Society of Laparoscopic & Robotic Surgeons | Chapter 20

Chapter 20


“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

Here we are again, pivoting upon an unmistakable turning point, where all the stars seemed aligned just so, just in favor for all things endoscopic. The momentum for the endoscope was simply brilliant. All manner of technology poured forth specific to the endoscope, a consequence of not only the great success of the late 1960s fiber optics revolution, but also the result of the outstanding innovations generated by that peerless class of 1960s pioneers who continued working their magic deep into the ‘70s and beyond. The laparoscopic retrieval of oocytes, tubal ligations, the first successful endoscopic removal of polyps from the entire colon, and so many more gynecological operative procedures were being routinely performed by this time. Some statistics report that even as early as 1971 between 6 or 7 million laparoscopies were being performed each year in the USA alone.

From the technological side, the gadgetry coming down the pike was nothing short of gorgeous genius: Hopkins lens, fiber optics (this time perfected), glitch-less bipolar generators, beaming lasers, and Semm’s CO2-automatic insufflator, just to name a few. TV cameras for documenting and teaching were now a fairly standard operating room companion and working to improve the outstanding visualization problems associated with these new technologies were a world class team of experts from companies like Storz, Olympus, ACMI, and Philips. It was as if we had left earth and had gone to endoscope heaven, where the prevailing law of physics dictated that all laparoscopic operative procedures were possible and a laparotomy turned out to be some mythological creature concocted by the ancients.

Stopping Just Short of True Operative Procedures (Exception Tubals)
Indeed, it seemed every imaginable ingredient was there for the offering. Yet, strangely, a peculiar reticence concerning operative endoscopy still weighed upon the times. Or perhaps more accurately, the idea simply had still not ripened enough to fall off the diagnostic tree. This holding back seems strangely familiar, no? We experienced this same anticlimactic disappointment in the 1930s, when the same on-the-verge feeling reached a great pinnacle, only to fall back upon a comfortable plateau. If there ever was one, the moment was exactly now, when ostensibly the laparoscope should have and could have bound from its shackles to take off toward its crowning glory– operative video endoscopy.

And you the reader, nearly defeated by the burden of hanging on for so long, waiting in exquisite impatience for the redemptive moment to unfold, for The Conclusion to come. Alas, it was not to be. We have to wait for what seems like an interminable time span of another ten years before that one grand moment arose.

A Stairway to Heaven
But don’t give up just yet, exhausted reader! Put the saddle back on, for there is still a glorious story to be told for this decade poised just before the great leap forward, one characterized by a good many great minds making great medical moments happen– with great music in the backdrop, even, to make the journey all the more pleasant. This was the era when the accumulation of knowledge, technology and clinical success for endoscopy had accreted to a point of no return, where one could see the hopeful future set atop the helm of an inevitable horizon.

1970s Influential Events in Gynecological Laparoscopy’s Return to Forefront
The dual technical breakthroughs of both fiber optics and the Hopkins lens revolutionized endoscopy. Even though both of these technologies were invented in the 1950s, they did not become fully incorporated into all endososcopic instrumentation until the late 1960s and early 1970s. Once they did finally trickle down, laparoscopy changed almost overnight. The new levels of visualization and illumination were simply phenomenal and these two technologies alone were the most crucial that endoscopy ever received in its entire history. Finally the laparoscopist could see clear and color-true images, with a breathtaking 3-D like field of vision with a depth of field never before imagined. Just as importantly, with the new “cold light” the risk of thermal injuries to the abdominal organs by incandescent light was eliminated. With these new miracle technologies now in place, diagnostic laparoscopy could truly and finally transform into its brighter and bigger future of advanced operative laparoscopy.

The 1970s Superstar – Laparoscopic Sterilizations
For gynecological laparoscopists, the early part of the 1970s was a time marked by great paradoxical events. On the one hand, by the mid-1970s training in laparoscopy had been added to “all major gynecologic residency programs” in Europe, with America following soon thereafter. Yet, the transition away from culdoscopy was still not complete. The success of laparoscopic tubal ligations was probably one of the most important factors to help precipitate the final closure to the culdosscopy era.

With the groundbreaking work by earlier pioneers such as Palmer, Frangenheim, Semm, Steptoe, Rioux and other, the use of laparoscopic tubal sterilizations had become fairly standardized within the first few years of the 1970s. In fact, most consider laparoscopic tubal ligations to have been the crucial development which initiated operative gynecological laparoscopy. By 1976, it was one of the most popular elective procedures in endoscopy, with reports showing that from 1971 to 1976, laparoscopic sterilizations increased from a mere 1% to an astonishing 60%. There was a heyday of new technologies and techniques in order to make the procedure safer and more reliable. In 1973 Rioux and Kleppinger introduced bipolar technique for sterilization because more cases of bowel injury were reported with the use of monopolar. Their invention significantly decreased the amount of complications associated with electro- cautery. Jaroslav Hulka and George Clemens developed mechanical means of sterilization, using a spring-loaded clip for laparoscopic applications. Today, laparoscopic sterilization by occlusive method is now the most popular method of interval sterilization.

The Rise of Superstar Complications
To rise to the top, you must first get to the bottom of things.
–Robert C. Savage

There is perhaps no other dreaded word in the English vocabulary for laparoscopists than “complications.” Yet, like any new medical discovery, complications will natural be an attendant part of the discovery process. A new breed of complications with the lap seemed to crop up with each new decade, as lap expanded into other fields and territories. One such complication which began to appear in the 1970s was sterilization problems, with growing mishaps involving tissue burns through unipolar. Semm reported that parallel to the rise in popularity of tubal ligations, in that same period, between 1971-1975, the failure rate of laparoscopic sterilizations (with mostly unipolar) reached as high as high 20% in Germany.

Bipolar – 1970s
Many were working feverishly to address the complication rates associated with tubal sterilizations, with bipolar and mechanical occlusion methods being the most important advances. Bipolar already had a long, though convoluted history. Some early forms of bipolar endoscopic instruments were available as early as the 1920s, especially in endo-urological devices. More modern forms were advanced as early as 1959 by Walz in Germany. Yet it took another almost 15 years for the technology to be adopted for tubal sterilizations. Until the mid-1970s, unipolar electrocoagulators continued to be used, especially in the US, despite a significant degree of complications arising from tissue burn. In 1973, bipolar technology was finally developed and adapted for use with laparoscopic surgery by three or four independent sources; Rioux and Cloutier in approximately 1974, Kleppinger, and Hirsch. A fourth pioneer named Stephen L. Corson has also been cited for contributing to the development of bipolar dividing forceps. Rioux was particularly upset about all the overlooked problems with the existing technologies. In an article on the subject he wrote, “The authors being unable to accept the indifference with which complications are reported, and realizing that they will happen in spite of all recommendations, developed a new instrument.”

Rise of Organizations and Training Centers
Based on such an explosion of growth that occurred for gynecological laparoscopy, including concerns about the attendant rise in complications, it was indeed time for an organization to help guide the way. This is precisely what Jordan Philips believed was needed for gynecological laparoscopists and in 1972 he founded AAGL, which has now become one of the most prominent.

The first AAGL conference held in Las Vegas was a smash hit and served to drum up even more positive attention for laparoscopy. At this 1972 meeting, Frangeheim presented his video which laparoscopically captured an ovulation occurring, which became a pivotal moment for many in the audience who were witnessing these advances for the first time. ACOG President Keith Russell attended this meeting and gave a warm welcome to AAGL for its role as a vital new organization.

Hands-on training courses also blossomed, with Gomel and Rioux offering some of the earliest in 1970. Jan Berhman of University of Michigan was also involved in the earliest training courses, as was Semm with his introduction of the Pelvic-trainer in the early 1980s, which was an ingenious invention for accelerating the learning curve even more.