Chapter 1 - Society of Laparoscopic & Robotic Surgeons

Chapter 1

Endoscopy as a Philosophy
Perhaps the most unique aspect of the history of the endoscope lies in the issue of categorization. Just what is endoscopy anyway? Is it an instrument or technique? “Revolution or Evolution?” Many have come to understand the meaning of endoscopy as merely that of a technology or instrumentation. Because its roots as an almost exclusively diagnostic tool are so recent, this limited conceptualization has been somewhat difficult to escape. A more accurate definition however places endoscopy firmly in the realm of a new philosophy, one rooted in what is now referred to as minimally invasive surgery.

Interestingly, the idea of minimal intervention is not necessarily a modern phenomenon. Historical artifacts provide plausible evidence indicating many ancient societies had an interest in minimal intervention as far back as 4,600 years ago. In fact, prior to the mid-19th century, surgeons very rarely operated on the abdominal cavity. Rather, their efforts were confined to indirect methods such as dietary changes and purgatives.

One may also interpret much of the Hippocratic Corpus as predominantly advocating this minimalist approach, as can be inferred by the modern version of the Hippocratic ancient edict “First, do no harm.” Hippocrates specifically instructed physicians to avoid as much as possible invasive methods, allowing instead allow for the body’s own miraculous powers of healing to take effect. Of course, this approach was certainly influenced by the fact that invasive surgeries were almost unthinkable, as the mortality risk from infections was simply too great. Nevertheless, in reviewing the history of medicine, we can see that a philosophy of minimally invasive medicine has been an integral part of medicine for thousands of years.

“Big Surgeon = Big Incision”
Sometime between antiquity and the late 19th and early 20th century, the favored form of surgical intervention transformed into one dominated by big incisions. Exploratory laparotomies eventually came to be understood as integral to the treatment and diagnosis of many types of disease states that had defied other methods of diagnosis. Ironically, this growing preference for “classical” open surgery was most likely influenced significantly by the scientific advances in asepsis and anesthesia during the same time period, discoveries which finally ushered in the era of modern medicine.

With the advent of anesthesia and antiseptic however, this meant that for the first time in living patients the physician could now get right to the source of disease without having to rely on deductive reasoning or blind biopsies. Diseases of the abdomen could now be palpated, visualized, and treated surgically. Paradoxically then, while treatment options and recovery rates expanded, so too did the circumference of incisions. Open approaches were soon codified as the gold standards of “classical surgery,” a point that later served to interfere substantially with endoscopy’s progress .

The Modern Era of Planx’s Quantum Physics and Einstein’s Relativity
The more we live by our intellect, the less we understand the meaning of life. –Leo Tolstoy

Taken collectively, these great strides in medicine, coupled with parallel advances in science and technology so characteristic of this late Industrial era, engendered a growing sense of scientific infallibility. By the 20th century, great thinkers such as Einstein, Hans Otto and Max Planx were revolutionizing classical understandings of science. Even Newtonian physics was called into question during this transformative time. In fact, after a nearly 200 year reign as supposedly irrefutable fact, many of Newton’s empirical observations of gravity were found to be significantly flawed, as demonstrated by Einstein’s brilliant theoretical work1.

Traditional surgical conventions continued to undergo rapid change as well. The surgeon, once referred to as a mere butcher in Hippocrates’ time, was, by the 19th century, transformed into an idealized father-physician, whose unique position of authority over the human body was accepted in some sense as a reassuring presence amidst the uncertainties of life and death. Such changes in the surgeon’s status were reflected in the growth of new elite societies for surgeons only. Surgeons thusly began taking a place of prominence above internists and other disciplines. Many snappy aphorisms from our not too distant past supported this growing reverence for surgeons and by extension, for their surgical procedures too. Such sayings as “to cut is to cure, “the greater the surgeon, the bigger the incision,” and “wounds heal from side to side, not top to bottom,” were all common refrains which helped reinforce the prevailing attitude about the superiority of open surgical methods. Influenced by this entrenched dogma, the inherent morbidity associated with large incisions was de-emphasized, due mainly to the lack of surgical alternatives. Contrary to today’s standards, a large incision was seen as a necessary evil, unequivocally required to save the very life of the patient. In relation to certain death, the various morbidities and uncertainties associated with laparotomy were understandably viewed as acceptable risks given the medical limitations of the time.

Yet, just like Newtonian physics, these classical theories of surgery would ultimately be challenged by the conceptual breakthroughs driven in part by the burgeoning field of modern operative endoscopy. Of course, the sacrosanct system of scientific lore is often paradoxically unwelcoming of new-fangled notions, subjecting novel ideas to sometimes rancorous resistance. Our discipline clearly witnessed such a backlash to new ideas when we saw, for instance, operative videolaparoscopy so vehemently lambasted in its early ascendancy. Indeed, videolaparoscopy, by catalyzing such profound changes to the very foundation of so-called “classical” surgery, came to symbolize an unwelcome threat to the entire order of things.

Facing such institutionalized beliefs about classical surgery, the aspect most remarkable about the endoscope’s story relates not so much to its ingenious technological progression, but rather to those individuals standing behind the progress whose courage and tenacity enabled them to boldly call into question orthodoxy, envisioning for the world a path of progress well beyond technical limitations, while facing simultaneously almost riotous ridicule for attempting to change established practices. The pioneers of endoscopy were therefore truly exceptional, for they were able to recognize the deeper humanistic significance of the endoscope, not as simply a “piece of technology,” but as something that instead signified a revolutionary advance for medicine and society.

Still, despite so much progress, despite so much unimaginable success, ambivalence and suspicion about operative endoscopy persists even today. As recently as 2003, editorials insinuate the worst, with rhetoric such as “just because we can [do endoscopy] doesn’t always mean that we should.” Another recent article implicates excesses of industry and the “glitz” of new technology as culprits with the following:

“Surgical technology in the area of endoscopy seems to be exploding, but at what cost? … Today, I ask the question: Who is driving the bus? Industry or physician? The focus on the basic principles of surgery is fast becoming blurred amongst the glitz of new technology.”

These sources are not alternative reads either; they are mainstream publications with a wide and influential audience. For these reasons alone, taking a moment to review the endoscope’s developmental process will help us recognize just how dominant ideologies or cultural influences act as such profound forces in shaping the practice of medicine. In other words, medicine and science are not as objective as we so often assert. To review history then will keep alive this important exercise in critical introspection.

1. Of course, Newton’s particle theory of light- which was half right at any rate- had also been overturned 100 years earlier.