Society of Laparoscopic & Robotic Surgeons | Chapter 17

Chapter 17

1940’s

Introduction
“OK Einstein, so what’s the speed of dark?”
-Steven Wright

This period in time was indeed one characterized by “the speed of dark,” as the catastrophic events of World War II unfurled, leaving in its wake the deaths of nearly 50 million people worldwide. Naturally, for the medical community there were abrupt disruptions too, with many volunteering or recruited to serve as battlefield medics.

Despite the unspeakable devastations taking place, dedicated physicians from around the world still kept their patients the central focus of their lives. In fact, this era witnessed some of laparoscopy’s greatest pioneers, who carried on down the path which the 1930s generation of Kalk, Ruddock, and others had so firmly secured.

Gynecological Endoscopy
For gynecological laparoscopy, a striking divergence takes place between European and North American development. In this decade, we witness the beginning of a new trend in America, the rise of culdoscopy, while in Europe and elsewhere, the true laparoscopic approach remains the most popular. The next generation- Palmer, Decker, Power and Barnes, WB Normant for hysteroscopy, and many more– proved to be so influential, that their work would continue to shape the development of gynecological endoscopy for the next twenty years.

1940s Laparoscopy Stage Setting
We begin here where we left off in 1939, which was a time when the literature about laparoscopy was paradoxically lamenting its lack of broad acceptance on the one hand, while calling for practitioners to curb their enthusiasm on the other.

The calls for temperance were apparently the result of unexpectedly high rates of complications, such as cases of air embolism, which were more prevalent in a time before electronic monitoring systems. Such unpredictable complications may have been the crucial factor which led US physicians to adopt the alternative approach of culdoscopy, which required no insufflation or general anesthesia, which meant that it could be performed without the need for a hospital. This new endoscopic approach was advanced by Decker, whose 1944 article introduced the idea, along with his positive experiences with it. Laparoscopy couldn’t have been that entrenched at this time because culdoscopy easily displaced it within a decade of Decker’s 1944 debut. In fact, so popular was this new method that it essentially brought laparoscopy into a state of near extinction. Advances in other imaging technologies just emerging at this time, such as radiology and ultrasound, also helped to curtail interest.

Unfortunately too, economic concerns exert more influence over medicine than we would like to believe. This has been particularly true with laparoscopy, which required insufflation, expensive optics, general anesthesia (with some exceptions in its development) and a multitude of auxiliary instrumentation. During times of trouble, such as during the Great Depression and now, in the middle of World War II, such factors may have been perceived as rather exorbitant investments of time, money, and additional training to boot. Other forms of endoscopy (which didn’t need insufflation) continued to thrive and develop, especially endo-urology and gastro-esophagoscopy.

Whatever the causes were, what we do know is that between the 1939 peak in interest and until as late as 1966, there was a considerable decline in publications associated with laparoscopy, marking a distinct 25-year gap in its development in America.

Preface to Palmer
Ultimately, since the use of laparoscopic application in gynecology became less prevalent in the US, naturally technological developments specific for the laparoscope stagnated somewhat in the US. We therefore return to Europe, where the next great influx of innovation occurred.

Some of the biggest events in the beginning of the 1940s that helped our next generation of pioneers include the 1941 introduction of Brubaker and Holinger’s proximally placed magnesium flash bulb. This technology, with its brighter light, allowed for the first motion pictures of endoscopic surgeries to be achieved, with Brubaker and Holinger presenting in 1945 the world’s first ever motion picture of a live bronchoscopy. This was apparently the first or one of the first times that a proximally placed light had been reintroduced into endoscopy, the last time having been in Nitze’s time of the late 19th and early 20th century. The Brubaker system however was apparently not broadly adopted for routine use due to its extreme bulkiness and excess heat from the lighting.

Palmer (1904-1985)
How do we begin to tell the story of one of the 20th century’s greatest pioneers whose brilliant works shaped nearly thirty years of laparoscopic history? It is indeed an impossible task to attempt to capture all the visionary luster of Raoul Palmer, the Swedish-born French gynecologist whose laparoscopic legacy reaches near sainthood for those of us who were fortunate enough to have known him. At a loss for words, others refer to the phenomenon of Raoul Palmer as simply “the Palmer era.” Simply put, he was the man responsible for transforming just about every aspect of gynecologic laparoscopy and became one of the strongest influences in reviving and maintaining interest in gynecological laparoscopy. From his insightful change to the deep Trendenlenberg position, to his more accurate methods for monitoring the intra-abdominal pressure, Palmer changed laparoscopy from an occasionally performed technique to an absolutely indispensable means of obtaining invaluable diagnostic and therapeutic results. Palmer’s 1947 publication led to wide spread acceptance of laparoscopy in ob-gyn medicine, which launched a renaissance of discovery for Europe.

His summarized list of groundbreaking grand slams includes, for a start, being one of the fathers of gynecologic laparoscopy. Palmer earned this title by racking up an unwieldy list of accomplishments, including but definitely not limited to: bringing gynecological laparoscopy back to life in both Europe and America; the first to suggest safer methods and monitoring of insufflation; the first laparoscopic retrieval of ovocyte [1], the first to make true headway into achieving operative gynecologic procedures on a routine basis; and the first film of a live gynecological laparoscopic procedure [2].

To retrace these brilliant milestones in more detail, we begin with the year 1929, when Palmer began his medical career. In 1934 he was appointed head of gynaecological research at the Faculty of Medicine in Paris, and later in 1938 began working at Hospital Broca in Paris. He started his career as a demonstrator in the gynecology department, specializing as a fertility surgeon. Early on, Palmer was performing laparotomies for fertility concerns. An excellent account of these early years was retold by Manhes, who described the scene of Palmer’s formative years as follows:

“He immediately understood how imperfect and absolutely arbitrary was the way of diagnosing feminine pathologies, and saw instantly what a brilliant future there would be for laparoscopy. It inspired him with a belief to continue with dogged perseverance despite the criticism and sarcasm of his peers, to discover, design and invent new equipment and above all to create a ‘SCHOOL’ in his Faculty, where he trained innumerable disciples from all over the world.”

In other words, he was bothered that prior to the operation, he had no insight into the amount of lesions or locations of adhesions. This led him to devise his own procedure, dubbed “preoperative exploratory coelioscopy” beginning in 1943. It is amazing to think that Palmer was able to accomplish anything during this time, for he was situated right in the middle of World War II– in Paris- during the German occupation of France.

It was during this early 1940s period that Palmer also discovered the benefits of placing his patients in the deep Trendelenburg position and “mobilizing the uterus by means of a cannula inserted into it.” Like others before him, Palmer experimented with different techniques and technologies, even adopting briefly Decker’s culdoscopic procedure. However, having found that method quite inadequate for visualizing the pelvic organs, Palmer eventually discovered that the deep Trendelenburg position provided not only the greatest margin of safety for his patients, but also allowed much greater visualization of the pelvic organs. The position itself also acted as a natural means of insufflation by filling the pelvic with air.

Using the combination of these novel features, Palmer established his optimal pre-operative staging, which eventually led in the early 1960s to his performing operative procedures that had rarely been achieved, including most impressively the retrieval of ovocytes sometime in the year 1961 (some sources cite 1958) and tubal ligations beginning in 1962. Indeed, Palmer was one of the most influential pioneers in the area of laparoscopic sterilization. He contributed to the literature, and worked continuously toward improving the technique, using monopolar instrumentation at first, before bipolar methods had been perfected. Other operative procedures performed by Palmer in this manner include the electro-coagulate the uterine horns, draining of cysts, and lysis adhesions.

Palmer is also considered the first laparoscopists to recognize the critical importance of monitoring and controlling the pressure from insufflation. Kurt Semm drew considerable inspiration from Palmer’s work. Indeed, the physiological aspects of intra-abdominal pressure were so poorly understood, that the details were not really worked out until the 1960s. Prior to Palmer’s discovery, many patients were dying from air embolism caused by insufflation complications. Therefore, Palmer’s ability to accurately define the maximum units of tolerable pressure (25 mm Hg) was a much-needed improvement that made laparoscopies finally a much safer and more predictable surgical method. He also noted that this level had to be continuously maintained and monitored throughout the entire procedure, and that the speed of the insufflation should be limited to 400-500 cc per minute. No one before him came even close to making these discoveries [3]. Finally, he recognized the superiority of CO2 for insufflation and switched to that medium instead of the commonly used atmospheric oxygen.

Palmer also changed the approach of laparoscopy from the upper to lower abdomen. At first glance, this appeared to be a minor change, yet it turned out to increase safety by making bowel and major vessel perforations less likely. This was because, in combination with the deep T position, the bowel and other viscera fell forward toward the upper abdomen. In this way, the laparoscopist was able to make the trocar and veress needle entries with a greater degree of safety built in.

Palmer’s 1947 publication detailing these innovations and their use in his first 250 cases turned out to be a tremendous sensation throughout Europe and was highly influential in helping to get laparoscopy accepted into gynecological practices.

Palmer – 1950s
It seems one by one, Palmer began systematically addressing the laparoscope’s every last flaw, from minor annoyances to major impediments. The ovaries for a gynecologic laparoscopist were in the category of major; as in major impossibility. Like the pancreas to internists, the delicate (and sacred) ovarian ducts were deemed early on as too fragile for most forms of laparoscopic intervention, with the exception that some were able to drain ovarian cysts from time to time. Yet in 1958, Palmer made one of the most crucial breakthroughs for operative laparoscopy by introducing his specially designed forceps equipped with an electro-cautery component which could safely take ovarian biopsies. While there had been other forceps invented by this time, such as those by Ruddock, none had been designed with the delicate ovaries in mind. This instrument was later used by Palmer to perform tubal ligations, another breakthrough for the times (notwithstanding though Bosch’s introduction to this nearly two decades earlier). The forceps invention was said to have brought “immediate fame” to Palmer, apparently “in the US especially.” In this way, Palmer became among the few to have pushed the boundaries of what was thought possible for gynecologic operative laparoscopy.

First Ever to View a Human Ovocyte Laparoscopically
One of the most spectacular moments in laparoscopic history has got to be 1961, the year in which Palmer along with his colleague, R. Klein, became the first to laparoscopically view and retrieve an ovocyte in a living patient, which was later used for performing some of the earliest attempts at vitro fertilization. Steptoe in fact mentions being highly influenced by Palmer’s work in this field.

This achievement was a remarkable feat for the times and represented one of laparoscopy’s most critical turning points. Though Steptoe and Edwards received more attention for their efforts in retrieving a human ovocytes (because it resulted in the birth of Louise Brown), it is impressive to ponder that Palmer had achieved the necessary first step of retrieval for IVF purposes almost fifteen years earlier.

During the 1950s, many technological advances were made which Palmer was quick to adapt. Palmer cited the most important one as being the 1952 introduction of the quartz rods lighting, commenting “Laparoscopy became a practical method only when the illumination became 100 times more potent… this was first achieved in France with the Fourestier-Vulmiere instrumentation…”

Using this new light source, Palmer became one of the first to adapt the film and photographic technologies for use with the laparoscope, making his first color movie film of a live pelvic surgery in 1955. Palmer was also inventing and modifying new scopes, with one of his most impressive being a 5 mm scope, presented in 1957, which was one of the smallest in the market and which came equipped with the most powerful lens system available.

Conclusion Palmer – Palmer Helps Revitalize Laparoscopy in America
Palmer influenced not only his own generation, but also the next generation of endoscopists after him, including those who would be leaders of the 1960s- 1980s eras, such as Behrman, Melvin Cohen, Manhes, Richard Fikentscher, Patrick Steptoe, Robert Neuwirth, Jacques Rioux, and Victor Gomel. Each of these gynecologists visited Palmer in France and returned to their hometowns to help promote laparoscopic development in the US, Canada, and beyond. One source cites Cohen’s visit to Palmer in 1966 (and then subsequently sharing the technique with North Americans via demonstrations and publications) as being one of the most influential factors in revitalizing laparoscopy in America, which had been supplanted by culdoscopy at the time. His long-list of technical breakthroughs were unprecedented for the times. As well, Palmer was a prolific researcher, publishing in his lifetime over 800 articles and several books. Perhaps of most importance, Palmer is remembered as a beloved teacher and mentor whose generous spirit and genuine love of teaching ultimately served to indirectly influence the entire field of minimally invasive surgery.

DECKER
Introduction to Decker

By 1939, we have in America a confused and paradoxical picture of laparoscopy, with some pockets of exceptional progress, surrounded by other regions where the method was viewed with great circumspection– and misunderstanding.

Albert Decker and the Introduction of Culdoscopy
This hesitation in adopting laparoscopy– however so slight– left a wide opening for alternative diagnostics to be considered. This was indeed the perfect moment for Albert Decker to advance a new approach.

During the early part of Decker’s career at the Knickerbocker and Governor Hospital in New York, Decker had been taught the laparoscopic method for diagnosing the abdominal cavity. He worked with the technique for ten years, but eventually gave it up by 1938, even though he knew of Ruddock’s work and favorable results with it. The motivation behind Decker’s innovation stemmed from his concern about deaths and complications arising from insufflation and general anesthesia mishaps when performing laparoscopies. The general anesthesia was apparently his greatest concern, and since laparoscopy required its use, he needed to think of an alternative. He therefore conceived of a different approach for visualizing the lower abdominal cavity with introduction to an approach similar to Ott’s from 1901. This is interesting commentary, since the earliest 1930s reports about laparoscopy specifically mentioned that many of the physicians were using only local anesthesia. Perhaps sometime between 1928 and 1938, general anesthesia may have become the preferred method once it had been made safer.

At first it was difficult to gain proper visualization in the vaginal route due to the presence of the intestines. In order to overcome this problem Decker came up with various innovations, first experimenting with various positions, settling eventually on the knee-chest position, which then became one of the most popular methods in the US for the next 20 years. Incidentally, knee-chest positioning had been used as early as 1893, with French urologists and Howard Kelly being some of the earliest to use it in cystoscopic procedures.

Next, he designed his own scope, called the Decker Culdoscope, which was specialized for the vaginal technique. This instrument was essentially a modified laparoscope, which also utilized an optics component and trocar.

After World War II, Decker focused on promoting his technique to the world and began publishing several articles throughout the 1944-1952 time period. Even after his first publication on the subject in 1944, Decker’s work was fairly swiftly adopted throughout the US, and for a brief time too in Europe. By 1949, Decker’s procedure had become well known enough to warrant an editorial review in The Lancet, which gave the procedure a very positive rating, concluding that:

“…when one considers the frequency of errors in clinical diagnosis, the number of unnecessary laparotomies performed, and the temptation to radical surgery that exposure of the abdominal viscera presents, even the most conservative gynecologists will acknowledge that culdoscopy offers considerable advantages.”

Decker also followed up with extensive publications on the method and was able to extend the use beyond diagnostic and into more therapeutic uses, including aspiration of cysts. Later, Decker published a well-regarded textbook in 1952, titled “Culdoscopy: A New Technique in Gynecologic and Obstetric Diagnosis.” From all these threads of influence, Decker almost single-handedly changed the landscape of endoscopy in America. For the next twenty years his culdoscopic method dominated gynecologic endoscopy, nearly rendering laparoscopy extinct in America.

One of the First Motion Pictures of a Gynecologic Endoscopic Procedure
For a modern audience of gynecological laparoscopists, it’s tempting to skip the chapter on Decker and get back to the real deal. However, one of Decker’s groundbreaking achievements deserves our utmost attention; he became one of the earliest ever to produce live films of a gynecologic endoscopic procedure (in his case, a culdoscopic film). Dubbed cine culdoscopy, Decker attached a motion picture apparatus to his cystoscope and was able to capture some live films through the culdoscopic incision. In the end, he abandoned further work on the matter because the additional lights required had generated too much heat, causing tissue burns. Still, there are film archives of his work available today for viewing. Decker often worked together with his colleague Cherry and much of Decker’s work is reported as team of “Decker and Cherry.” Unfortunately for Decker’s legacy, his brilliant work in this area often gets overshadowed by the more prominent laparoscopic pioneers of this era.

Whether he intended to or not, Decker had actually started a revolution within a revolution. The culdoscopic approach, as it became known, would dominate American gynecology for more than two decades, with its peak during approximately 1950-1970, and fading out only in the late 1960s and early 1970s, when irrefutable evidence about the laparoscopic approach (now equipped with better technologies of course) began re-entering the literature and practices everywhere.

OTHER INNOVATIONS
Hysteroscopy

WB Normant (1943-1957) is considered the “father of American hysteroscopy.” He contributed greatly to the literature and expressed several controversial opinions, including saying that D&C was a blind procedure and therefore should only be done hysteroscopically.

Notes
1. There are conflicting reports on both if Palmer was able to actually achieve this, and if so, in which precise year.
2. We make a distinction here between Decker’s first film, which was made via culdoscopy and not laparoscopy.
3. Kelling’s work on matters of insufflation were so far off the mark, that we don’t mention them here.