville to learn the new falloposcopy must be mentioned here. After technique. At the same time, Sung Tao Ko Lindemann (1971) [30] and Semm (1974) from Chicago upheld the laparoscopic established the CO2 hysterectomy, the real appendectomy by Semm and brought his breakthrough in the operative hysteroscopy instruments to America. A paper on came after 1980 -basically as fluid laparoscopic appendectomy that Kurt Semm hysteroscopy. Today hysteroscopy is a routine and I submitted to the American Journal of procedure and one cannot imagine diagnostic General Surgery was rejected by declaring and therapeutic interventions without it. this as an unethical surgical technique. The same experience we also had in Germany From today’s point of view, the ideal entry for when a lecture of Kurt Semm to the college of viewing the tubal lumen is by hysteroscopy, general Surgeons on Laparoscopic through a transcervical and transuterine 7 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure catheter with 0.8 – 0.3 mm thick telescope or still preserving its heritage and brand flexible falloposcopes . recognition, the organization eventually The worldwide evolution for improvement of dropped its full name, “American Association endoscopic surgery has begun; its end is still of Gynecologic Laparoscopists” and became not in sight [31]. The aim of this surgery is to known simply as the AAGL, along with the achieve better surgical results as with phrase “Advancing Minimally Invasive conventional operative techniques and Gynecology Worldwide.” definitely less side effects. On the wider Today with a membership extending to over international level let us mention Jordan M. 110 countries, the AAGL is an internationally Philipps under who’s organization Kurt recognized authority in minimally invasive Semm, Liselotte Mettler and various other gynecology. With over 7,000 members team members of the Kiel School of worldwide, the association counts among its Gynecological Endoscopy, which we really membership the foremost authorities in founded in the year 1990 only, but it existed gynecology and pioneers in technique and under Kurt Semm’s driving patronage since procedures and continues besides renounced 1970, were able to teach in 85 Endoscopy and as active other previously mentioned courses all over the USA and worldwide our international and national societies in our endoscopic surgery between the years of 1985 field. – 2005. In 2005 numerous centers around As extremely active colleagues on the the world had started to teach their own American continent in the USA since 30 courses, which they continue to do. Single years let me also mention the 3 Iranian port entries and particularly Robotics have pioneers in Endoscopic Gynecologic Surgery moved in with high demands and striking that influenced our field like none others by results. Contained in bag morcellation has their intuition, love and dedication to their substituted controlled electronic morcellation. work, the laparoscopic surgery, totally Let us see what the future brings. dedicated to their new country ,the USA, the Jordan M. Philipps (1923-2008) [32] founded NEZHAT brothers: Camran Nezaht, Farr the American Association of Gynecological Nezhat and Ceana Nezhat [33] and the Laparoscopy (AAGL) now the International initiator of Total Laparoscopic Hysterectomy, Society of Minimal Invasive Gynecology in Harry Reich 1971 The AAGL is the leading association Our late German colleague Thoralf promoting minimally invasive gynecologic Schollmeyer (1964-2014) (Fig. 3-4) was from surgery among surgeons worldwide. When 2007 onwards the director of the Kiel School established in 1971 it was known as the of Gynecological Endoscopy and the American Association of Gynecologic President of the German Society of Laparoscopists. As the field of minimally Gynecological Endoscopy (AGE) when he invasive gynecologic surgery grew, the died in 2014. He deserves to be especially membership of the AAGL quickly expanded mentioned in an historical outline as his around the globe and came to encompass professional life was fully dedicated to the more than laparoscopy alone. education in Endoscopic Gynecological Although the organization had outgrown Surgery. He was the first editor of our second American roots, its name and acronym edition of PRACTICAL MANUAL for “AAGL” had become highly recognized LAPAROSCOPIC and HYSTEROSCOPIC worldwide. To best portray its expanding SURGERY of the KIEL SCHOOL in 2013 mission and international constituency, while and a truly believing endoscopic surgeon till 8 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure the end of his early death by the age of 52 the human in vitro fertilization and embryo years in 2014. Being a patient himself over 8 transfer technique (IVF – ET) together with years he showed us how a dedication to the Robert Edwards profession and family moves rocks. The 11) Hans-Joachim Lindemann, born in 1920, development of gynecological endoscopy in laid the groundwork for hysteroscopy clinic, research and science and the support of 12) Kurt Semm (1923 – 2003), the father of young researchers characterized his life. He operative gynaecological endoscopy followed his own way which was marked by 13) Erich Mühe (1938 – 2005) first extreme passion, audacity and endurance of cholecystectomy – however, Philippe Mouret pain with high ethical and medical values (born 1938) from Lyon, France is worldwide [34]. known for his first cholecystectomy in 1987 as he was able to publish it. 14) Jordan M. Phillips (1923 – 2008), 2. Milestones for the development of propagator and “prophet” for gyne endoscopic gynecological endoscopic surgery surgery world-wide. 15) Maurice Bruhat (1934 – 2014) What have been the milestones in the 16) Thoralf Schollmeyer (1962 – 2014) development of endoscopic surgery? Let me first mention a few of our already passed 3. The last 50 years – a rocky road, what do away colleagues who set the intellectual and I know about it and who are the present technical basis for endoscopic surgery: and future giants in our field?

1) Philipp Bozzini (1773 – 1809) and the light There arises the question what gives life and a guide certain professional field a meaning? It is 2) Antonin Jean Desormeaux (1815 – 1894) always only the connection to human beings and his endoscopes in our field, colleagues, co-workers and 3) Georg Kelling (1866 – 1945) and his air technical advisers that make our work insufflation apparatus meaningful. 4) Max Nitze (1848 – 1906), an early After my nearly 50 years in gyne endoscopic urological endoscopist who developed surgery (1967 – 2017), I look back on this cystoscopy evolution with great respect and happiness. 5) Heinrich Kalk (1895 – 1973) and his Just as life is full of adventures, sadness and insufflation apparatus which allowed joy, so has our field of endoscopic surgery abdominal biopsies of the liver etc. experienced its ups and downs before finally 6) Raoul Palmer (1904 – 1985), the European finding its wide acceptance of today. For all of father of endoscopy in the lithotomy position us working in gynaecological endoscopic 7) Hans Frangenheim (1920 – 2001) built his surgery the development has been a rocky first abdominal insufflator in 1959 road. Many of us had to accept blasphemy, (Fig. 1) professional inconveniences and mistrust but 8) Harold Hopkins (1918 – 1994) developed of course also a lot of understanding, joy, the rod lens system of modern endoscopes success and acceptance from our patients, our 9) Karl Storz (1911 – 1996) was responsible colleagues, hospitals, governments and for the development of the cold light source in families. Unlike in any other field the 1960 international family of colleagues and friends 10) Patrick Steptoe performed many has grown rapidly and it is interesting how laparoscopies in Great Britain and developed everyone has given new contributions into this 9 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure evolution. Let me mention my close friends Societies (IFFS) the surgical field was still like Harry Reich, Jacques Hamou, Jacques dominated by micro surgery via laparotomy Donnez, Dennis Querleu, Mark Possover, and only slowly laparoscopy and hysteroscopy Arnaud Wattiez, Christopher Sutton, Ray were accepted as valuable surgical tools. Garry, Ellis Downes, Frank Loffer, Harry Reich, Tom Lyons, Camran Nezhat, Farr During my gynaecologic speciality training Nezhat, Ceana Nezhat, Robert Zuravin, Linda from 1970 – 1976, the field of gynaecologic Bradly, Karl-Werner Schweppe, Diethelm endoscopic surgery gained ground in Wallwiener, Hans Tinneberg, Ivo Meinhold- Germany. The breakthrough came with the Heerlein, Ibrahim Alkatout, Günter Noe, first cholecystectomy performed by Erich Bernd Holthaus, Thilo Wedel, Bruno van Mühe in 1985 and by Phillipe Mouret in 1987. Herendael, Prashant Mangeshikar, Prakash During my IVF research experience with Bob Trivedi, Bhaskar Goolab, Artin Ternamian, Edwards in Cambridge from 1975-76, I Chi Long Lee, Hirohiko Yamada, Peter frequently participated with Patrick Steptoe in Maher, Robert O’Shea, Adel Shervin, Lotte laparoscopic follicular punctures. Medical Clevin and many others. societies and Journals coming up on “new” topics best reflect the impact new strategies Kurt Semm was my teacher for 25 years. He have. dedicated his life to the development of endoscopic surgery.  1968 – 1984, formation of ESCO, from which started ESHRE in 1984. Today, our numbers have grown and we are a  1970 – 1975, development of gyne big medical technical family with increasing endoscopic surgery, sterilizations. success in the treatment of our patients.  1972, foundation of AAGL. Congratulation to the original American- After 3 years of medical work in the Peruvian Canadian Pioneers: Jordan Phillips, Louis jungle, Kurt Semm hired me upon my return Keith, Jacques Rioux and Richard in 1969. In 1970 I met Elizabeth and Raul Soderstrom. The Journal of Minimally Palmer, in 1971 Patrick Steptoe and Bob Invasive Gynecology is the most respected Edwards and in 1972 Melvin Cohen in journal in our field today. Chicago. From 1971-72 I was the  1975, in Kiel we began to use a coordinating doctor for the “Society of teaching scope for laparoscopy and started Patients Damaged by Laparoscopy“in Kiel. video projection on monitors for visitors; At this time Prof. Ober who was President of however, the worldwide propagation of video the German Society of Obstetrics and laparoscopy was undertaken by Camran Gynecology told me after I presented a short Nezhat 10 years later. By 1976 all ectopic lecture on laparoscopic ovarian cystectomies pregnancies in Kiel were performed by “Young lady get yourself away from this laparoscopy. dreamer Semm and perform valuable  1975, Kurt Semm was accused of mal gynaecological surgical procedures by medical praxis with laparoscopic surgery. laparotomy and vaginal surgery. There followed a CTG scan of Semm’s brain Jordan Phillips, in the founding years of and legal fights. AAGL from 1971 – 1973, adhered to the  1975 – 1976, I carried out six months’ principle that ”Laparoscopy is a diagnostic training in physiology with Robert Edwards in tool and assists sterilization (coelioscopy)”. Cambridge, UK. In the International Federation of Fertility

 1975, at a training course in Italy, From 1970 – 1990 we developed gyne Jordan Phillips realized that operative laparoscopic surgery in Kiel under Kurt laparoscopy had a future and congratulated Semm. I participated in numerous national Kurt Semm and me for promoting it. and international endoscopy courses in Kiel,  1976, attainment of my postdoctoral Clermont Ferrand, Brussels, Lyon, Strasbourg lecture qualification (habilitation) on IVF. and world-wide. We had many visitors in Kiel  1980 – 1996, 85 trips to the US for from all over the world. In 1973 Jan endoscopy courses on the East and West Behrman, one of the many past presidents of Coasts and in the Mid-West, organized by AAGL, came just for one day to Kiel, entered Jordan Phillips and AAGL. the operation theatre, observed a laparoscopic  1981, the first laparoscopic adnexectomy, said thank you and left for a appendectomy in Kiel. Kurt Semm and I were hunting trip to Austria. He wanted to see with threatened to be thrown out of the German his own eyes that adnexa were extirpated Society of Obstetrics and Gynecology. laparoscopically. His spreading of this news in  1986, Camran Nezhat describes video the USA helped to start gaining recognition laparoscopy worldwide.  1989, formation of the International Society for Gynaecologic Endoscopy (ISGE) 4. The Kiel School of Gynecological  1989 first LTH and TLH (Reich, Endoscopy

SEMM) In 1990 the Kiel School of Gynecological  2004 Introduction of Robotic surgery, Endoscopy was founded by Liselotte Mettler. the DaVinci systems being the so far most From 2007 - 2014 Thoralf Schollmeyer was advanced ones – others to come the director of the Kiel School. In those 7  2014 First pregnancy after uterine years he dedicated an immense amount of his transplantation (Matt Branstroem) time to structure, educate and train doctors in  2017 First laparoscopic uterine gynaecological endoscopy. He left us as explantation at successful uterine president of the German Society of transplantation in Pune, India ( Sheilesh Gynecological Endoscopy, way too early! Our Putambekar) thoughts are with him at present. Ibrahim  Many gyne endoscopic national Alkatout and Göntje Peters as leaders of the societies have now been formed. The old Kiel School are performing an excellent job in German Society of Gyne Endoscopy was the clinic within the German Society of revitalized in 1984 as the AGE Gynecological Endoscopy. We are holding 10 (Arbeitsgemeinschaft Gynäkologische annual courses for German International Endoskopie e.V.). To name just a few, a participants for basic advanced and robotic French society, the Australian AGES, an and endoscopic training. Our centre is one of Asian-Oceanic, a Latin-American, and a the well-recognized endoscopic training Canadian society have developed, in addition centres by the AGE (Arbeitsgemeinschaft to multidisciplinary societies of endoscopic or gynäkologische Endoskopie) and ESGE minimally invasive surgery/medicine (SLS, (European Society of Gynecological ITS, ISGE). Endoscopy).  1994, formation of the European Society for Gynaecological Endoscopy The Kiel School, based on the early (ESGE). developments of Kurt Semm, has published numerous textbooks over the last 25 years [17,

31, 35-39]. In 2016 the “Kurt Semm Centre contained bags or in homogenized tissue, to for laparoscopic and robot assisted surgery” be genetically examined after its extraction, was newly established in Kiel. It is the first will be easily possible. interdisciplinary endoscopic centre in Germany serving the three aims of patient’s Bloodless surgery with articulated and robotic treatment, surgical education and training in instruments with multiple degrees of liberty Germany. Further development of the modern and precision coagulation will be possible. assistant surgery and its potential for the Computer-assisted instruments tips will allow future is one of the present activities. the surgeon to position the angles to the desired tissue planes and give tactile feedback.

5. Gynecological endoscopic surgery today and tomorrow. What are the goals of good In conclusion, it must be stressed that the surgery? history of laparoscopy and hysteroscopy and its introduction in the surgical practice is a These goals are identical whether we perform story of many researchers, who for years laparotomy, laparoscopy or endoscopic battled against prevalent general thinking procedures; regardless of the angle, location and partly against rejection of their brainchild or means of access: They are identical for all of performing ‘gentle operations.’ Many of fields of endoscopic surgery reaching today the pioneers were ignored, called dreamers or into robotic single and multiple part surgery. regarded as crazy. It is only through their Robotic tools, three dimensional vision and persistence, their tenacity, their strong force feedback are essential features in personalities and their intense dedication to surgery. They make surgery more precise and life and love , that they could stand firm in the easier. The surgical goals remain as: face of adversities [40].  Recognition of relevant pathology The history of laparoscopy is a unique mixture  Possibility of radical treatment in of various trends in different fields, spurred by endometriosis and cancer the activities of established societies as well as  Minimal trauma, bleeding and tissue opportunities of their publication and laceration influenced by the world’s progress, recession,  Adhesion prevention war, piece and the love of the individuals for  Preservation of urogenital tract in life. The influence of industry, which has kept women of reproductive age pace and actively supported this development  Utilization of the best instruments for years, is the driving force besides the (with as many degrees of liberty as possible, heroes of doctors and engineers that bring up robotic transmission, etc.) new ideas.(41) Without suitable technology, this dissemination would not have been  Preventing organ decent Let us continue along the path of minimal possible. Endoscopic development and its trauma, maximum vision and good tactile future does depend on new inventions, on the feeling to ensure optimal surgical success audacity of leading heroes, their input into this until the time of better image guided surgery, field but also on their management of life to the application of “magic bullets” to destroy continue to survive and on a healthy and cancer without side effect becomes reality and successful cooperation with the medical better molecular-genetic recognition of technical industry and the governments of our disease will make extensive surgeries countries which grant us the freedom of unnecessary in the future. Tissue extraction in 12 Copyright 2017 KEI Journals. All Rights Reserved. Medical Research Archives. Volume 5, issue 6. June 2017. The evolution of gynecologic endoscopic surgery over 50 years – a pleasant adventure research and development for the best of all present leaders of the Kiel School, Ibrahim our patients (42,43,44) Alkatout and Goentje Peters. Thanks also to Acknowledgement: my personal office manager, Nicole I would like to acknowledge Dawn Rüther, Guckelsberger, for her support till today. Office Manager of the Kiel School of I appreciate the continuous support of my 3 Gynaecological Endoscopy, for her dedication sons, Bijan, Firus and Moritz, who did not and continuous support over the last 27 years want to enter our fascinating field of medicine and her coworker, Birthe Schollmeyer, over and my 2 daughters in law, Viviana , who is a the last 10 years. It gives me great pleasure nurse and Anupama, who is a gynaecologist. to acknowledge Walter Jonat and Nicolai Maass as my chairmen after Kurt Semm as well as the

References

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Legend to Figures

Figure 1 Figure 2 Hans Frangenheim (1920 – 2001) Kurt Semm (1923 – 2003)

Figure 3 Thoralf Schollmeyer (1962 – 2014)

Figure 4 Thoralf Schollmeyer with C.Y. Liu and wife and Liselotte Mettler and husband