Since ancient times, medical men desired to inspect human body cavities and passages to understand their complexity and to treat their diseases. Easily accessible body cavities like mouth, rectum, or even vagina were already inspected in ancient times with the help of speculums.
Accounts of catheters and rectal speculums are handed down from Hippocrates II. The Greek, born on the island of Kos and known for the Hippocratic oath, inserted in vagina tampons with threads using hollowed kalabass. However, the Greeks did not dare to use a speculum to view rectum or inspect vagina.
Erasistos, born in 320 bc in Keos, was first to describe anatomically correct curved catheters. Oreibasis, born in 325 bc in Pergamon, invented an indwelling catheter at Rome in the times of Julius Caesar. He also dilated urethra with a goose quill swathed in swollen parchment.
The origin of endoscopy can be traced back to a reference in Babylonian Talmud. The treatise describes a lead funnel with curved mouth, furnished with wooden outlet (Mechul). Both the parts were inserted into vagina to show, by retraction for the first time to human eyes, cervical os as an internal organ to diagnose uterine bleeding and differentiate it from vaginal bleeding.
A triple-armed vaginal mirror and a rectal speculum were excavated in Pompei. The Syrian gynecologist, Archigenes from Apameia, who practiced in Rome from 95 to 117 bc, wrote a thesis on uterine bleedings. He used a cervical mirror for inspection and commented on various forms of gynecologic palpatory examinations as well as external and internal inspection.
Abu al-Qasim Khalaf ibn al-Abbas Al-Zahrawi, an Arab, is regarded as Middle Ages’ most eminent surgeon. Also known as Alsaha-Ravius or Albucasis of Cordoba (936–1009), he used a glass mirror to reflect light to view the inside of vagina. He described his speculum as “two rods, one lying on the top of the other, which is introduced in the cervix (probably meant vagina) to expand it with the help of screws.”1
The first endoscopic light source can be traced back to Gulio Cesare Aranzi (1530–1589). This Venezuelan used camera obscura (1587) to focus a ray of light to view nasal cavity. He held water-filled spherical glass bottle in front of a hole in a shutter in a darkened room and projected that focused light to view nasal cavity. He recommended an artificial light source on rainy days.
French gynecologist and surgeon, George Arnaud de Rosil (1698–1774), gave new significance to vaginal speculum, which was developed over a century. Arnaud2 was the first to use endoscopic examination lamp making use of a covered lantern. The light source was a night lamp that was placed in a box painted silver from inside. Similar to camera obscura, light focused through a convex lens could be used to illuminate vagina, which was opened with a speculum.
Philipp Bozzini (1773–1809), who marks the turning point from the old to new medicine, must unquestionably be mentioned for his contributions to development of modern endoscopy. Bozzini studied in Mainz and Jena where he became acquainted with Christoph Wilhelm Hufeland who published the Journal of Practical Pharmaceutics and Art of Wound Healing. In 1804 he published first description of his instruments in a small Frankfurt newspaper.4
The equipment had optical part with illumination device and mechanical part that adapted itself to the anatomy of body orifice. In 1806 he published a detailed account of his light guide.3
In 1807 the national industrial Comptoir, Weimar, published the monograph, The Light Guide or the Account of a Simple Device to Illuminate Internal Cavities and Passages of Living Animals. Bozzini himself made sketches and even engraved them in copper.4
Bozzini constructed an instrument for vagina, rectum and oral cavity, including throat. One could see and even operate on a modest scale with it. Even though light source was too weak and visual field too small, all further attempts at cystoscopy in the next 70 years were exclusively based on Bozzini's illumination principle using extracorporeal light source to reflect light. His principle of using artificial light source, reflection of light toward the object to be examined as well as the light conduction and directing the reflection and re-reflection to the observing eye, substantially influenced international discussions on the development of endoscopes.
Antonin Jean Desormeaux (1815–1894) constructed the first portable endoscope5 (Fig. 1.1) and presented this historic development on November 29, 1843, for which received a part of Argenteuil prize from Academie Imperiale de Medicine. Desormeaux was first to clinically use Bozzini's light guide for which many regard him the “father of endoscopy.” His instrument was a system of mirrors and lenses with an open flame as a light source. Skin burns were a most frequent complication. The light guide was essentially used in patients with urological illnesses.
The most important development of endoscopic abdominal surgery is connected with photography and television. Theodor S. Stein (1868) started it in Frankfurt. In 1874 he introduced his “photo endoscope” (Fig. 1.2).6
Gynecology was the so to say initiator of the development of operative endoscopy. Apart from Desormeaux,7 Aubinais,8 and Pantaleoni9 must be also mentioned for their attempts to inspect uterine cavity, which is today's hysteroscopy. The technical development of endoscopy to perfection was left to cystoscopy. The plausible cause is that Mignon filament (Edison) at the tip of the cystoscope by Nitze and Leiter10,11 posed no danger of burns because urine in the urinary bladder ensured appropriate cooling (Fig. 1.3).
In 1881 Johann Mikulicz (1850–1905) and Leiter adopted the principle of rigid optic system developed by Max Nitze and successfully constructed first clinically usable gastroscope.12 Mikulicz carried out several clinical examinations at Billroth's surgical clinic in Vienna.5
Between 1890 and 1900 George Kelling (1866–1945) of Dresden worked on anatomy and physiology of stomach “to determine the size of the stomach.”13–15 He gained experience in oral air insufflation14,15 and worked on pressure ratio of gastrointestinal tract and abdominal cavity. Simultaneously he worked on improving the techniques of examination of gastrointestinal tract, which resulted in application for a patent.16
Kelling's know-how of gastric and esophageal endoscopy and his knowledge of air insufflation were foundation for future attempts to carry out thera- peutic and diagnostic examinations in closed body cavities. The brilliant idea of connecting his air insufflation apparatus to Fiedler trocar and Nitze cystoscope led to the birth of laparoscopy.
On September 23, 1901, George Kelling gave the historic lecture on “Tour of the Oesophagus and Stomach by Flexible Instruments” to natural history scientists and doctors’ 73rd meeting in Hamburg. He also introduced his new procedure that he called “coelioscopy.”17 Kelling had used his oral air insufflation apparatus for intra-abdominal insufflation (Fig. 1.4) together with a Nitze cystoscope for illumination to see abdomen of a dog, in animal experiment for the time.
I question myself, how the organs will react to the air introduced inside? To find out, I have developed a method to introduce the endoscope in the closed abdominal cavity (Coelioscopy) (Kelling 1901).
After an interval of a century and considering the status of endoscopy today, one can evaluate Kelling's endoscopic work as follows:
- Contradicting the spirit of times, Kelling had favored endoscopic procedure to exploratory laparotomy.18
- With far sight Kelling challenged stagewise treatment of malignancy and for this purpose sent repeated reminders for the primary use of endoscopic procedure.19
- Kelling, for the first time in 1901, formulated indications and contraindications of coelioscopy/laparoscopy.
- Kelling demonstrated for first time the possibility of intraabdominal diagnostics by endoscopic inspection and palpation.21
- In 1901, Kelling advised, clearly foreseeing the problems in training young doctors, to practice endoscopic procedures on cadavers. A hundred years ago, dummies were not available to the pioneer of endoscopy.
- Kelling, a visionary, had predicted use of endoscopic interventions, particularly laparoscopy as daycare procedures (1901).22
- Ahead of his time, Kelling had recognized profitable economical aspects of endoscopic surgery.23
In 1911 internist Hans Christian Jacobaeus (1879–1937), from Stockholm, introduced the term “laparothoracoscopy.”24 He was first to view thorax and abdominal cavity by endoscopy and recommended endoscopic technique to view other body cavities. In contrast to Kelling, he inserted the trocar directly without creating pneumoperitoneum. Jacobaeus began like Kelling by breaking down adhesions under thoracoscopic vision.
Bertram M. Bernheim (1880–1958) of Johns Hopkins Hospital introduced endoscopic surgery in the United States in 1911. He called the procedure “organoscopy.”25 His instrument consisted of half-inch proctoscope and a simple light.
Heinz Kalk (1895–1973), a gastroenterologist from Berlin, known as founder of German school for laparoscopy, developed a 135° lens system and double trocar.26 He used laparoscopy as a diagnostic method in diseases of liver and gallbladder. In the publication of his experiences in 1939, he reported over 2000 liver punctures under local anesthesia with no fatalities. He broke down adhesions by laparoscopy.6
Constant improvements in laparoscopic methodology smoothened the way for its wider operative use. The important steps in the process were use of harmless carbon dioxide (CO2) for pneumoperitoneum by Zollikofer in Switzerland (1924), coagulation of adhesions by Fervers in Germany (1933)27 and intra-abdominal use of monopolar current by Ruddock in the United States (1934).
Boesch, from Swiss Aarau, reported in his paper on laparoscopy about “wonderful perspective of the feminine, not deformed genitals of woman and about the exposure of hidden organs, e.g., the ovaries with an elevator (palpation probe).”28 He noted further: “with the laparoscope we have obtained a way to carry out the tubal sterilization for the given indication without laparotomy. With a suitably insulated coagulation clamp, the tubes can be coagulated at multiple places in 3–5 minutes under endoscopic vision.” Frank H. Power and Allen C. Barnes developed in 1941 the same technique in the United States; however, they used a peritoneoscope for tubal sterilization.29
The insufflation of abdominal cavity by instruments was problematic for a long time. Kelling carried it out with Fiedler trocar, which had a blunt “mandrin” to avoid injuries; Otto Goetze (1886–1957), who coined the term “pneumoperitoneum” in 1918, produced a similar instrument with spring mechanism (Fig. 1.5) for air insufflation for contrast radiograms.30
In 1938, the Hungarian Janos Veress (1903–1979) (Figs. 1.6 and 1.7) developed a special canula with spring mechanism aiming to create pneumothorax and consequently to treat tuberculosis, which was prevalent at that time.31 With little modifications Veress needle is used still today to create pneumoperitoneum for laparoscopy. Its special mechanism prevents injury to internal organs during needle insertion through anterior abdominal wall.
In 1960, gynecologists first began small operative interventions. However, French gynecologist Raoul Palmer had already carried out laparoscopy in Trendelenburg position in 1944. In this position intestines were displaced out of pelvis and consequently could be better assessed during operation. Additionally, he required continuous gas insufflation, which was controlled automatically. Palmer also carried out the first laparoscopic sterilization in Paris.
Fig. 1.7: Publication by J. Veress about the Veress needle developed by him.Source: German Med Sci. 1938; 41:1480.)
Piercing of umbilicus for laparoscope by Raoul Palmer in 1946 was a groundbreaking procedure in gynecology. Like Kelling, he called endoscopic diagnostic procedure “coelioscopy” and developed several methods to insert the endoscope. The abdominal access involved many technical difficulties because of mainly blind insertion technique through anterior abdominal wall.32
Decker, an American, introduced laparoscope transvaginally through vaginal fornix.33 He called this procedure Douglasscopy or culdoscopy (Figs. 1.8A and B). From a diagnostic perspective, Douglasscopy was insufficient. This technique that was initially prevalent in America later lost its importance. In 1998 it was team of Brosens et al34 that brought about a renaissance of this procedure as transvaginal hydrolaparoscopy for diagnosis of sterility.7
Hans Frangenheim (1920–2001) and Kurt Semm (1927–2003) helped in a special way to develop laparoscopy in Germany after the Second World War.
In 1950, Hans Frangenheim (Fig. 1.9) began his training in gynecology at Anselmino and in 1951 came in contact with laparoscopy for first time. He was called to medical clinic in Cologne where a lower abdominal tumor was diagnosed during hepatoscopy and further line of treatment had to be decided. Looking back he wrote:
I sensed there, that a new aid had presented itself for the field of gynecology and so began to look into literature. A remark made by Kalk in a textbook had impressed me the most, which said, it is certain that gynecology would open a big field of indications for laparoscopy.
After his appointment in October 1955 to the post of assistant medical director of the National Gynecological Hospital at Wuppertal, Frangenheim attended lectures by Palmer in Paris and realized that laparoscopy was clearly superior to culdoscopy, which was still practiced in Germany. Then he concentrated on regulating uncontrolled gas insufflation, developing new instruments and photographic documentation of endoscopic findings. He had difficult time with German endoscopy firms. Finally, with modified anesthesia equipment from Draeger, he succeeded in reducing gas pressure from customary 50 to 15 mmHg. and restricting CO2 gas flow to maximum of 5 L/min. Frangenheim even defined indications for diagnostic laparoscopy in extrauterine pregnancy, chronic lower abdominal pain, sterility and ovarian tumors.
His monographs, Laparoscopy and Culdoscopy in Gynecology,35 Laparoscopy in Gynecology, Surgery and Paediatrics,36 Diagnostic and Operative Laparoscopy in Gynecology—Atlas with Colour Illustrations37 as well as countless publications and lectures contributed to further spread of the method.
In 1966 he was medical superintendent of gynecological clinic at Konstanz and European Congress for Endoscopy was held under his presidency in Konstanz and from that event laparoscopy received further impetus. In 1982 Frangenheim received First Order of Merit of the Federal Republic of Germany for his outstanding work. On the occasion of his 80th birthday Semm praised Frangenheim for his contribution with these words: “Today the name, Frangenheim is inseparably associated with the gynecologic laparoscopic methods. His achievements for Germany and for the world are epoch making and will go down in the annals of history.”38
The Kiel University clinic for women under Semm (1927–2003) (Fig. 1.10) is regarded as birthplace of modern endoscopic surgery. Semm, collaborating with Richard Fikentscher (1903–1993), developed a new universal insufflation equipment39,40 for the diagnosis of tubal patency, i.e., blowing through fallopian tubes by Rubin.41
8Befitting his knowledge of tubal insufflation, Semm developed an apparatus called “CO2 Pneumo” for insufflating CO2 gas during laparoscopy to minimize operative risks of endoscopy.42 The instrument was in use from 1964 onward at the second university clinic for women in Munich and created pneumoperitoneum automatically.42 The cold light (extracorporeal light that shone across a bundle of fiber glass) was simultaneously developed. Together, they eliminated intestinal burns and gas embolus, which were main dangers of gynecological laparoscopy. In spite of all progress world over, gynecological diagnostic laparoscopy was universally rejected. So, Semm selected the word “pelviscopy” to project that a new technique was developed. Starting from 1965, within three years, this new method spread quickly within Germany as a diagnostic procedure of female infertility. In 1976, Semm developed an electronic version of CO2-Pneumo with the quadrotest for operative pelviscopy43 (Figs. 1.11 and 1.12).
After Semm demonstrated “CO2-Pneumo” at the Congress of American Fertility Association in Washington in 1969, Cohen published a book on this procedure in 1970. In the United States, acceptance of this new method of pelviscopic procedures in gynecology was phenomenal. Even though the method was used a million times, it was employed in 95% of the cases only for tubal sterilization, unlike in Europe,44 where Boesch already accomplished this 35 years before.28 The ignorance about the laws of physics while using the high-frequency (HF) energy in closed body cavities was the cause of many grave accidents causing burns to the internal organs like intestines and ureter. Such incidents once more deeply incriminated this method.
Fascinated by the idea that pelviscopy can be used not only for sterilization but also for other operative purposes,45 Semm introduced it in his new regimen for hemostasis in New Orleans in 1974 (Figs. 1.12A to I). The use of HF current for creating destructive heat was not required in endocoagulation. The human body did not come in contact with the electrical energy. Optimally controlled hemostasis takes place at 110°C. Between 1970 and 1980, the HF current in the monopolar and bipolar techniques using inadequately covered apparatus led to uncontrollable burns; today, in clinical endoscopic practice also, it is ensured that the electrical energy used under supervision does not lead to burns. The modern coagulation and cutting equipment, which work on mono- and bipolar current, have control mechanisms that minimize risk of unintentional burns. Bipolar and monopolar instruments have a controlled, restricted coagulation zone.46
Figs. 1.12A to I: Equipment cart for gynecological endoscopy: (A) Video camera system, monitor, digital video camera; (B) Cold light source; (C) CO2 insufflation equipment—thermoflator®; (D) Hysteroflator for hysteroscopy; (E) Video recorder and video printer; (F) Suction irrigation equipment; (G) Coagulation equipment for monopolar and bipolar coagulation—endocoagulator; (H) Equipment for CO2 pertubation; (I) NaCl bottles, warmed up to 37°C.
Semm, who produced his own instruments, as he was a skilled instrument maker himself, built an automatic CO2 insufflator in 1963, introduced thermocoagulation in 1973, and used for first time Roeder loop to stop arterial bleeding. For laparoscopy he developed special suction irrigation equipment and an electronic insufflator. Difficult interventions were possible because of methods of hemostasis (endosuture with intra- and extracorporeal knots) developed by Semm and his range of instruments. However, many physicians, gynecologists as well as surgeons criticized Semm for his vehement use of so-called keyhole surgery. They were of the opinion that due to the modern anesthetic techniques, big operations by laparotomy posed no problems and Semm had exaggerated the problems with subsequent adhesions. 9Some treated news of the new spectrum of operations (oophorectomy or the removal of complete uterine appendages, treatment of tubal pregnancy) with disbelief and concluded that Semm has started his operation as laparoscopy and then ended it as conventional operation by laparotomy.
Semm was exposed to most intense hostility of the German gynecologists (and endoscopic surgeons) when he carried out first laparoscopic appendectomy in 1983.47 The surgeons especially saw no need to abandon established operative method and to replace it with technically more difficult one. Semm's first attempt at publishing his method therefore met with rejection. The fact that a gynecologist wanted to show the surgeons how an operation should be carried out was simply unthinkable at that time. Semm had crossed the limit that was till then considered as sacrosanct. But he knew that endoscopic surgery had enormous potential not only in gynecology but especially in surgery and therefore continued with his endeavors in laparoscopy, unperturbed toward the goal, of reducing the surgical trauma to the patients. Two German surgeons, Friedrich Gotz and Arnold Pier, followed Semms's intent and provided a wider base to laparoscopic appendectomy.48 In the early 1990s they had already carried out hundreds of appendectomies in this way and perfected the technique, which they could now use even in acute appendicitis.49
In 1977 a 10-mm morcellator (Semm) was produced for pelviscopy purposes. However, in today's operative pelviscopy where even fist-sized myomata is removed from uterus with little blood loss, this instrument is not very effective. So in 1988, manually operated serrated edged macro morcellator (Semm) of 15–20 mm diameter was introduced. The instrument could reduce a myoma of about 5 cm size to small pieces within a few minutes. The posterior colpotomy for removal of myoma or even a small abdominal incision was not required any more.50 Since the introduction of horizontal morcellation, the morcellators are motorized and are available in 10 to 24 mm diameters.
Just like laparotomy, intra-abdominal irrigation equipment are necessary in laparoscopy also to guarantee good view. The acquapurator of 1974 gave way to CO2 aquapurator in 1990. Today the aquapurator biotherm has removed many problems of hypothermia, even in operations of longer duration. In 1994, insufflation of preheated CO2 was introduced to preserve isothermia.
In September 1985 a surgeon from Böblingen, Erich Mühe (1938–2005), performed laparoscopic cholecystectomy for the first time in the world using Semm's instruments.51 In 1986, Mühe reported 97 successful laparoscopic operations.52 In 1989, Reich et al. described the first laparoscopic-assisted vaginal hysterectomy.53 In 1991 Mouret carried out the first cholecystectomy by video laparoscopy.
In the 1970s and 1980s most surgeons simply ignored the development of laparoscopic operations because of introduction of new medicines, impressive results of intensive care and innovations in anesthesia that facilitated extensive surgeries. The basic concept, that a big problem (disease) requires a big solution (abdominal incision), was so deeply rooted in surgeon's thinking that there was no place for “keyhole surgery.” This is why surgical fraternity refused to accept and modify gynecological instruments for their use.
However, contrary to general development some surgeons accepted the challenge and accelerated introduction of laparoscopic techniques in surgery. A group of German surgeons was particularly active in this process and in December 1976 started Chirurgische Arbeitsgmeinschaft für Endoskopie und Sonographie (CAES) in Hamburg. In the United States, the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) was set up five years later. In the following years both organizations laid foundation for the introduction of endoscopy in clinical practice.
Prompted by Dr. Bernd Manegold, a surgeon from Manheim and one of the founders of the CAES, the first edition of scientific journal Surgical Endoscopy was published in 1987 under the direction of many leading endoscopists. Just the following year the first World Congress for Surgical Endoscopy was held in Berlin, which was a great success where 500 experts from all over the world participated. This finally led to acceptance of endoscopy in surgery.
In 1983, British urologist John E. A. Wickham (born in 1927) used the concept of “minimally invasive surgery” for the first time. The concept attracted attention in 1987 after Wickham published his vision of extensive endoscopic treatment in the famous British Medical Journal.54 In spite of the strong criticism it mirrored the general trend of the 1980s as minimally invasive techniques had greatly fascinated doctors and their patients.
This development was further accelerated by crucial technological innovations. The introduction of new light sources (Palmer 1953), Hopkins-optics (1960) and cold light source had already improved illumination in endoscopic operations in 1960.21 The video technique was also important. The new video 10camera was much smaller and therefore easier to manage than its predecessor and the videocassettes also were simpler for everyday use than the 8 or 16 mm film. In 1980s more surgeons used video cameras, but even the latest and smallest of the camera together with endoscope proved unwieldy because it altered the balance and made precision work difficult. Electronic minicamera brought the breakthrough: a 4-mm optoelectronic transducer (CCD) converted the view from inside body cavity to electronic impulses and transferred them to a monitor. The combination of optic trocar and video camera opened new possibilities for surgeons because now with both hands free, they could operate ambidextrously and simultaneously follow on the monitor what was happening along with the entire team.
The years that followed were molded by a lively exchange and reciprocal stimulation. Video laparoscopy of cholecystectomy in 1987 in Lyon by Philipe Mouret (born in 1937) and his presentation of the procedure in the SAGES meeting in Louisville triggered a downright boom in France and also encouraged surgeons across the world to tread this path further.
Another milestone was realization of appendectomy by laparoscopy, which Kurt Semm started in patients that showed besides their gynecological problems subacute appendicitis. Although we performed laparoscopic appendectomies since 1981 and numerous German general surgeons had visited Kiel for that purpose, only when Semm presented his laparoscopic appendectomy in Baltimore in 1988, JB Mckernan and W. B. Saye took it up and in June 1988 they reported first laparoscopic cholecystectomy in the United States using Semm's instruments and combining the procedure with laser technology. As a result many successful endoscopists visited both protagonists in Nashville to learn the new technique. At the same time, Sung Tao Ko from Chicago upheld the laparoscopic appendectomy by Semm and brought his instruments to America. A paper on laparoscopic appendectomy that Kurt Semm and I submitted to the American Journal of General Surgery was rejected by declaring this as an unethical surgical technique. We also had the same experience in Germany when a lecture of Kurt Semm to the College of General Surgeons on Laparoscopic Appendectomy was rejected as an unacceptable technology. The news about these sensational methods reached even the media in the United States. During a TV talk show it was made public with the help of gallbladder operation. After that the Nashville surgeons received hundreds of calls not only from the patients but also from doctors.
In October 1989, when Douglas O Olsen and Eddie Joe Reddick announced their courses casually at the congress of American College of Surgeons (ACS) for laparoscopic cholecystectomy, they were booked in shortest time and new courses had to be planned. Many American observers felt that laparoscopy has pervaded the entire surgical fraternity in the United States. In the following weeks, a wave of enthusiasm about this new technique passed through the nation and training courses sprung like mushrooms. The industry was confronted with an abundance of orders so that waiting period rose up to six months. In the beginning leading endoscopists tried to canalize the development and to warn about the risks of injudicious use but soon they realized that it was not possible. No one had thought before 1989 that one of the most established operative method in surgery, cholecystectomy, would change so radically within just a few months. Even surgeons who had substantially contributed to this development were surprised by the speed. Literally thousands of surgeons had to restrain themselves. The courses were booked for months and the shortage of instruments was an unheard of phenomenon in the Western medicine. In the following years with the spread of laparoscopy, as the experiences increased, new operative methods quickly developed in many operative specialties.
The production of endoscopic instruments in the industry showed an upswing and the interaction and interest of the various medical specialties—surgery, urology, and gynecology—increased. Today the interest of the industry, doctors and patients worldwide is reflected in a common endeavor—betterment of surgery in many aspects through modern technology. That is reflected in further developments in the use of digital picture control, robotic instruments, computers, and telesurgery. Numerous specialities that have emerged and which deal increasingly with oncological fields also reflect these efforts. That is why in 1965 the German Society for Gynecologic Endoscopy and in 1971 the American Society for Gynecologic Endoscopy were founded. The World Society for Gynecologic Surgery (1986), the European Society for Gynecologic Endoscopy (ESGE, 1990), the Asian Society of Gynecological Endoscopy, the International Society for Gynecologic Endoscopy and the International Society of Gynecological Endoscopy (ISGE, 1991) came into being with yearly or two-yearly meetings.
The development of hysteroscopy and fallopioscopy must be mentioned here. After Lindemann 11(1971) and Semm (1974) established the CO2 hysterectomy, the real breakthrough in the operative hysteroscopy came after 1980 basically as fluid hysteroscopy. Today hysteroscopy is a routine procedure and one cannot imagine diagnostic and therapeutic interventions without it.
From today's point of view, the ideal entry for viewing the tubal lumen is by hysteroscopy through a transcervical and transuterine catheter with 0.8– 0.3 mm thick telescope or flexible falloposcopes.
When one compares the gynecologic endoscopic surgical work of the 1980s, primarily the sterilization, conservative operations on the adnexa and the enucleation of myoma were described. As against that, from 1989 the publications on adhesiolysis, appendectomy, lymphadenectomy and laparoscopy-assisted vaginal hysterectomy in different variations frequently appeared. In surgery, besides gallbladder resection, fundoplication, and hernia operations, extensive splenectomies, bowel resections, and great advances in surgical oncology and neurosurgery are described. In orthopedics, the operations on knee are improved further. In urology, there are reports on nephrectomies and the first robotic prostatic resection. In gynecology, robotic optic holders and instruments are employed.
The worldwide evolution for improvement of endoscopic surgery has begun; its end is still not in sight.55 The aim of this surgery is to achieve at least the same, if not better results as with conventional operative techniques. On the wider international level mention should be made of Jordan M. Philipps under whose organization Kurt Semm, Liselotte Mettler, and various other team members of the Kiel School of Gynecological Endoscopy, which we really founded in the year 1990 only, but it existed under Kurt Semm's driving patronage since 1970, were able to teach endoscopy courses all over the United States in 1985 and our endoscopic surgery worldwide between 1985 and 2005. In 2005 numerous centers around the world had started to teach their own courses, which they continue to do. Single-port entries and particularly robotics have moved in with high demands and striking results. Contained in bag morcellation has substituted controlled electronic morcellation. Let us see what the future brings.
Jordan M. Philipps (1923–2008) (Fig. 1.13) founded the American Association of Gynecological Laparoscopy (AAGL), now the International Society of Minimal Invasive Gynecology, in 1971 The AAGL is the leading association promoting minimally invasive gynecologic surgery among surgeons worldwide. When established in 1971 it was known as the American Association of Gynecologic Laparoscopists. As the field of minimally invasive gynecologic surgery grew, the membership of the AAGL quickly expanded around the globe and came to encompass more than laparoscopy alone.
Although the organization had outgrown its American roots, its name and acronym AAGL had become highly recognized worldwide. To best portray its expanding mission and international constituency, while still preserving its heritage and brand recognition, the organization eventually dropped its full name, “American Association of Gynecologic Laparoscopists” and became known simply as the AAGL, along with the phrase “Advancing Minimally Invasive Gynecology Worldwide.”
Today with a membership extending to over 110 countries, the AAGL is an internationally recognized authority in minimally invasive gynecology. With over 7,000 members worldwide, the association counts among its membership the foremost authorities in gynecology and pioneers in technique and procedures and continues besides renowned and as active other previously mentioned international and national societies in our field.56
As extremely active colleagues on the American continent in the United States since 30 years, let me also mention the three Iranian pioneers in endoscopic gynecologic surgery who influenced our field like none others by their intuition, love and dedication to their work, the laparoscopic surgery, totally dedicated to their new country, the United States, the Nezhat brothers: Camran, Farr and Ceana Nezhat.57
Our late German colleague Thoralf Schollmeyer (1964–2014) was from 2007 onward the director of the Kiel School of Gynecological Endoscopy and the president of the German Society of Gynecological Endoscopy (AGE) when he died in 2014.12
He deserves to be especially mentioned in an historical outline as his professional life was fully dedicated to the education in endoscopic gynecological surgery. He was the first editor of our second edition of this book and a truly believing endoscopic surgeon till the end of his early death by the age of 50 years in 2014 (Fig. 1.14). Being a patient himself over eight years he showed us how dedication to the profession and family moves rocks. The development of gynecological endoscopy in clinic, research and science and the support of young researchers characterized his life. He followed his own way, which was marked by extreme passion, audacity and endurance of pain with high ethical and medical values.
In conclusion, it must be stressed that the history of laparoscopy and hysteroscopy and its introduction in the surgical practice is a story of many researchers, who for years battled against prevalent general thinking and partly against rejection of their brainchild of performing “gentle operations.” Many of the pioneers were ignored, called dreamers or regarded as crazy. It is only through their persistence, tenacity, strong personalities and intense dedication to life and love that they could stand firm in the face of adversities.58
The history of laparoscopy is a unique mixture of various trends in different fields, spurred by the activities of established societies as well as opportunities of their publication and influenced by the world's progress, recession, war, peace and the love of the individuals for life. The influence of industry, which has kept pace and actively supported this development for years, is the driving force besides the heroes of doctors and engineers that bring up new ideas. Without suitable technology, this dissemination would not have been possible. Endoscopic development and its future does depend on new inventions, on the audacity of leading heroes, their input into this field but also on their management of life to continue to survive and on a healthy and successful cooperation with the medical technical industry and the governments of our countries, which grant us the freedom of research and development for the best care of all our patients.
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