leather‐covered tin lantern using a wax candle light source.
Source: Courtesy of Dr. David C. Twedt.
Enter the German gastroenterologist Heinz Kalk (1895–1973), who in 1929 introduced a foreoblique lens system, which effectively increased the field of vision. Kalk is considered by many to be the greatest clinical laparoscopists of all times. He was disturbed by the contemporary high fatality rates associated with liver biopsies, and he was the first to introduce a safe and accurate method of endoscopic biopsies of liver, gallbladder, and kidney. With Kalk's improvements, the increased usefulness of the scope invigorated surgeons to start using the technology. Before Kalk, endoscopy had mainly been applied by gynecologists and urologists. Kalk was fortunate to, just barely, make it out alive during the Stalingrad invasion of 1943. His survival was fortunate to the development of laparoscopy, because the highly productive physician continued his prolific scientific publishing and research well into the 1950s. During the 1950s, he began collaborating with Karl Storz in the development of instrumentation.
Another landmark in the 1930s was when the Hungarian physician Janos Veress developed a novel spring‐loaded needle 1937. The needle was originally used to perform therapeutic pneumothorax to treat patients suffering from tuberculosis. However, laparoscopists quickly realized its potential for safe creation of pneumoperitoneum [2].
Meanwhile, back in America, John Ruddock (1891–1961), an internist from Los Angeles, was most likely the principle driving force behind the acceptance of laparoscopy in the United States during the 1930s and beyond. Ruddock was known to work tirelessly to advocate for the laparoscope and to make a plea to internists and surgeons to work more cooperatively toward the goal of bringing minimally invasive care to patients. With his “peritoneoscope,” he was able to diagnose patients with metastatic gastric carcinoma by minimally invasive means, sparing them a nontherapeutic and thus wasted laparotomy, as metastatic disease was considered non‐operable at the time.
By the end of the 1930s, operative laparoscopic procedures were finally in more general clinical use, and no longer reserved for a few dedicated centers. However, paralleled with this development was also rising death rates from endoscopy complications. Some of the early pioneer physicians were visionary enough to comment on “the need for doctors to essentially retrain themselves” as an important impediment to general acceptance of laparoscopy.
Out in the Cold: 1940s to mid‐1960s
The increasing rate of deadly complications associated with rising use of laparoscopy was likely the reason that a 25‐year gap in development was taking place in America between 1939 and 1966 [2]. Fortunately, the development continued in Europe, with the Swedish‐born French gynecologist Raoul Palmer (1904–1985), achieving brilliant milestones. During the early 1940s, in occupied Paris during World War II, he discovered the benefits of Trendelenburg position on pelvic visualization. He developed safer administration of insufflation, video capture of procedures, and not the least; he excelled in the training of innumerable disciples from all over the world. Many of the great laparoscopists in the 1960s through the 1980s were trained by Palmer who apparently was a generous and beloved teacher and mentor.
Unfortunately, the development of laparoscopy was not straightforward. In 1961, it suffered a great fall from grace when its use was banned in Germany as a “prohibitively hazardous procedure”: a result of faulty insufflator and electro‐cautery units. By 1964, the ban was lifted due to improvements in component technology, but its reputation was none‐the‐less damaged.
Controversy Galore: 1970s to 1990s
For twenty‐first century laparoscopic surgeons, the controversy surrounding laparoscopy as late as in the 1980s and 1990s seems unbelievable.
One of the remarkable pioneers, who persevered despite a massive storm of criticism, was the gynecologist Kurt Semm (1927–2003). In the 1970s, his innovations included the electronic insufflator with capability to precisely monitor intra‐abdominal pressures, which greatly increased pneumoperitoneum safety. He all but eliminated thermal injuries by improving on radio frequency cauterization. He pioneered extra‐ and intracorporeal knot tying and may have invented the loop applicator. However, the latter has been vehemently challenged by another gynecologist, H. Courtenay Clarke, who published on ligation and suturing techniques in the early 1970s.
In 1980, Semm performed the first laparoscopic appendectomy. No one could believe this was possible, and he was accused of pathological hoaxing. At the time, the gap between surgeons and gynecologists was immense. Semm's entrance into general surgery was seen as an attempt of a gynecologist to bolster his “operation ego” [4, 5]. All his attempts to publish on his surgical technique were refused with the reasoning that such “nonsense will never belong to general surgery” or that it was “unethical.” Even Semm's gynecological colleagues thought he had gone too far and attacked his publications, as being faulty and biased. The insulting criticism often went to extremes; the projector was unplugged during his presentations, with the motivation that unethical surgery was presented. After Semm lecturing on laparoscopic appendectomy, the President of the German Surgical Society wrote to the Board of Directors of the German Gynecological Society, suggesting suspension of Semm from medical practice.
Camran Nezhat (1947–), a laparoscopic surgeon affiliated with Stanford University medical center in, Palo Alto, CA, and with University of California San Francisco, is another such persevering pioneer [6]. He developed video‐laparoscopy, which removed the need for the surgeon to look directly through the eyepiece of the scope (Figure 2). This was a milestone and a prerequisite for the laparoscopic revolution that followed; a surgeon simply cannot perform advanced procedure crouched over an eye‐piece. His development also made him one of the most controversial figures in the movement of minimally invasive technology. Opponents of MIS accused laparoscopists like Nezhat to hide their complication rates and advancing dangerous methods for personal gain. A couple of high‐profiled lawsuits in the early 2000s triggered nationwide media coverage, as Nezhat was accused of medical malpractice and racketeering. Both suits were dismissed, and the allegations were considered frivolous lawsuits in the one case, and the attorney in the second was subsequently charged with contempt of court. Allegations of research fraud were made against Nezhat, all which were found unsubstantiated.
Figure 2 Laparoscopy performed in 1974, before the introduction of video laparoscopy.
Source:Courtesy of Dr. David C. Twedt.
Fortunately, some surgeons saw these hard‐earned achievements for their true value and by early 1990s laparoscopic appendectomies were performed by these early adaptors in vast numbers. Shortly thereafter the “laparoscopic revolution” broke out and suddenly Semm's and Nezhat's expertise and publications were in great demand. Finally, in 2002 Semm received the Pioneer in endoscopy award from the Board of Governors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) [5]. Nezhat also has won numerous awards and honors from prestigious societies like ACOG, ACS, ASRM, and the Excel Award from the Society of Laparoendoscopic Surgeons.
Small Animal MIS
With the human laparoscopic physicians leading the way, small animal MIS has not been nearly as controversial as its human counterpart. Like in the medical field, MIS was fairly slow to be incorporated in general veterinary clinical practice. Our development appears to parallel that of human surgery, but with an approximately 20‐year delay. A “laparoscopic revolution” like that in the
