Kiyokazu Nakajima Jeffrey W Milsom and Bartholomus

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 first to use reflected light as a source of illumination for an endoscopic examination. Giulio Caesare Aranzi in Venice (1530-1589) developed the first 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 filled 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,

Table l.l. Chronology of important events in surgery



"Lichtleiter" of Bozzini



Nitze cystoscope



Experimental laparoscopy in canine



Laparoscopy in humans



Sharp pyramidal trocar



Carbon dioxide pneumoperitoneum



Oblique scope and dual puncture technique



Insufflation needle



Rod-lens system



Automatic insufflator



Laparoscopic cholecystectomy in humans



Computer chip TV camera



Videolaparoscopic cholecystectomy



Laparoscopic colectomy

mirrors, and tubes through which the light passed. As well as describing the "Lichtleiter" (Figure 1.1) in detail, he explained the difficulties of reflecting 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

Kerosene Lamp 1853
Figure 1.1. "Lichtleiter" of Bozzini (1806) with various attachments for different body orifices.
Mechul Endoskop
Figure 1.2. Desormeaux cystoscope (1853).

animal fuel was difficult. Nevertheless, Desormeaux described and conducted numerous investigations of the urethra and bladder.5

In 1867, the first 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 produced 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 fluid into the bladder and for introducing ureteral catheters.

Boisseau de Rocher made the next important step in the development of modern endoscopes in 1889. He separated the ocular part of


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 first 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 insufflated with air filtered through a sterile cotton swab. He named the procedure "Kolioskopie." In the same year, a Russian gynecologist named Dimitri Ott independently 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 first 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 intraperi-toneal structures. He achieved his first 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 syphilis), 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 first surgeon to perform a type of laparoscopic-assisted operation: after finding 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 modified the method of illumination in 1914. He designed an instrument that permitted the source of light to remain outside the abdomen by reflecting the light through a trocar into the field of

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, extrauterine pregnancy, salpingitis, and ovarian tumors. He was the first to stress that laparoscopy is a useful tool in diagnosing suspected postoperative hemorrhage in the peritoneal cavity.

The first 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 insufflation 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 insufflation of the peritoneal cavity, he proved that an artificial pneumoperi-toneum was not harmful or dangerous. He also defined the following contraindications for pneumoperitoneum: cardiac and pulmonary diseases, "meteorism," septic process in the peritoneal cavity, and extensive adhesions.

In 1924, W.E. Stone15 wrote about "peritoneoscopy" in a canine model. He inserted a nasopharyngoscope through an incision in the abdominal wall and successfully completed diagnostic laparoscopies in 14 dogs. He preferred to use air insufflation instead of carbon dioxide because air insufflation did not require any special instruments. He also developed a rubber trocar gasket.

Otto Steiner,16 unaware of the experiences of other researchers, also described in 1924 his technique of "abdominoscopy" using a cysto-scope, trocar, and oxygen to insufflate the abdomen. In the same year, Zollikofer17 first described the use of carbon dioxide gas to induce pneumoperitoneum. It quickly became the most popular distending gas because of its noncombustible properties as well as its rapid absorption after a procedure.

In 1925, Short18 summarized the advantages of laparoscopy: "1.) It can be done without discomfort; 2.) the incision is so small that it is only necessary to keep the patient in bed for a day or two; 3.) very few special instruments are needed; 4.) it can be done at the patient's own house; and 5.) it is available when it would be dangerous to perform laparotomy."

Almost a quarter century after Kelling's initial report, an excellent review of previous experiences about "endoscopy of the abdomen" was given by Nadeau and Kampmeier19 who also described their technique in detail as performed in three patients. They said the "appliances necessary for the performance of abdominoscopy are relatively few . . . a trocar and cannula, a cystoscope, . . . a no. 18 spinal puncture needle, a hypodermic syringe and needle, a small scalpel, and a small foot pump, rubber tubing, and connections for inflating the abdomen."

A number of important reports establishing laparoscopy as a valuable diagnostic tool were published by the German hepatologist Kalk,20 who introduced a 45° lens system, and was the first to advocate the dual-trocar technique. This latter innovation led the way to the concept of operative laparoscopy. Kalk performed 100 laparoscopies in 4 years without any major complications and was able to diagnose various liver and gallbladder diseases, and stomach, pancreas, and renal cancer with his technique. His efforts proved that intraabdominal manipulation using laparoscopic techniques could be safely performed. He published 21 papers between 1929 and 1959 that established the use of laparoscopy to study and make accurate pathologic diagnoses of internal organs. Many authorities consider him to be the "father of modern laparoscopy."

One of the earliest reports of a therapeutic laparoscopy was in 1933, when Fervers21 described laparoscopic lysis of adhesions. In his report, he also described the use of ureteral catheters passed through his endoscope to palpate the gallbladder for stones. In addition, while using "cold cautery" electro surgery and insufflating the abdomen with oxygen, he described an explosion inside the peritoneal cavity with multiple audible "detonations" and "flames" visible through the abdominal wall. Laparoscopic inspection of the peritoneal cavity showed only minor injuries of the peritoneum, and the patient recovered fully after several days of observation without any additional treatment. Fervers thereafter wisely argued against use of oxygen in establishing pneumoperitoneum.

In 1937, Ruddock,22 an internist from Los Angeles, California, reported 500 cases in which diagnostic laparoscopy was performed over a period of 4 years. He firmly established diagnostic laparoscopy as a safe procedure with very low morbidity. Injury of the intestine (stomach, small bowel, and colon) occurred in only eight patients (1.6%) in his series, and only one mortality occurred in a patient who died of hemorrhage after laparoscopic biopsy of the liver. Examinations were unsuccessful in only three patients (0.6%). He also described a biopsy forceps with electrosurgical capability to perform coagulation and tissue biopsy simultaneously. The tip of the biopsy forceps was designed so that it formed a cup containing the tissue when closed. In addition, Ruddock's patients did not experience postoperative intestinal paralysis after laparoscopy. After laparoscopy, his patients were permitted to resume eating meals without interruption. Since Ruddock's time, laparoscopy has remained the method of choice in diagnosing cases of undetermined ascites and tuberculous peritonitis, in assessing the operability of certain intraabdominal lesions, and whenever there is a question of intraabdominal metastases.

Until the 1930s, pneumoperitoneum was accomplished with a Goetze-style spring-loaded needle. In 1938, Veress23 developed a modified spring-loaded needle to safely introduce air into the thoracic cavity. This needle, which now bears his name, is now commonly used to create pneumoperitoneum and remains almost unchanged since its invention.

A new era of endoscopy began in 1952 when Fourestier et al.24 developed and described the "cold-light" fiberglass source that provided, at a low temperature, intense light through a quartz rod from the proximal to the distal end of the telescope. The physicist Hopkins introduced rod-shaped lenses as light transmitters with air lenses between the glass elements to further increase illumination. This design dramati cally improved the resolution and contrast of the telescope in 1953.25 Most currently used laparoscopes are designed according to the principles of the Hopkins lens system.

In the 1960s, the German gynecologist Semm,26 one of the most innovative and productive researchers and clinicians in the field of laparoscopy, contributed several important innovations in laparoscopy: a controlled, automatic carbon dioxide insufflator, an irrigation system, the Roeder loop applicator, hook scissors, a tissue morcellator, and the pelvitrainer teaching model.

Up until the late 1970s, laparoscopic techniques were almost solely in the repertoire of gynecologists and internists. Surgeons of this era equated surgical prowess with large incisions (big surgeons : big incisions), and ignored these procedures largely. Until the early 1980s, laparoscopic visualization of the peritoneal cavity was restricted to the surgeon who held the scope. The introduction of elaborate "teaching scopes" that were connected to and branched away from the main endoscope enabled the assistant to view what the surgeon was seeing. Unfortunately, these scopes were cumbersome and ineffective when the surgeon and assistant had to coordinate actions. Thus, complex therapeutic operations were not possible using these scopes and, as a result, laparoscopy was unpopular and rarely used in general surgery during the 1970s and 1980s. The development of the computer-chip television camera allowed everyone in the operating room simultaneously to view the image generated by the laparoscope. Surgeons thereafter accelerated the technical advances of safe and improved therapeutic laparoscopy and introduced therapeutic laparoscopic procedures into the field of general surgery.

The first incidental laparoscopic appendectomy is credited to Semm in 198127 and the first laparoscopic cholecystectomy in humans to Mühe in 1985.28 In March 1987, Philippe Mouret, in Lyon, France, removed a diseased gallbladder from a patient during a gynecologic laparoscopic procedure.29 He clearly exposed the porta hepatis by forceful cephalad retraction of the gallbladder fundus, using a laparoscopic video camera. Shock and disbelief were the initial reactions when the report of the procedure was first presented at major national meetings in the United States in April 1989 (Society of American Gastrointestinal Endoscopic Surgeons, Louisville, Kentucky) and in May 1989 (American Society for Gastrointestinal Endoscopy, Washington DC). The following year, the largest lecture hall at the meeting of the American College of Surgeons in San Francisco was so full that surgeons were crowding in the entryways, craning their necks to get a view of the video presentations.

The advent of laparoscopic cholecystectomy was the single most important stimulus to the expansion of operative laparoscopy in surgery. Within a short time, various operative procedures have been performed laparoscopically including esophagectomy, selective or truncal vagotomy, abdominal cardiomyotomy, total or partial fundo-plication, partial gastrectomy, gastrojejunostomy, splenectomy, adre-nalectomy, choledocholithotomy, resection of liver metastases, and inguinal herniorrhaphy.30

The earliest report of laparoscopic colon resections was in 1991, wherein Moises Jacobs et al.31 from Florida described their initial experience of "laparoscopic-assisted" colon resection in 20 patients. In the last 10 years, thousands of colorectal resections have been performed all over the world. Some very skillful surgeons have consistently introduced new surgical techniques with excellent outcomes and thus motivated other surgeons to apply these techniques to their patients. Every part of the large intestine colon has now been resected using laparo-scopic methods. This chapter serves only as a prelude to the developments in laparoscopic colorectal surgery that are highlighted in the remainder of this book.

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