By Victoria Stern
The emergence of laparoscopy and laparoscopic technologies has represented one of the most essential paradigm shifts in the practice of surgery. Surgical practice has witnessed the introduction of the aseptic technique, general anesthesia and antibiotics, all of which decreased patients’ pain and the rate of infection during surgery.
“There are milestones in the progress of modern surgery that cannot be denied,” said Robert Sewell, MD, a general surgeon at the Master Center for Minimally Invasive Surgery, in Southlake, Texas. When laparoscopy—a minimally invasive approach to surgery—emerged, patients experienced less pain and potentially fewer complications after surgery. “This event rivaled the others in terms of benefits to patients,” Dr. Sewell said.
Over the next several months, General Surgery News will explore the historical landmarks in laparoscopy—from the first-ever procedure attempted on a dog, to today’s experience with single-incision laparoscopy and natural orifice transluminal endoscopic surgery—including interviews with some of the pioneers who helped shape the minimally invasive approach to surgery.
Start of a Transformation
On Sept. 23, 1901, Georg Kelling, MD, a surgeon and gastroenterologist, performed a laparoscopy on a live dog in front of an audience at the 73rd Congress of the Naturalist Scientist’s Medical Conference, in Hamburg, Germany. He named the procedure ‘coelioscopy’ (also spelled coelioskopie or koelioscopie).
“Kelling was the first to establish modern laparoscopy as a field by synthesizing existing technologies to form the trio of features that still defines the procedure today: an abdominal approach, at least two entry ports and artificial insufflation,” wrote gynecological surgeon Camran Nezhat, MD, FACS, FACOG, in his 2011 book, Nezhat’s History of Endoscopy: A Historical Analysis of Endoscopy’s Ascension since Antiquity’ (Endo Press).
Born in Dresden, Germany, on July 7, 1866, Dr. Kelling began his medical education when he was 18 years old, at the Universities of Leipzig and Berlin. In the summer of 1898, he went to the Royal Surgical Clinic in Breslau, where he learned his endoscopic skills from several well-known surgeons. He learned how to perform oral gastrointestinal insufflations—pumping gas into the abdomen to generate enough pressure to create a space between the stomach and small intestine—a skill that would become essential during his first laparoscopic procedure.
Dr. Kelling earned a doctorate in 1890, with a specialty in gastric and intestinal disease. Six years later, he opened a practice in Dresden, Germany. Although a surgeon by profession, he became intrigued by the idea of nonsurgical treatments and wanted to address the problem of gastrointestinal bleeding. Hemorrhaging into the abdomen proved fatal for patients, but many never showed the telltale signs, such as the presence of blood in vomit. At that time, the only conclusive way to diagnose or treat the condition was through laparotomy. However, Dr. Kelling believed that trying to address the problem by opening the abdomen could put the patient in greater danger. Dr. Kelling devised a nonsurgical approach to diagnosing and treating intra-abdominal bleeding safely. He wrote: “I asked myself, how do the organs react to the introduction of air? To find out, I devised a method of using an endoscope on an unopened abdominal cavity” (Münch Med Wochenschr 1901;48:1480-1483,1535-1538).
His instincts proved correct. More recent research shows that making a larger incision impairs an individual’s immunity, said J. Barry McKernan, MD, PhD, the surgeon credited with performing the first laparoscopic cholecystectomy in the United States.
By 1901, Dr. Kelling had found a safe way to view the abdomen using insufflation and determined that creating a pressure of 50 mm Hg alleviated bleeding into the abdomen, a technique he called ‘Luft-tamponade’ (air tamponade) (Figure 1). He also recognized the risk for injuring internal organs by incorrectly placing a trocar and found the best angle of entry was 45 degrees.
During Dr. Kelling’s demonstration of a laparoscopy using a live dog as a subject, he made an incision through which he inserted a Nitze-Leiter cystoscope to magnify and view the inside of the abdomen. The Nitze-Leiter cystoscope, first used in 1872, created illumination through an electrically heated platinum wire that allowed Dr. Kelling to see the interior of the abdomen through telescopic lenses. He then created a second incision, placing a trocar in the abdomen to insufflate the cavity with air, which allowed a better visual. This event marked the first laparoscopic endeavor. The dog survived the procedure. After performing coelioscopy on 20 dogs, Dr. Kelling deemed the procedure safe, noting that “after an examination, a dog is as cheerful as it was before [the procedure]” (Münch Med Wochenschr 1901;48:1480-1483,1535-1538).
Laparoscopy, however, was not Dr. Kelling’s main interest, and he initially did not publish his work on coelioscopy (Zeitschr Biol 1903;44:161-258).
Nine years after Dr. Kelling performed laparoscopy on dogs, Hans Christian Jacobaeus, MD, a Swedish internist, performed clinical laparoscopic surgery on a human—an electrical worker who had been diagnosed with hepatic cirrhosis (Münch Med Wochenschr 1910;57:2090-2092). Unlike Dr. Kelling, Dr. Jacobaeus did not use insufflation. Although not much is known about how Dr. Jacobaeus got involved in laparoscopic surgery, in 1912 he published a monograph describing the 97 laparoscopies he had performed between 1910 and 1912, in Stockholm’s community hospital (Beitr Klin Tuberk 1912;25:185-354). He observed that all of his patients, except one, improved after undergoing the procedure.
Despite these events, which physician performed the first laparoscopic procedure in a human remains somewhat ambiguous. Dr. Jacobaeus often is credited with this accomplishment; he was certainly the first to perform a large series of laparoscopic procedures in human patients and the first to broadcast his experience, but Dr. Kelling claimed he had done two such procedures in humans before Dr. Jacobaeus. Having read about Dr. Jacobaeus’ laparoscopic procedures, Dr. Kelling tried to defend his crown and wrote to journal editors with a detailed account of his work in humans (Nezhat C. Endo Press; 2011). By 1923, Dr. Kelling had published a history of his clinical experience over two decades.
In the 50 to 60 years that followed the first laparoscopic procedure in humans, early pioneers of laparoscopy experimented with the technique, but it did not make much headway in the general surgery community until the 1970s and 1980s.
“The work of Dr. Jacobaeus sparked some interest in laparoscopy around the world. Progress was occurring, but in small pockets and in small measures,” said Dr. Nezhat, president of the Association of the Adjunct Clinical Faculty, Stanford University Medical School, and adjunct clinical professor of surgery and gynecology at Stanford University, in California.
Dr. Nezhat pointed to the discovery that carbon dioxide was better than oxygen or air for insufflation. “Operating rooms [literally] exploded and patients died because people didn’t realize oxygen was flammable. Patients also died from air embolism because initially no one realized that too much pressure during insufflation could cause serious complications,” he said. “All of these [issues] took decades to discover and were, unfortunately for the patient, often only learned by trial and error.”
Additionally, the surgery itself was difficult for innovators and researchers. “Laparoscopy was a ‘one-man band,’” said Dr. Nezhat. “Surgeons had to look through the eyepiece of the laparoscope [holding it in one hand] and do the procedure with their free hand. That’s why there was minimal progress.”
A German gynecologist, Kurt Semm, MD, then appeared on the scene. Born on March 23, 1927, in Munich, Dr. Semm attended Ludwig Maximilians University School of Medicine and received his degree in 1951, with a specialty in obstetrics and gynecology. He became fascinated with laparoscopy and explored the technique for almost 20 years before performing a laparoscopic appendectomy.
However, by the 1960s, laparoscopy had earned a bad reputation in Germany. It was associated with high complication rates, in part because surgeons were burning patients during laparoscopic procedures, so the technique was banned there temporarily.
“I started in 1963 with surgical [pelviscopy], now called laparoscopy, and everybody—the whole world—was against me,” Dr. Semm recalled in an interview with James Daniell, MD, at the 1999 International Society of Gynecological Endocrinology conference in Montreal. The ban was lifted in 1964.
By the late 1970s, Dr. was performing a range of laparoscopic procedures, including myomectomy, ovariectomy, tubal ligation and ovarian cyst resection, and had helped to create new technologies such as the electronic insufflator (Figure 2).
In an interview with journalist Grzegorz Litynski, Dr. Semm described how he devised a way to suture during laparoscopic surgery. Dr. Semm recalled being on a plane traveling from the United States to Germany, when he thought of a way to create a knot outside the abdomen and transfer it inside. This account may not be completely accurate. Another gynecologist from Buffalo, N.Y., H. Courtenay Clarke, MD, already had developed a method for laparoscopic extracorporeal knot tying, and had published and patented his technique—the extracorporeal knot-pusher—before Dr. Semm (Fertil Steril 1972;23:274). Dr. Semm may have learned of Dr. Clarke’s technique during his stay in the United States, and had the idea to adopt it as a disposable extracorporeal knot-pusher on the plane ride home to Germany.
Soon after, Dr. Semm was able to pass a knot into the abdomen through a 5 mm trocar. “After the loop became routine, I thought to myself that I could do everything in a different way,” Dr. Semm said in the interview (JSLS 1998;2:309-313). Extracorporeal knotting soon became common practice in the Women’s University Clinic in Kiel, Germany, and “from there, it went step by step: the intracorporeal knot, the microsuture,” Dr. Semm recalled.
In the Feb. 1, 1980, issue of The Medical Tribune, Dr. Semm was asked: “When will the first appendix or gallbladder disappear into an endoscope?” Eight months later, on Sept. 13, Dr. Semm successfully completed a laparoscopic appendectomy.
Although Dr. Semm often is credited with being the first physician to perform a laparoscopic appendectomy, a surgeon in The Netherlands, Henk de Kok, MD, performed a laparoscopic appendectomy three years earlier (Arch Chir Neerl 1977;29:195-198).
“Dr. de Kok did the first laparoscopic appendectomy,” Dr. Nezhat said. “And contrary to reports, he did not perform a mini laparotomy.” Dr. de Kok used a laparoscope to identify and mobilize the appendix and removed it through a 1-cm incision, Dr. Nezhat recalled. In fact, he had done 320 laparoscopic appendectomies by 1980, but he downplayed his accomplishment because the medical establishment continued to be wary of laparoscopy.
It was Dr. Semm who publicized the technique, and much of the surgical community in Germany persecuted Dr. Semm for his work. Some surgeons asked for him to be suspended from medicine and many thought his actions to be unethical. “People accused him of being crazy,” Dr. Nezhat recalled.
At the 2002 meeting of the Society for Laparoendoscopic Surgeons, where Dr. Semm was being honored, a former student, Liselotte Mettler, MD, relayed several anecdotes describing the disdain he encountered for his work during the 1970s and 1980s. Dr. Mettler, now professor emeritus in the Department of Obstetrics and Gynecology, University Hospitals of Schleswig-Holstein, Kiel, revealed that in 1970, after Dr. Semm had introduced laparoscopic surgery to the University of Kiel, his colleagues made him have a brain scan to check for brain damage. She also recalled that during a slide presentation Dr. Semm was giving on ovarian cysts, an audience member unplugged the projector, saying the surgery was unethical and should not be presented (JSLS 2003;7:185-188).
Despite the intense criticism, Dr. Semm pressed onward. After his paper on laparoscopic appendectomy was rejected by the American Journal of Obstetrics and Gynecology because the editors deemed the procedure “unethical,” Dr. Semm found a home for his work in the journal Endoscopy (1983;15:59-64).
In the 1980s, Dr. Nezhat was performing complex procedures, including laparoscopic treatments for severe endometriosis (Fertil Steril 1986;45:778-783), and in 1985, German surgeon Erich Muhe, who had seen Dr. Semm’s technique, performed the first laparoscopic cholecystectomy.
“If you can treat severe endometriosis [using a] laparoscope, you can do practically anything laparoscopically,” Dr. Nezhat noted.
For almost a decade, Dr. Nezhat also had been working to popularize video laparoscopic techniques. Although he encountered resistance, video laparoscopy eventually was recognized as an important paradigm shift in surgery.
“It was the video laparoscope that made it possible to operate with two hands, look on the monitor and engage the whole operating room,” Dr. Nezhat said. “That is why these procedures become so advanced after video laparoscopic appendectomies.”
In 1988, Dr. Semm traveled to Baltimore to present a video of his laparoscopic appendectomy. When Dr. McKernan heard about this, he also traveled to Baltimore to view it. “Dr. Semm’s procedure was on a horrible 8-mm film, but the second I watched it, I could see it involved basic surgical principles,” he recalled. Intrigued, Dr. McKernan returned home to Marietta, Ga., to work on laparoscopy, and shortly after, he performed the first laparoscopic cholecystectomy in the United States. “Dr. Semm was the father of operative gynecology,” Dr. McKernan said. “He was so ahead of everyone else at that time.”
The next column in this series: The first Laparoscopic Cholecystectomy