Chapter 13 - Society of Laparoscopic & Robotic Surgeons

Chapter 13

The Glory Days of Endoscopy
1910s-1920s, Post-Jacobaeus

From the outset, the 1910s looked like the roaring 20s for endoscopy. Some of the obstacles that stunted the growth of endoscopy in the 19th century were just about cured by the newly invented technologies of the early 20th century.

Within just a few years of Kelling’s, Ott’s and Jacobaeus’ groundbreaking successes, a heady collection of bold pioneers continued to push the still- developing technology to ever unprecedented heights. The successful expansion of the scope into areas once thought inaccessible– namely laparoscopy and thoracoscopy- proved to be just the catalyst needed to plant the fledgling seeds of a unified framework for all endoscopic disciplines.

Indeed, the glory days had arrived. If you had been waiting with baited breath for a true launching pad to help endoscopy take off, now more than ever the time seemed just ripe enough. Physicians from multiple disciplines all across the world were enthusiastic about this promising surgical method. It seemed everyone wanted a piece of the action, from bronchoscopists to urologists, from Boston to Berlin, the enthusiasm was simply brimming and irrepressible. By this time too, several textbooks had been published on endoscopy (though not yet on laparoscopy specifically). And many articles even began one of the earliest calls for temperance in the enthusiasm for endoscopy, warning that endoscopy could not- and should not– replace the more tried and true laparotomies.

Of most significance, we at last begin to see a great deal of progress in advancing endoscopy toward more operative procedures, rather than just diagnostic. Electricity allowed for scopes to be made with more gadgetry, with new features to make more complicated procedures possible for the first time. Indication to this technology spillover phenomenon and of the endoscope’s popularity can be deduced by noting the many medical device companies that seemed to sprout up over night, effectively placing many different types of endoscopes on the market. There were now also operating endoscopes available. A bewildering array of novel instrumentation and auxiliary parts were invented as well to accommodate these new operating scopes. From ligasures to automatic electro-cautery devices, it was clearly a trend in the making and one that held great promise based on the reported clinical successes.

With such a fantastic outpouring of new technologies at their disposal, the next generation of pioneers were blessed with a great burst of momentum to set them sailing on to the new target, taking the reigns where Jacobaeus left off– the abdominal entry.

The Continuation of Laparoscopy in Its Infancy
1) Nordentoeft 1912
2) Americans 1911

Severin Nordentoeft (also Nordentoft)
Danish surgeon Severin Nordentoeft, from the city of Aarhus, appears sporadically and mysteriously throughout the early years of the 20th century. Recent research by Kieser CW, Jackson RW has uncovered new information about his brief but important contributions to endoscopy, namely that he was the first to found the field of arthroscopy, and as well, was one of the earliest– after Jacobaeus and Bernheim– to successfully perform laparoscopies as early as 1912.

Arthroscopy – A Brand New Endoscopic Application is Realized
Nordentoeft is most important because he developed an entirely new application of the endoscope. Nordentoeft was one of the first to realize that endoscopy would facilitate the diagnosis orthopedic conditions, a procedure that became known as arthroscopy. To facilitate this work, Nordentoeft designed an endoscope reminiscent of the Jacobaeus-model thoracoscope; it was comprised of a fluid valve, trocar 5 mm in diameter, and an optic tube. He also made an innovative discovery to use a saline solution as the optical medium in order to help maximize visibility. With these innovations, Nordentoeft was able to capture exquisite visual detail of the anterior region of the knee. Regrettably, the record is not clear as to whether his descriptions were the result of working with live patients or with cadavers.

One of the other most astonishing facets uncovered about Nordentoeft was that he was among the earliest in 1912– just after Jacobaeus and Bernheim- to view pelvic organs with the scope using an abdominal approach. The details of his clinical work were outlined in a paper he presented to the 1912 German Society of Surgeons, held in Berlin, Nordentoeft, called “Endoscopy of Closed Cavities by the Means of My Trokart-Endoscope.” As well, he is credited for introducing the technique to American practitioners.

Orndoff, Ruddock and others would prove to rely peritoneoscopy a great deal (Orndoff 1920, Ruddock 1934). Also, though Ott was the first, Nordentoeft was an early advocate of the Trendelenberg position for endoscopic procedures. In addition, he also experimented with suprapubic cystoscopy. These modalities were less common, and so establishing their safety and efficacy during these formative years of laparoscopy were especially important.

Conclusion Nordentoeft
After Nordentoeft’s initial groundbreaking work with the scope, it seems he shifted his attention away from arthroscopy entirely and dedicated his energies instead to the field of radiotherapy, which was just beginning to develop as a promising specialty at the time. In fact today, Nordentoeft is recognized by Danish radiologists as a pioneer of x-ray therapies rather than endoscopy per se. Though his pioneering work in arthroscopy and laparoscopy has been largely overshadowed by the better-known work of Kelling and Jacobaeus, today we recognize Nordentoeft’s primacy in groundbreaking endoscopic efforts.

American Endoscopists Burst onto the Scene
Though many historians have referred to the 20th century as the American century, from the perspective of endoscopy, one would have been hard pressed to have come to such a conclusion. And given that the world was still facetiously referred to as Pax Brittanica, America certainly did not seem poised to take the helm as a superpower, much less the reins of endoscopy. However, American innovators were about to explode onto the scene, bringing with them even grander intrigues of the imagination. No doubt catalyzed by the great strides that German pioneers had made, a new generation of the Americans began one of their greatest eras of endoscopic ingenuity. After Kelling, Ott, and Jacobaeus, American gynecologists were some of the next to embrace the new field of laparoscopy, finally making laparoscopic gynecologic procedures visible on the horizon.

Bertram Bernheim
One of the most influential American endoscopic pioneers contemporaneous with Jacobeaus was Bertram M. Berheim, an assistant surgeon at Johns Hopkins University Hospital. Bernheim is the American pioneer credited with performing the first laparoscopy in the United States at John Hopkins in 1911, within just a year of Jacobaeus’ 1910 debut. Using a 12 mm proctoscope with a half-inch diameter, and ordinary light for illumination, Bernheim inserted the scope through an epigastric incision in order to inspect the peritoneal cavity of a jaundiced patient. Before learning of both Kelling’s and Jacobaeus’ prior work, Bernheim published his experiences, naming the procedure “organoscopy.” Bernheim stated that he believed the procedure had potential, but that his superiors at the hospital were not convinced of this apparently new-fangled technique and encouraged him to abandon the idea.

Nevertheless, Bernheim persisted and was one of the earliest in the States to provide detailed and quite fascinating accounts of his early experiences. Bernheim’s narrative was also one of the most conservative of voices in these early years. He cautioned endoscopists to proceed slowly and to take note of the very important contraindications. In one patient a diagnostic laparoscopy was performed on a patient with suspected carcinoma. The clinical results were mixed, which led Bernheim to forewarn of troubles concerning patients afflicted with cancerous conditions. For this patient, he failed to visualize the tip of the pancreas, which turned out to have been cancerous. Only upon examining the patient via open laparotomy, was the cancerous pancreatic tip found. Bernheim’s negative outcome for this case may have been influenced by the fact that he only suspected liver or gallbladder cancer, not pancreatic. Even so, Bernheim concluded that the pancreas was essentially inaccessible, noting that “obviously, a structure lying as deeply as the pancreas could not be inspected.” Aside from this near miss, Bernheim did eventually report that overall, the diagnostic success rate was very high for laparoscopy.

Bernheim’s well-respected and amply published successes helped to catalyze a new frontier in surgery, and he is recognized for his numerous contributions to both endoscopy and medicine in general. Not only did he do critical initial research in cardiovascular surgery and blood transfusion, he the first to perform a laparoscopy in America. However, with the disruption caused by WWI, Bernheim drifted away from laparoscopic surgery and leaned toward vascular surgery and biology. Rising to the rank of captain, he served the effort as operating surgeon.

Otto Steiner – 1924
We often keep them so interested in our description of their organs that they are quite amused.
–Otto Steiner, 1924

Otto Steiner’s 1924 publication on laparoscopy, what he termed “abnominoscopy” has been cited as an influential event which affirmed the scope as a tool of immense diagnostic value. Steiner practiced at Grady Hospital in Atlanta, Georgia. Perhaps no other article of this period offers the reader more poetry in its description of the method, which he believed he had been first to discover. Upon viewing the pelvic region for the first time, he said it was like “the fulfillment of a dream.” Of course, like Kelling and others at the time, the potential dangers associated with insufflation were apparently not understood. Concerning the process of filling the abdomen with atmospheric air, Steiner stated unequivocally, “At first we measure the quantity of air used, but we have found that this is unnecessary for the abdomen is not very sensitive to inflation and easily withstands the quantity of air necessary….” Steiner only used local anesthesia (novocaine), and again boldly stated that this was not a problem for his patients, even going so far as to say “We often keep them so interested in our description of their organs that they are quite amused.” The position of the patient was changed depending on what region he wanted to see, with at times even having the patient sit upright, but mostly horizontal, with a deeper than horizontal position (he did not use the term Trendelenberg) required to view the lower pelvis. In the end, he declared the procedure to be a method “not difficult, is not dangerous and does not require a special amount of skill. The examination can easily be done under local anesthesia.” He mentioned that the gynecologist would especially find the method of great value. The liver, stomach, spleen, appendix, pelvic region organs, and gallbladder, including the sounding for stones, were all visualized. He found the palpation of the organs with the scope to be the most important diagnostic benefit. The main drawback to Steiner’s article is the lack of clinical feedback about his patient trials. At first reading, one gets the impression that these experiments were only carried out on “fresh cadavers” as he described them. In any case, this article has gone down in the American history of laparoscopy as one that ignited (or re-ignited) great interest in the method.

Stewart and Stein
An article in 1924 by WE Stone of Topeka, Kansas mentions in passing that laparoscopy entered the US in 1919 by Stewart and Stein. Stein and Stewart reported early use of a radiological exam in 1919- 20, in which they insufflated the abdomen to obtain better radiological views.

Handy New Inventions
Despite all this flurry of activity, there were still tedious details to attend to, such as irrigation and insufflation problems that seemed to be pricking at the heels of the pioneers enough to make much of their attention have to be tied up with such dilemmas.

Albarran Lever – 1906
We can’t forget to mention J. Albarran and his 1897 catheter lever and the role he played in the advancement of catheterization. Albarran’s work replaced just about all other methods catheterizing of the ureter for his day. This Albarran lever made the ureterocystoscope generally more accepted, and practitioners like Nitze and Casper immediately adopted his invention into their own designs.

Otto Goetze – 1918 Goetze Developed an Automatic Pneumoperitoneum Needle
In 1918, Goetze developed an automatic pneumoperitoneum needle. This innovation was characterized for its safe introduction to the peritoneal cavity for use in diagnostic radiology. He suggested in an article entitled “Die neues Verfabren der Gasfullung fur das Pneumoperitoneum,” that the needle could be used in laparoscopic procedures.

Richard Zollikofer
Richard Zollikofer, a Swiss gynecologist, was one of the first to recognize the benefits of using carbon dioxide to create pneumoperitoneum and introduced his method for doing so in 1924; (other sources cite the date as 1920). This procedure could be performed in place of filtered air or oxygen because of its fast absorption and to minimize the risk of explosion. Later, JC Rubin in 1925 also used CO2 gas to distend the uterine cavity.

A Movie Star is Born: The Scope’s Screen Debut and the Continuation of Endo-Photography

Finally, we begin to see developing the great stir of interest brought about by the invention of cinema, a technology which completely changed the landscape of human cultures throughout the 20th century. The fantastical possibilities this represented for medicine was definitely not overlooked by our endoscopists of this era, who were some of the first indeed to adopt this new technology for medicine.

As it turned out of course, the endoscope was the perfect ham for the movie camera. Photogenic from any angle, slim and gleaming, she was just a knock- out on film. Of course, she was no match for living, pulsing internal viscera, a shoo-in to steal the show. Today, we can only imagine the awe-struck wonder it must have been like to see for the first time these images on screen. The medical literature of the era helps orient us to this time. We begin with the first documented case of a live endoscopic film.

To accommodate the growing interest in surgical endoscopy, this new generation of inventors also focused on trying to make the endoscope’s light source bright enough to allow for photographs to be taken inside the body cavity. There had been at this time at least a 30 years of surgical photography serving as historical precursor for early 20th century endoscopic photography.

In 1898, Lange and Meltzing designed the one of the very first flexible gastrocameras, publishing their results after using it on fifteen patients. True, this instrument did not have operative or diagnostic attachments; regardless, it is stunning to consider that a flexible scope was actually developed so many decades previous to the era of fiber optics. The invention of fiber optics did not occur until over fifty years later.

Soon after, fresh photographic wonders fell onto the scene one after the other, and by the beginning of the 20th century endo-photography became quite sophisticated. Other particularly significant highlights were: Felix Schlagintweit’s suprapubic photography in 1902, Casper’s photo and demonstration cystoscope in 1903, Jacoby’s sterocystoscopy in 1905, Hans Goldscmidt’s irrigation urethroscope complete with Nitze-camera in 1907, C. Benda’s color film and microscopic positive color pictures of the same year, Fr. Fromme’s female photocystoscope and color photograms of 1908, Otto Ringleb’s improved telescopes and cysto-photo apparatus of the same year.

Training as a Focal Point Just Developing
The split arm attachments not only held endo-photography equipment, but also were referred to sometimes as demonstrating devices, since the telescope end had two viewing stations. This was obviously beneficial when working with assistant surgeons and the like and an incredible foreshadowing of what we would eventually come to take for granted today; video endoscopy. The training devices available, bladder phantoms and other endoscopic training simulators, were on the market as early as 1887.