By Victoria Stern

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Erich Mühe, MD
From: JSLS. 1998;2(4):341-346.

German surgeon Carl Johann August Langenbuch, MD, performed the first open cholecystectomy in Berlin in July 1882. More than 100 years later, on Sept. 12, 1985, Erich Mühe, MD, a surgeon from a small town in Germany, performed the first laparoscopic cholecystectomy.

Although it took more than a century for the gallbladder to be removed laparoscopically, the procedure soon spread like a firestorm and helped transform the field of surgery, said Edward Felix, MD, assistant clinical professor of surgery at the University of California, and director of bariatric surgery, Clovis Hospital, Fresno, Calif.

But Dr. Mühe’s contributions were not recognized until years later because he encountered stifling resistance from the academic community in Germany. During that time, laparoscopic cholecystectomy caught on in France, the United States and soon the rest of the world, eventually becoming standard practice.

“Dr. Mühe introduced laparoscopic cholecystectomy, but was vilified for his work,” said Frederick Greene, MD, FACS, clinical professor of surgery, University of North Carolina School of Medicine, Chapel Hill, and former president of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). “Eventually, he was exonerated and given appropriate praise. Although his contributions were greatly important, Dr. Mühe’s experience goes to show you what happens when you’re a little ahead of your time.”

Dr. Mühe was born on May 23, 1938, and graduated from medical school in 1966, at 28 years old. He became an assistant in the surgical clinic at the University of Erlangen, Germany, where he completed his surgical training in 1973. In September 1980, Dr. Mühe learned that a German gynecologist, Kurt Semm, MD, had performed an appendectomy laparoscopically, and he became intrigued by minimally invasive surgery.

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By 1982, Dr. Mühe had moved to Böblingen, Germany, a small town several hours west of Munich, known primarily for its automobile and computer industries, to take over as the head of surgery at Böblingen County Hospital. After learning laparoscopy from German gynecologist, Willi-Rinehard Braumann, MD, Dr. Mühe wondered whether it would be possible to remove a gallbladder using Dr. Semm’s technique. But Dr. Mühe noted that Dr. Semm’s equipment seemed too narrow for a bloated gallbladder to squeeze through (J Minim Access Surg 2011;7:165-168).

One day, Dr. Mühe, who was an avid cyclist, realized he could access the abdomen through a tube shaped much like the one on his bicycle. Using this framework, he collaborated with Hans Frost, who worked at the German manufacturing company WISAP (now called Blue Cap AG) to develop a laparoscope through which he could fit a gallbladder. Together, the men created the could could could could “galloscope,” which Dr. Mühe used to perform the first laparoscopic cholecystectomy.

During the procedure, Dr. Mühe inserted the galloscope, fitted with side-viewing optics, through the umbilicus and into the peritoneal cavity to insufflate the abdomen with carbon dioxide. He made two or three more small incisions of 3 to 4 cm in the lower abdomen, inserting a pistol grip applier with hemoclips to ligate and pistol grip scissors to cut between the cystic duct and artery. He then removed the gallbladder through the galloscope. Dr. Mühe described his pioneering effort in Endoscopy (1992;24:754-758).

Dr. Mühe modified his technique after performing six procedures, eliminating the need for pneumoperitoneum and the lens. Instead, he accessed the gallbladder at the right costal margin, which made a “roof” directly over the gallbladder, creating just one 2.5-cm incision. He used a trocar sleeve and a light cable to perform “open tube” cholecystectomies, which he thought was a simpler technique that also provided better cosmesis.

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The “Galloscope” of Mühe had side-view optics, an instrumentation channel with valves, light conductor, and duct for creating pneumoperitoneum.
From: JSLS. 1998;2(4):341-346.

In April 1986, after performing 94 procedures, Dr. Mühe presented his laparoscopic cholecystectomy technique to the German Surgical Society (GSS) Congress. In October, Dr. Mühe gave a lecture on cholecystectomy without laparotomy to the Lower Rhine-Westphalian Society. In both instances, the audience reacted with vehement disapproval, said J. Barry McKernan, MD, PhD, the surgeon credited with performing the first laparoscopic cholecystectomy in the United States. The academic elite in Germany considered Dr. Mühe’s work as dangerous.

By 1987, Dr. Mühe had performed many laparoscopic cholecystectomies without a hitch. In March of that year, however, he faced a problem with a particularly difficult gallbladder. His patient was moved to the ICU, which was run by an anesthesiologist who said the patient was too sick to be operated on. The patient died of complications soon after.

“Instead of the malpractice cases we have in the United States, Dr. Mühe was brought before the criminal court for manslaughter,” said Michael Kavic, MD, professor of surgery at Northeastern Ohio Universities College of Medicine in Rootstown, Ohio, and founding member of the Journal of the Society of Laparoendoscopic Surgeons. “He was dragged through courts for several years, and was harassed and hounded. Those years almost broke him.”

To add fuel to the fire, in a June 1986 article, a German magazine, Medical Review, suggested that Dr. Mühe had actually taken his bicycle frame and used it to perform his laparoscopic cholecystectomies, Dr. Kavic said.

It took a few years, but in 1990, Dr. Mühe finally found vindication. A group of his peers had recognized that the patient had not died as a result of the procedure itself, but because of negligence by those who ran the ICU. By that time, laparoscopic cholecystectomy had spread across the United States, and the medical community outside of Germany knew little to nothing of Dr. Mühe’s contribution. Years later, SAGES recognized Dr. Mühe for performing the first laparoscopic cholecystectomy, and invited him to present on his experience in March 1999 at its annual meeting in San Antonio.

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Mühe’s open tube laparoscopic cholecystectomy, Technique No. 2. Patient with one access, directly above the gallbladder without pneumoperitoneum because the costal arch is a firm bone roof.
From: JSLS. 2001;5(1):89-94.

Each country was isolated from the other,” Dr. Kavic said. “No one really knew what was going on in Germany, France, the United States, because back then the revolution in personal communication had not yet taken place. Making a transatlantic telephone call was a huge deal and a huge expense, and if you had published an article in France or Germany, it stayed there.”

Lap Chole in France

For a time, surgeons in France were hailed as the first to perform laparoscopic cholecystectomy. In 1988, Francois Dubois, a surgeon practicing in Paris, was performing mini-laparoscopic cholecystectomies, removing the gallbladder through a one-inch incision using a headlight for illumination, recalled Dr. McKernan. Dr. Dubois bragged to the nurse in the operating room, asking her whether anybody had ever seen a gallbladder come out through such a small incision. This nurse, who had worked previously with a surgeon in Lyon, France, Phillipe Mouret, MD, replied that yes, in fact, she had.

Dr. Dubois called Dr. Mouret immediately, and the two met in Paris. Dr. Mouret brought a video and pictures of the procedure. Soon after the meeting, Dr. Dubois was performing laparoscopic cholecystectomy using Dr. Mouret’s technique, and was the first to publish on the technique in France.

Several months earlier, on March 17, 1987, Dr. Mouret had performed his first laparoscopic cholecystectomy on a 50-year-old woman suffering from painful pelvic adhesions and symptomatic gallbladder lithiasis. He was scheduled to perform two operations: gynecologic adhesiolysis, and cholecystectomy. According to an article he wrote on his experience (Ann Acad Med 1996;25:744-747), Dr. Mouret used a hook dissector to free the gallbladder, and then sealed the cystic artery and clipped the cystic duct with a clip applier. Because there was no video on which to view the inside of the abdomen, Dr. Mouret had to lie on the patient’s thigh in order to look through the laparoscope (J Minim Access Surg 2011;7:165-168).

In 1988, Jacques Perissat, MD, a renowned gastrointestinal and laparoscopic surgeon who worked at Bordeaux Segalen University in France, saw Dr. Dubois’ laparoscopic cholecystectomy. Dr. Perissat helped modify the technique by using extracorporeal shock wave lithotripsy to break up gallstones in a noninvasive way. With Dr. Perissat’s support, the procedure gained credibility in France’s academic climate, which normally resisted change, Dr. Kavic said.

Dr. Mühe finally received the GSS Anniversary Award for his pioneering work in endoscopic surgery in 1992, the same society that had rejected his ideas six years earlier. The president of GSS, Franz Gall, MD, called Dr. Mühe’s work in laparoscopic cholecystectomy “one of the greatest original achievements of German medicine in recent history” (JSLS 2001;5:89-94).

By this time, the laparoscopic revolution was in full force. “Many things had come together at the same time,” Dr. Kavic recalled. “We had the laparoscope, a camera that could videotape procedures and enabled surgeons to teach and spread the word among colleagues who didn’t speak the same language.”