Chapter 1 History of Laparoscopic Surgery

Chapter 1 History of Laparoscopic Surgery Kiyokazu Nakajima, Jeffrey W. Milsom, and Bartholomäus Böhm Although laparoscopic surgery has transformed surgery only in the past two decades, its evolution is only the natural byproduct of the medical doctor’s curiosity to directly visualize and treat surgical diseases. The earliest known attempts to look inside the living human body date from 460 to 375 BC, from the Kos school of medicine led by Hippocrates in Greece.1,2 They described a rectal examination using a speculum remarkably similar to the instruments we use today. Similar specula were discovered in the ruins of Pompeii (70 AD) that were used to examine the vagina, the cervix, and the rectum, and obtain an inside view of the nose and ear.1 The Babylonian Talmud written in 500 AD described a lead siphon, named “Siphophert,” with a mouthpiece, which was bent inward and held a mechul (wooden drain).1,3 The apparatus was introduced into the vagina and was used to differentiate between vaginal and uterine bleeding. During these early years ambient light was used. The term “endoscopein” is attributed to Avicenna (Ibn Sina, 980–1037 AD) of Persia, although an Arabian physician, Albulassim (912–1013 AD), who placed a mirror in front of the exposed vagina, was the fi rst to use refl ected light as a source of illumination for an endoscopic examination. Giulio Caesare Aranzi in Venice (1530–1589) developed the fi rst endoscopic light in 1587. He used the Benedictine monk Don Panuce’s principle of the “camera obscura” for medical purposes – the rays of the sun coming through a hole in the window shutter were concentrated by a glass jar fi lled with marbles and then projected into the nostrils.3 In 1806, Bozzini looked inside the bladder using a man-made light source with an apparatus called the “Lichtleiter” (Table 1.1).4 Bozzini envisioned and clearly described in his writings that endoscopy could someday be used as a diagnostic tool for the urethra, bladder, rectum, vagina, cervix, and pharynx as well as a surgical tool for endoscopic polypectomy or removal of bladderstones. He also surmised that endoscopy would augment understanding of the physiology and pathology of an organ if it could be visualized in vivo. His “Lichtleiter” used a candle as a light source and consisted of a light container, 1 2 K. Nakajima et al. Table 1.1. Chronology of important events in surgery 1806 Bozzini “Lichtleiter” of Bozzini 1879 Nitze Nitze cystoscope 1901 Kelling Experimental laparoscopy in canine 1911 Jacobaeus Laparoscopy in humans 1920 Orndoff Sharp pyramidal trocar 1924 Zollikofer Carbon dioxide pneumoperitoneum 1929 Kalk Oblique scope and dual puncture technique 1938 Veress Insuffl ation needle 1953 Hopkins Rod-lens system 1967 Semm Automatic insuffl ator 1985 Mühe Laparoscopic cholecystectomy in humans 1986 Berci Computer chip TV camera 1987 Mouret Videolaparoscopic cholecystectomy 1991 Jacobs Laparoscopic colectomy mirrors, and tubes through which the light passed. As well as describ- ing the “Lichtleiter” (Figure 1.1) in detail, he explained the diffi culties of refl ecting light through tubes, a problem that remained unsolved for another century. Almost 50 years later, Desormeaux presented an improved endoscope to the Academy of Medicine of Paris. In 1853, he reported the use of a kerosene lamp as an external light source, equipped with a chimney vent and a concentrating mirror (Figure 1.2). “Endoscopy,” a term coined by Desormeaux, remained crude for most of the 19th century because internal visualization remained relatively poor, and management of a light source dependent on combustion of fossil or Figure 1.1. “Lichtleiter” of Bozzini (1806) with various attachments for different body orifi ces. Chapter 1 History of Laparoscopic Surgery 3 Figure 1.2. Desormeaux cystoscope (1853). animal fuel was diffi cult. Nevertheless, Desormeaux described and conducted numerous investigations of the urethra and bladder.5 In 1867, the fi rst internal light source was described by Bruck, a German dentist.6 He examined the mouth using illumination provided by a loop of platinum wire connected to an electrical current. Because the wire generated intense heat, the loop was cumbersome and dangerous to use; consequently, Bruck’s platinum loop never attained widespread popularity. For most of the 19th century, cystoscopy was limited because endoscopes illuminated the interior of the bladder poorly, and they showed only a small part of the visualized object. In 1887, Nitze developed a cystoscope that dramatically overcame these major limitations.7 To increase the intensity and extent of illumination, he placed a platinum wire powered by electricity at the tip of the cystoscope and cooled it by using a continuous stream of water through the cystoscope. Placing the light source at the tip not only increased the intensity of the light, but also was advantageous in that the light was directly coupled with the cystoscope, making the procedure much easier to perform because the light source moved with the cystoscope. Although having the light source at the tip of the endoscope widened the illuminated area, visualization was still limited until Nitze added a prismatic lens system to his cystoscope. With his newly designed instrument, which had a diameter of only 5 mm, he was able to adequately visualize an area the size of the human palm. Nitze also incorporated additional channels in his operating cystoscope through which ureteral probes could be passed. Together with Joseph Leiter, an instrument maker, they pro- duced a commercial cystoscope that revolutionized cystoscopy and became the forerunner of modern cystoscopes and other endoscopes, including laparoscopes. Subsequent to the invention of the incandescent lamp by Thomas Edison in 1880, Nitze and Leiter replaced the platinum wire with a light bulb in 1887 (Figure 1.3). Brenner further improved the cystoscope in 1889, building a small channel through the cystoscope for passing fl uid into the bladder and for introducing ureteral catheters. Boisseau de Rocher made the next important step in the develop- ment of modern endoscopes in 1889. He separated the ocular part of 4 K. Nakajima et al. Figure 1.3. Nitze cystoscope (1887). the cystoscope from the lamp-carrying beak by using a sheath through which multiple different telescopes could be introduced. This change allowed greater latitude of observation and manipulation through the cystoscope. In 1902, the fi rst actual laparoscopy, or endoscopic visualization of the peritoneal cavity, was reported by George Kelling, a surgeon from Dresden, Germany.8 At the meeting of the German Biological and Medical Society in Hamburg in September 1901, he showed that laparoscopy could be performed in a canine model. He inserted a Nitze cystoscope into the peritoneal cavity of a living anesthetized dog and examined the viscera. The abdomen was insuffl ated with air fi ltered through a sterile cotton swab. He named the procedure “Kölioskopie.” In the same year, a Russian gynecologist named Dimitri Ott indepen- dently described a technique for directly viewing the abdominal cavity in humans without an endoscope. He inspected the abdominal cavity with the help of a head mirror and a speculum introduced through a small anterior abdominal wall incision. The fi rst major series of laparoscopies in humans is attributed to H.C. Jacobeus. In 1910, Jacobeus reported 17 cases in which laparoscopy was accomplished using a Nitze cystoscope with “cold burning” lamps and a cannula with a valve system.9 He also performed 20 examinations in human cadavers in which he evaluated the risk of injury to intraperitoneal structures. He achieved his fi rst clinical experiences in patients with ascites because puncture of the abdominal cavity appeared to be easy and without risk of inadvertent injury to intraperitoneal viscera. By 1911, he had described 80 laparoscopies, with only one reported complication – a hemorrhage into the peritoneal cavity from a trocar incision.10 With laparoscopy, he was able to recognize different kinds of liver diseases (cirrhosis, metastatic tumors, tuberculosis, and syphi- lis), gastric cancer, and “chronic” peritonitis. In 1911, Bernheim, of the Johns Hopkins Medical School, reported on “organoscopy” using an ordinary proctoscope or cystoscope, with illumination from an electric headlight.11 He made an incision in the epigastrium, inserted the scope, and inspected the viscera. He was probably the fi rst surgeon to perform a type of laparoscopic-assisted operation: after fi nding nothing on “organoscopy,” Bernheim drew “a part of the stomach out through the wound, made an incision in its anterior wall, and inserted the cystoscope directly into its cavity.” Roccavilla modifi ed the method of illumination in 1914. He designed an instrument that permitted the source of light to remain outside the abdomen by refl ecting the light through a trocar into the fi eld of vision.12 Chapter 1 History of Laparoscopic Surgery 5 To facilitate trocar insertion, Orndoff,13 in 1920, used and described the pyramidal trocar point currently still in use. He reported diagnostic laparoscopies in 42 cases and described tuberculous peritonitis, extra- uterine pregnancy, salpingitis, and ovarian tumors. He was the fi rst to stress that laparoscopy is a useful tool in diagnosing suspected post- operative hemorrhage in the peritoneal cavity. The fi rst automatic spring-loaded needle for initiating pneumoperitoneum was developed by Goetze in 1918.14 He did not design the needle for laparoscopic visualization of the abdominal cavity but rather for insuffl ation of oxygen into the peritoneal cavity and to improve conventional plain abdominal X-ray techniques. By studying the heart rate and body temperature in 90 outpatients undergoing oxygen insuffl ation of the peritoneal cavity, he proved that an artifi cial pneumoperitoneum was not harmful or dangerous. He also defi ned the following contraindications for pneumoperitoneum: cardiac and pulmonary diseases, “meteorism,” septic process in the peritoneal cavity, and exten- sive adhesions.

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