Chapter 19 - Society of Laparoscopic & Robotic Surgeons

Chapter 19


Last season’s fruit is eaten. And the full-fed beast shall kick the empty pail. For last year’s words belong to last year’s language and next year’s words await another voice.
–TS Elliot

There are no words left to describe the 1960s; everything important has been said or sung. The voice of a new language reverberated through the air, awakening a dream for the world where human rights would finally reign free. As for the revolution that was about to hit endoscopy, the great 1950s technological coup that was fiber optics was without doubt the most important catalyst. Yet technology alone can’t talk or walk; it needed the great vision of men and women who saw the great potential it represented and brought it into living color. To these pioneers, we turn now, which brings us precisely to 1960, the year in which so many extraordinary things were achieved that we can only touch upon some of the most salient moments.

Gynecologic Laparoscopy
Gynecologic laparoscopy had been growing steadily since the beginning of the 20th century. By this time however, endoscopy needed a new generation of pioneers to help force progress in the field to the next level. Building off of the earlier work by the previous decade’s pioneers, such as Frangenheim and Palmer, and Albano and Cittadini of Italy, the next generation had a great body of experience from which to draw. We start the decade off with the incomprehensibly brilliant, Kurt Semm.

Semm Introduction
Being charged with the task of summarizing Kurt Semm’s extraordinary life in only a short space is practically cruel and unusual punishment since such a feat is essentially a sheer impossibility; Semm’s breathtaking achievements simply fall outside the grasp of language. Indeed, others have found themselves at a loss for meaningful words too and have resorted to mythical terms to describe his work, designating Semm “the Magician from Kiel.” What we can say for certain is that Kurt Semm goes down in history as one of the most critically- acclaimed fathers of laparoscopy, one of the most influential the world has ever seen.

The full scope of his contributions can barely fit into any one category, but his main works fall into the category of outstanding engineering inventions and unprecedented firsts in advanced operative laparoscopy. His most intangible legacy– courageous advocacy of laparoscopy– is perhaps the most unforgettable essence of Semm, and is the part which will live on in our hearts forever.

Germany 1956–1961 – Series of Bans on Laparoscopic Instruments

1961 proved to be a critical moment in Germany, as the laparoscopy experienced a great fall from grace when the German Federal medical institutions actually enacted a total ban on its use, proclaiming it to be a “prohibitively hazardous procedure.” The problems had started earlier in 1956 when Germany’s VDE prohibited use of distal electronic flash devices in laparoscopes for reasons of safety. Later, the ban extended to all laparoscopic devices with electronic components (which meant all of them at this stage).

With improvements to the component technologies of the laparoscope, a lifting of the ban in 1964 temporarily eased the use of the laparoscope back into Germany, although the damage to its reputation had been done; for the next several years, in a sort of unspoken manner, it was confined back to its role as an almost exclusively diagnostic procedure.

The moment of Semm’s arrival onto the scene was therefore complicated by these undercurrents of tension. Even so, the time frame of 1965 onward is considered as the great turning point for laparoscopy’s slow journey back into a place of acceptance. Semm’s role in making this underdog story transform into that of a hero’s was absolutely critical.

Enter Semm, 1965:
Hot on the heels of a temporary German ban on the laparoscope in 1961, Kurt Semm would rise in the medical field as one of its most vocal and unwavering supporters. Despite the extraordinary – and life-saving– innovations he advanced, many tried to discredit the outcome of his work.

Part of the reason for the German ban on laparoscopy had related to complications arising from both faulty insufflators, as well as from the monopolar electro-cautery units used in early generation laparoscopic tubal ligations. It was Semm’s personal mission to address both of these serious flaws in the laparoscope’s design.

1966 – Automatic Insufflator
In Semm’s view, laparoscopy was not accepted by many due especially to the uncontrollable and unpredictable complications associated with insufflation. His design principles were inspired in part by the outstanding work of Palmer on this very issue. After numerous rounds of tinkering, his experience with this device was published in 1966. Semm’s CO2-pneu machine was an electronic insufflator which facilitated complex procedures’ technical resemblance to general surgery, which made creating a distended abdomen much more precise and safe. It also was capable of monitoring intra-abdominal pressures with an unprecedented degree of precision. Ultimately, this translated into safer laparoscopy, which helped reduce instances of bowel perforations and retroperitoneal vascular injuries.

Many of the early American pioneers in the 1960s, including Cohen, adapted Semm’s instrument into their own practices and thereafter were able to perform significantly safer and less cumbersome procedures. Many believe that this particular innovation, introduced at this most critical time of 1966, was very influential in getting laparoscopy accepted and reestablished in America.

New Thermo-Coagulator
As for the problem of tissue burning during laparoscopic sterilization, Semm took a most thorough approach, investigating every aspect of the dilemma. After an extended period of experiment and analysis, Semm reported on a new method to the AAGL in New Orleans in 1973. The defining feature of Semm’s device was that it produced a constant low current (aka, radio currents, thermal). Radio frequency waves such as this had been used in endoscopic surgeries in some cases as early as the 1910s. This type of current was later re- introduced to endoscopy by most notably, Max Stern in 1926. Based on some of these earlier design principles, Semm made significant improvements and customized the device for tubal ligations. The current was 140 degrees and there would be localized and controlled application; he claimed to have performed nearly 300 procedures using this new style. It also was able to coagulate hemostasis at 100 degrees Celsius. This innovation was said to have revolutionized laparoscopic surgery by virtually eliminating thermal injuries. In 1967 Semm reported his own series of successful laparoscopic tubal ligations, which generated a great deal of interest in the subject finally too in the United States.

For Semm, this was but a start. He became a staunch supporter and promoter of thermo-coagulation, not only publishing a number of articles in both English and German on the subject, but devoting much of his text, Pelviscopy and Hysteroscopy, to it as well.

At this juncture, Semm’s demonstrated great confidence, a symbol to the reality he already could envision for laparoscopy. In the text From Laparoscopy to Pelviscopy, Semm announced: “The procedures presented in this operative manual are just the beginning of this new surgical era and will stimulate the development of numerous variations.”

In 1973, Semm made for another crucial turning point: the development of extracorporeal and intracorporeal knots, the first glimpse of advanced operative laparoscopy’s future suture. The specific invention here was the loop applicator, a Roeder Loop into a 5 mm trocar, and within a year of its introduction, Semm had incorporated its use as a routine procedure in his clinic.

An inventive outpour ensued from Semm, with the following inventions: an aqua-purator, which switches back and forth between aspiration and insufflation of physiologic saline solution, the high-volume irrigation/aspiration system; a perfected EndoLoop applicator; and a tissue morcellator, capable of morcellating large fibroids for the first time laparoscopically.

Despite the increased level of safety that all of Semm’s inventions ultimately brought to laparoscopy, accolades for his work were far from unanimous. For many surgeons, there is nothing more aggravating and offensive than a colleague who is not only prolific but also boisterous. Once more, Semm’s “new surgical era” would require a vast kennel of old dogs to learn new tricks. Indeed, general surgeons in particular were appalled at the idea of a gynecologist teaching “real” surgeons how to operate.

Although Semm was essentially not recognized in his own land, on the other side of the Atlantic, both American physicians and instrument makers valued his inventions for their simple application, clinical value, and safety.

Unfortunately, as this technique became more popular the rise in complications also increased. The need for better tools and better teaching was at hand. To meet this need Jordan M. Phillips founded the American Association of Gynecological Laparoscopists in 1971.

First Time Ever – Advanced Operative Procedures
Semm was the first pioneer to truly establish advanced operative laparoscopy. Semm adapted numerous surgical procedures to laparoscopic techniques, including tubal sterilization, salpingostomy, oophorectomy, salpingolysis, and tumor reduction therapy. Semm even popularized laparoscopic procedures outside of gynecology, such as omental adhesiolysis, bowel suturing, tumor biopsy and staging.

Almost Removed from the German Physician Society
By far, his greatest and most well-known “first ever” for advanced operative laparoscopy was the first completely laparoscopic removal of the appendix, performed by Semm on September 12, 1980, in Kiel.
The description of his technique was as follows:

“The technique, recommended only for non-acute cases, consisted of an extracorporeal ligation of the mesoappendix with endoscopic ligation of the appendix with a pretied loop. The appendix was transected across its base with electrocautery. Laparoscopy subsequently became a practical and popular technique for the evaluation and treatment of right lower quadrant pain in females, utilized by general and gynecologic surgeons alike.”

No one could believe this was possible at the time and as a result, Semm was unable to publish his surgical breakthrough in the hostile environment within the community of general surgeons in Germany. In fact, those who did not personally witness the work of the “Magician of Kiel,” accused Semm of pathological hoaxing. The seemingly superhuman quantity of operations Semm claimed to have performed insulted the intelligence of a great majority in the medical community. The open disgust extended to Frangenheim himself, a predecessor that Semm naturally had studied and admired. In true full scale academic brawl formality, Frangenheim published extensively against Semm and his methods, and Semm gladly responded in print and speech as well. Worse still, many apparently requested his banishment from the German Physician’s Society.

Indeed, the media had a field day with this feud. Personal altercations between the two men were published in widely read medical journals. The laparoscopic world was entrenched in heated and all too personal rivalry. With Frangheim’s influence, countless Semm writing’s were categorically denied publication. Again, media and the forces behind it were inappropriately interfering with medical progress and subsequent discussion (However, to his detractors’ credit, they were at least mainly motivated by the belief that Semm’s claims and instructions were dangerous).

Strong willed and not afraid to fight for what he knew was right, Semm stood his ground and forced a reckoning with what ultimately would become the greatest revolution in 20th century surgical history; that of the minimally invasive movement. Throughout his entire career, at one point or another, Semm had to fight skepticism in order to promote laparoscopic surgery as a method of lessening pain and trauma in infertility patients.

Conclusion Semm – Lifetime of Advocacy
Semm’s gifts were legendary and he lives on today in the sense that now all endoscopists are converts to advanced operative endoscopy, which became a reality through his visionary force and passionate advocacy. Even when the naysayers were practically beating down the doors of the OR to halt laparoscopy’s progress, Semm was there, defending at the trenches until the very last moment. Indeed, at the close of the 1970s, it was clear that operative laparoscopy had past the point of return from its humble origins as a diagnostic device; for this profound transformation an incalculable degree of credit goes to Kurt Semm.

1964 – First International Symposium of Gynecological Endoscopists
A true turning point for laparoscopy was the inauguration of the first world congress specifically in its honor. The 1964 first International Symposium of Gynecological Endoscopists, held in Italy, was said to have touched off a brilliant renaissance throughout the world, with the participants returning to their home countries transfixed with the dream of a new horizon.

The Legacy of Karl Storz – Engineering Endoscopic Magic

The story of minimally invasive surgery is utterly incomplete without mentioning the substantial contributions from Dr. Karl Storz, one of its most outstanding pioneers. Inventor, entrepreneur, engineer, and so much more, it would take more than one lifetime for anyone to come close to achieving the life works of Dr. Karl Storz. His business acumen and technical savvy are the stuff of legends, which, combined with his humility and charismatic personality, set in motion many firsts and turning points for the minimally invasive movement. With Storz’ pioneering insight, he changed endoscopy forever with such groundbreaking firsts as cold light technology, the production of the Hopkins rod lens, and extracorporeal light systems for video applications, just to name a few. Add these facts to the over 400 patents realized by Storz in his lifetime, along with over 1700 employees across the world now producing 7000 products, and one begins to realize that the title “instrument maker” does little to capture the depth and breadth of his life works.

From the Beginning – Humility and Hard Work
To think that the making of such a remarkable man began in such a small town as Tuttlingen, Germany, tucked away off the upper Danube valley, is quite heartening for all of us small town folk. Today of course, Tuttlingen now holds special preeminence as one of the leading medical engineering centers of the world. Yet at the start of Storz’ career, France, and other larger cities of Germany, such as Leipzig, were considered the leaders in the field of medical engineering. Yet, such daunting details were no match for Storz’ immense inner drive. From the very beginning, he was impassioned with the idea of excellence in his craft, understanding early on that he was not just dealing with a commercial enterprise, but rather, that every detail was integral to the very life and health of millions of patients everywhere. Even as a young apprentice, Storz made a practice of studying cover to cover the instrument catalogues of competitors, in an attempt to gain insight into the shortcomings of the current technologies so that he could then improve upon them. Later, when running his own company, Storz’ unwavering commitment to quality continued to be apparent in every nuance of his work. When asked in a 1996 interview about the initial phase of rapid growth his family-run business experienced, Storz demonstrated this commitment to perfection over profit when he explained that “At no time during that phase did we expand to the detriment of quality however.” He even made the difficult decision to “turn away potential business” if it meant that quality would suffer. And later, when referring to his practice of loaning instruments out without charge, he stated again that “Money was never allowed to be the first consideration. That was our guiding principle. The instruments had to be there to help the physicians to do their job. The rest then followed on its own accord.”

“The Optimal Fulfillment of Customers’ Needs” – The Storz Motto
And the rest that followed was indeed spectacular. From a purely business perspective, the tenets of sound management that Storz established from the earliest moments of his life reflect a level of wisdom and leadership that would serve as an exemplary case study for today’s young MBA students to follow. The tremendous and long-standing success of his family company, which today continues its tradition of excellence as led by his daughter, Sybill Storz and her son, Karl Christian Storz, can be traced back to several of Storz’ original guiding principles. Though it might sound cliché today, Storz truly put into practice the philosophy of customer first. This was no empty promise however. What this meant in practice was that Storz committed his time, energy, and resources to meet face to face with physicians from all over the world, flying all over the world attending their conferences, congresses, and of course, the operating room. Today this may seem a commonplace practice. However, during Storz’ time, instrument makers rarely took on this responsibility, instead leaving the investigation of physician’s needs up to middlemen or “dealers” as Storz described them. With remarkable acumen and unshakable conviction, Storz rejected this model of doing business. He recognized early on that being in touch with the physicians directly would help him understand what their needs and concerns were. And being a highly sensitive and astute learner, he was able to grasp the finest nuances communicated to him, illuminating for him the core of even the most difficult technical problems, which naturally helped him come up with innovative solutions.

The second guiding principle that Storz followed throughout his life was extraordinary level of personal integrity and generosity of spirit. These qualities permeated his every business dealing, and were especially apparent in the way he respected and nurtured his many employees. Long before it was fashionable to do so, he recognized his employees as being the most integral part of the company success. As a testament to this spirit of generosity, by the late 1990s, many of his employees had been with him for up to thirty years. Well ahead of the times, Storz offered his employees training, ergonomic factories, and insisted on keeping their manufacturing jobs right in Tuttlingen, even during the times when so many others were outsourcing to areas where labor costs were cheaper. When asked about the pressures pertaining to profit margins, he responded with his usual steadfastness of character by stating that as “a conscientious manufacturer,” there was simply “no room for the phrase ‘a quick profit’ in a medical instruments company.” Driven by such a values-centric business model helps to explain the level of trust, respect, and admiration he earned throughout the years from those with whom he worked. This legacy carries on today, as the name Storz is synonymous with unmatched quality and integrity.

The third quality embodied in Storz’ business philosophy was his strong commitment to continued research and development. This was one of the main driving forces behind his ability to be the first to market in the cutting-edge technologies that were so rapidly developing during the 1950s-1970s. He often referred to his commitment to research and development as one rooted in humility, which allows one to keep an open mind and therefore continue to learn and improve. One of the best examples of this was his early recognition and promotion of Harold Hopkin’s rod lens optical system. Several of the top instrument makers of the day actually turned down the now famous Hopkins’ telescope. Yet, in the first meeting with Hopkins and in viewing the early prototype, Storz immediately knew that this new technology would revolutionize endoscopy and commenced immediately with a licensing agreement and production.

Finally, one of the most essential ingredients to a successful enterprise is passion. And for Storz, this was indeed one of his most endearing of traits. It was this quality especially that kept him going during the difficult times right after the Second World War when he was just getting started. Down to the tiniest detail, Storz was enthralled with all aspects of his work, from the great wonders of medicine, to optics and lighting and employee satisfaction. Upon viewing the image presented from one of his newly minted Hopkins endoscopes, he recalls saying to his employees in his playful banter “Anyone who isn’t pleased with an image like that must be lacking in something.”

Prescience Personified
It is easy to get carried away with Storz’ incredible talent at business leadership and forget to mention his remarkable gifts of ingenuity and technical expertise. Yet, behind the scenes of the everyday operations was also a man keenly active in analyzing and engineering solutions to the technical shortcomings that plagued endoscopy in its early days. Naturally, with over 400 patents, in this brief précis, we can only touch upon the very tip of his tremendous intellectual outpourings. However, his invention of what is called “cold light” stands out as one of endoscopy’s most profound and revolutionizing contributions. Alone, this one technology reshaped the entire landscape of endoscopy and pushed it toward its true potential as an operative force. Without the cold light, the development of video technologies would have been significantly delayed.

His insight into the problem was certainly no accident. He understood from the very beginning of his career that the lack of intense (but cold) light was hindering the ability of endoscopists to move beyond simple diagnostics and into the realm of operative use. Just in understanding that endoscopy had the potential to move into an operative role was a unique accomplishment in and of itself, for many surgeons at the time were staunchly opposed to this idea in principle. Nevertheless, Storz was quick to grasp the significance of endoscopy’s potential, and was especially excited about the bundling of endoscopes with the latest television, film, and photographic technologies that were exploding onto the scene in the late 1950s. With the introduction of fiber optics, which was a technology initially recruited to transmit only images, Storz realized that the fiber bundles could also be used to transmit the long-sought cold, yet intensely bright, light source. Using the existing technologies of quartz rods to magnify the light sources of his specially designed extracorporeal flash systems, Storz engineered the first working endoscope bundled with both his Hopkins lens and the re-engineered fiber optics bundles, all of which in the aggregate permitted the most astonishing precise images ever achieved at that time.

And thus the cold light revolution was born. This one innovation enabled for the first time film and photographs to finally be captured which were actually of high resolution and therefore of clinical value. Many films and photographs had been made prior to Storz’ discovery, but because the light sources had been either too hot or too weak, the consequent poor resolution of the images captured simply rendered these nascent technologies mere novelties. As well, patient safety was vastly improved, since the now reliable extracorporeal light source could finally replace other systems which had simultaneously generated too much heat and/or too little light, all of which contributed to less accurate diagnoses and more chance for complications. Storz’ invention stands out as one of endoscopy’s greatest innovations, which in turn helped launch endoscopy’s migration from mere diagnostics to its stately form as an operative application.

Storz always acknowledged the role his family played, particularly his father, in shaping his strength of character, which ultimately served as the foundation for his life of integrity and success. In one of his last interviews in 1996, Storz expressed with tremendous pride just what great joy he felt in keeping that tradition alive by having his daughters by his side who today keep alive the shining legacy of his exemplary life. Storz’ deep dedication to his employees also lives on in the form of the University Vocational training program that he and his family built right there in Tuttlingen, so that not only his local German brethren, but international students as well, could continue to prosper and feel pride in being a part of such a unique and profound heritage.

More 1960s Pioneers and Developments
The broad acceptance of lap at this time was also influenced a great deal by many others in Europe, including Albano and Cittadini of Italy, who began their trailblazing work in the 1960s, and published a very influential article in 1967 and in 1972, published their textbook which became well known in Europe. Albano and Cittadini were present at the first International Symposium of Gynecological endoscopists held in Italy in 1964. Thoyer-Rozat of France was one of the world’s most influential laparoscopists throughout the 1960s and 1970s, with well-known publications and also one of the earliest textbooks for gynecological laparoscopy; Steptoe was also already working in the 1960s on techniques that would soon mesmerize the world. In 1967 Steptoe published the first textbook on laparoscopy written in English. It was widely disseminated and was another key factor that influenced Americans to defect from their culdoscopic ways.

Cohen and the American Re-Awakening – Back on the Saddle Again

The reintroduction of laparoscopy into the United States was said to have occurred sometime in either 1967, a year marking the resurrection from near extinction during the near twenty-year reign of culdoscopy. It was a true underdog moment of triumph and stands as one of the greatest turning points in American laparoscopic history. There, at the helm of this great second renaissance was Melvin Cohen, a gynecologist hailing from the Chicago School of Medicine, whose lifetime of innovations, advocacy, and clinical earned him the title as one of the fathers of the American laparoscopy movement.

Cohen’s tireless advocacy of laparoscopy began with his seminal 1967 report, considered one of the most well-articulated and well-circulated articles comparing culdoscopy to laparoscopy. The results of his exhaustive studies between the two approaches were absolutely striking and exposed a great deal of culdoscopy’s inherent limitations, leading Cohen to conclude that laparoscopy was without question the safer and superior approach for all gynecological procedures. This was a stunning upset for culdoscopy, which had enjoyed an unquestioned lead for so long.

One of First to Combine Television, Film to Endoscopy in the 1950s
Although best known for his brilliant clinical work and reintroduction of laparoscopy in the 1960s, Cohen had actually been on the cutting edge of things as early as the 1950s. In fact, Cohen was one of the earliest to be involved in expanding the use of television and video for endoscopic applications. In 1953, Cohen and Guteman introduced one of the earliest photographic and motion picture systems to be applied to endoscopes. Called the “Cameron” and also the “cavicamera,” these innovations were brilliantly conceived and highly influential in multiple endoscopic fields.

The Famous Visit to Palmer in 1966
Cohen’s journey in rediscovering laparoscopy began when he visited Palmer at Hospital Broca in 1966. Still, after just one visit to Palmer in 1966, Cohen was hooked. Within one year of that life-changing meeting, he published his groundbreaking 1967 article.

Revolution in Rewind
“When we first saw the beautiful view of the total pelvis and abdomen, afforded by laparoscopy we thought we had “died and gone to heaven.”
-Raymond Reilly, Brigham Young University, 1972

For Cohen, the several years it took to convince gynecologists of the laparoscope’s value must have felt like a revolution gone awry. The process of winning converts was definitely not a swift one. It was so clear to him, so clear to what seemed like all of Europe, it must have been nearly maddening to experience the great indifference the Americans were expressing. He tried in vain to get gynecologists to see that laparoscopy provided better results that culdoscopy.

The Great Defections
There were some converts beginning to surface in the late 1960s. The experience of Ronn Batt of Buffalo, New York, provides an excellent example of how some gynecologists really did get it and made almost immediate changes to their practices to accommodate laparoscopy. Batt had engaged in training in operative culdoscopy between 1966-1969, and had as a handy saying back then “have culdoscope, will travel.” Yet, after discovering Steptoe’s textbook on laparoscopy, which came out in 1967, and after additional training sessions in laparoscopy with Jan Behrman at the University of Michigan, Batt almost immediately switched over (or shall we say back?) to laparoscopy by the end of 1969; a transition of only a couple of years after seeing the publications, demonstrations, and textbooks.

Fear and Siegler
Alvin Siegler, in 1969, practicing in Brooklyn, New York, also reports on the very positive results he obtained with using laparoscopy to perform 114 successful diagnostic and operative laparoscopies, 44 of which were tubal ligations. He also mentioned that laparoscopy had not yet gained “wide acceptance” in America, despite what he strongly believed to be a clearly superior procedure than any other method. Like Batt, Siegler also refers to European works as being influential in his adopting the technique, mentioning in particular Steptoe, Sjovall, and Thoyer-Rozat. Siegler also notes how easy it is to obtain excellent photographs using the laparoscopic approach. As a convert, Siegler’s perspective is interesting to note during this time when rekindled belief about laparoscopy was just beginning to trickle in.

Yet, the quick transitions of Batt, Fear and Siegler appeared to be rather unique. There were deep thickets of culdoscopy hold-outs well into the 1970s. One of the best comments to illustrate this comes from Raymond Reilly of Brigham Young University, who recalled his first experience with laparoscopy, which took place only in 1972, with the memorable remarks: “When we first saw the beautiful view of the total pelvis and abdomen afforded by laparoscopy we thought we had died and gone to heaven.”

This delay in adopting new (or even in this case re-introduced) technologies is not too surprising actually. Firstly, adopting laparoscopy meant that gynecologists had to have access to operating rooms in fully-equipped hospital settings. Culdoscopy on the other hand, was a method that had been performed without general anesthesia or insufflation, attractive features for those in private practice who may not have had access to hospital privileges. The innovation by Clyman’s improvements to the culdoscope, along with his advances in operative culdoscopy also helped to reinvigorate interest in the procedure. Clyman in fact was part of a small but influential group of leading culdoscopists, which included himself and Decker, as well as Balin and Willson, and Telinde, whose collective publications were widely respected.

As for other hindrances to accepting the new method, there was also the issue of re-training, which most established physicians are loathe to undertake, given the enormous disruptions it was perceived to have on one’s practice. In short, it wasn’t looking like a clear-cut victory for the lap, even as late as 1972.

Conclusion Cohen
Of course, we all know the happy ending to this particular tale. In the end, Cohen’s advocacy and work was not in vain. His clinical experiences with laparoscopy translated into a series of well-regarded studies and textbooks, all of which eventually did serve to change the hearts and minds of the Americans. At the end of the day, it is clear that Melvin Cohen became one of the most influential catalysts for putting laparoscopy back in the American saddle.

Robert E. Fear, Capt, MC, USAF
“It is accepted by the patient far more often than exploratory laparotomy and, especially culdoscopy.”
–Fear, 1968, comparing laparoscopy to both laparotomy and culdoscopy

This great reawakening was also catalyzed by others in the United States who were in the same camp as Cohen in noting the baffling phenomenon of the decided disinterest in the laparoscopic method. Fear addresses this problem head-on in the first paragraph of his article on the subject, published in 1968. There are no minced words here, and you can almost hear his exasperated tone when he states:

“The Laparoscope is a precise diagnostic tool which should have a much more prominent place in American gynecology than it has at the present time. With modern optical systems, high intensity fiber-optic light sources, and convenient means of inducing and maintinga pneumoperitoneum, the instrument represents a precise, safe and acceptable a means of evaluating the gynecologic patient as is available today.”

One of the most interesting aspects about this article by Fear is that, for one of the first times in the century, the patient’s perspective about these varying options is brought into the dialogue, stating, again with a bit of a rhetorical whip to it:

“It is accepted by the patient far more often than exploratory laparotomy and, especially culdoscopy.”

In the final analysis, Fear does get to see the brilliant rebirth of laparoscopy, although we would still have to wait several more years for its true moment in the sun.