Society of Laparoscopic & Robotic Surgeons | Chapter 22

Chapter 22

Nezhat & the Rise of Advanced Operative Video-Laparoscopy

Chapter by Barbara Page

Unreasonableness Redefined
The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.
-George Bernard Shaw

One of the greatest transformations within the history of surgery has been the paradigmatic shift away from open surgery and into the realm of operative video-laparoscopy, an approach which truly captured all that minimally invasive surgery was meant to mean. Many have described the advent of operative video-laparoscopy as a change to surgery as “revolutionary to this century as the development of anesthesia was to the last century.”

Indeed, video-endoscopy is today the most common surgical procedure performed by gynecologists, colonoscopists, and gastroendoscopists. As for our own discipline, gynecologic laparoscopists were some of the earliest believers in the new way. By 1986, it was estimated that more than one million laparoscopic sterilizations were being performed in the U.S. alone. Today, gynecologic operative video-laparoscopy has freed millions of women from the era when debilitating, multiple laparotomies were the norm for even mild pelvic pathologies.

Nezhat and the Advent of Advanced Operative Video-Laparoscopy
However, getting to this point of general acceptance– a process which isn’t even complete yet– actually took years of persistent insistence. Some have called video endoscopy “an overnight surgical sensation that was 75 years in the making.”

To actually breathe life into video-laparoscopy, an entirely new way of operating had to be envisioned and accepted into the fold of convention. Yet, to convince an entire surgical discipline to re-learn how to perform surgery was no walk in the park. We all know, of course, that attempting to convince surgeons to do anything against their will is a headache in the making. But especially to force upon their heads a change so radical– that of shifting their sacred line of vision– was like courting a collision with catastrophe.

An outsized catalyst was needed to rend surgeons loose from the mighty clasp of custom. It was Camran Nezhat, considered the founding “father” of operative video-laparoscopy, who would use his visionary foresight and virtuoso surgical skill to bring this concept clamoring out of its dream-state and headlong into the realm of reality.

To achieve this, Nezhat rigged together video cameras intended for other uses and began operating off the monitor in the late 1970’s, which then allowed him to perform advanced procedures never before done by the laparoscope. By operating off the monitor, for the first time, laparoscopic treatment of extensive endometriosis involving extragenital organs was shown to be possible when Nezhat presented his work at the Annual Meeting of the American Fertility Society in 1985. A year later, his early clinical results on the subject were published in the Journal of Fertility & Sterility under the title “Laser Laparoscopy for the Treatment of Endometriosis.” After demonstrating the safety and feasibility of performing these complicated surgeries laparoscopically, Nezhat predicted in this article that if such a complicated and extensive disease as endometriosis could be treated laparoscopically, then almost all other pathologies could be managed in that way too, as long as a body cavity existed or could be created.

Prior to this innovation of operating off the monitor, the old way of peering through the scope directly rather than a TV screen presented inherent disadvantages of back strain for the operating physician and poor visualization of the peritoneal structure due to use of one eye through a narrow aperture. Video-laseroscopy refined the laparoscopic process by empowering the surgeon with the capacity to operate in a vertical position, to observe an enhanced field of vision upon the video monitor, and a reduction of back-strain and eye-fatigue encountered while operating directly through the laparoscope.

When all was said and done, Nezhat’s conceptual breakthrough would revolutionize modern abdominal and pelvic surgery, overturning in its wake almost 200 years of endoscopic tradition. Talk about rocking the boat; boy would there be dues to pay before this uber-idea could claim its place at the helm of the minimally invasive movement.

The Natural Order of Things?
Of course, today all of this may seem so natural, so evolutionarily inevitable, like the story of man walking upright. Yet, operative video-laparoscopy, a concept which now seems almost prosaic in its self-evident appeal, was not so obvious a solution during this late 1970s time period, nor was it an idea that came gently into being.

Looking back, one actually finds that the opposite was true. Rather, the birth of operative video-laparoscopy was more like a case of gravity defied. It was like suggesting a baseball player look the other way right when the ball is pitched; totally counter-intuitive.

To get a feel for just what Nezhat was up against in trying to convince the surgical world to believe in his ideas, let’s take a quick trip back in time to review the status of operative laparoscopy as it stood in the 1970s, in terms of the types of procedures being performed, available technologies, and cultural mindsets which were hindering its development.

Marooned in Mediocrity: The Early 1970s Just Before Video-Laparoscopy
Powerful indeed is the empire of habit.
–Publilius Syrus, Maxim 305

Operative Procedures Achieved by the 1970s
The late 1970s skepticism concerning gynecologic operative laparoscopy is not so clearly spelled out in other historical accounts. Many have made the inaccurate claim that gynecologists had “fully embraced” laparoscopy as a standard modality by the 1970s. While there is a grain of truth in this with respect to diagnostic laparoscopy, for advanced operative procedures, the story was quite different. This can be established by reviewing the literature and textbooks of this era, where one can plainly see that operative laparoscopic procedures being performed were essentially no more advanced than those which had been introduced nearly fifty years earlier by endoscopy’s early 20th century pioneers; draining cysts, lysis of adhesions, taking biopsies, electrocautery, and tubal ligations.

Aspiration of Ovarian Cysts – But Not Their Removal
The history of draining cysts laparoscopically serves as a perfect example to track these operative plateaus. As early as the 1920s, the American laparoscopic pioneers Ordnoff and Bernheim were some of the first to demonstrate how successful the “peritoneoscope” (aka laparoscope) was for this procedure. Jacobaeus was also able to drain ascites in the abdomen in the 1910s, a laparoscopic procedure similar in nature. Yet, over fifty years later, some of the most popular manuals and textbooks of the 1970s-1980s – Frangeheim’s Endoscopy and Gynecology, TeLinde’s Operative Gynecology, AAGL’s Manual of Endoscopy, Hulka’s Textbook of Laparoscopy, Baggish’s Atlas of Contract Hysteroscopy and Endoscopy, Wheeless’ Atlas of Pelvic Surgery– all specifically direct laparoscopists to focus only on aspiration as the standard practice. Surgical removal was made possible as a routine practice as a result of video-laparoscopy. Today of course clinical data demonstrates that up to 40% of these cysts do in fact refill, indicating therefore that surgical removal is the preferred standard.

Tubal Sterilizations
As for the endoscopic superstar of the 1970s- tubal sterilizations- it actually got its start back in 1936, when Boesch performed the world’s first documented laparoscopic tubal sterilization using electro-cauterization [1]. Naturally, the technique has been perfected over the years. Yet by the 1970s, conceptually the procedure had not changed much from its 1930s debut.

Indeed, with the exception of contributions from the era’s few virtuosos, such as Palmer, Semm & Mettler, Steptoe, Cohen, and Gomel, our entire discipline seemed stalled for what felt like was going to be forever at tubal sterilizations, as if it were the final frontier.

Blizok lokotok, da ne ukusish
Impossible, you might say! Fifty years without a new operative procedure? How could this be? After all, eye-popping technological advances were proliferating at an astonishing clip during this era; fiber optics, automatic insufflators, electronically controlled thermo-coagulators. Yet, here we were in the late 20th century, with men and monkeys flying to the moon and back, while we laparoscopists were still stuck back at the farm, doing mainly routine diagnostics. It seemed to be a clear case of Blizok lokotok, da ne ukusish. This old Russian proverb, translated as “your elbow is close, yet you can’t bite it” was an apt description for the times, because on the one hand, with the new technologies enabling video-laparoscopy even more, we were so elbow-close to breaking through and past the old ways. Yet, paradoxically, we were so far away from the “bite” because, as Nezhat and other pioneering laparoscopists of this era soon discovered, confronting psychological resistance to change was the far more difficult task to overcome.

Another Conundrum
There was another conundrum to overcome; new surgical techniques had to be invented which could accommodate being done in the new closed, video- laparoscopic manner. Doing a procedure endoscopically that was actually designed to be done via laparotomy presented actually one of the most formidable problems. There were essentially no textbooks or protocols established yet which would have demonstrated how to make these procedures actually feasible laparoscopically. Some innovations were beginning to pour through the pipeline; Semm’s and Mettler’s extracorporeal Roeder’s loop was one such example. Yet these contributions still did not resolve the majority of the problems having to do with achieving more advanced procedures.

In short, what this meant was that each procedure normally done via laparotomy would have to be re-invented. This process was naturally one of trial and error, a factor which especially exposed Nezhat and other laparoscopic pioneers to some harsh criticism in the early days.

An Overview of the Times – TV, Video, and Light Source Technologies
As for the nature of endoscopic technologies, many precursors to video had been established for many years prior to the 1970s. Cinematography and television had actually been used modestly in a handful of surgical centers since roughly the late 1930s. By the 1950, Japanese pioneers from Hayashida Hospital, Uji, Fukami and Suginara, developed one of the earliest endoscopic cameras, the gastrocamera, while in 1953 Cohen and Guterman introduced their Cameron cavicamera.

Some of the most sensational moments in endoscopy’s history came with the debuts of the world’s first television and color film broadcasts by French pioneers; Palmer’s 1955 color film debut of the first live laparoscopy; and in the same year the world’s first ever television broadcasts of live bronchoscopies, achieved separately by the French bronchoscopists, Soulas and Dubois de Montreynaud. Within a few years, Frangenheim of Germany would produce his famous 1958 color film of a gynecologic laparoscopic surgery, a feat which would reverberate throughout the world of gynecologic laparoscopists for years to come.

By 1960, Inui, Berci, and others had either invented themselves or collaborated with industry to bring miniaturized video endo-cameras into endoscopy by the 1950s-1960s. However, all of these systems were definitely not designed with advanced operative video laparoscopy in mind. For instance, Berci’s 1962 article was one of the earliest to mention both “TV” and endoscopy” in the title. While this article did an excellent job of delineating the latest TV technologies, nevertheless its singular focus was on the ways in which the new imaging technologies would enhance documentation and teaching capabilities; there is no mention of changing the method of performing endoscopic procedures, with the goal of advancing laparoscopy’s operative potential.

Even as late as 1977, Berci revisited the role of TV and video devices –referred to back then as “teaching attachments”- as technologies to enhance teaching only. Figures 1 through 5 from this same 1977 article also clearly show that the latest in camera-equipped endoscopes were still designed to be utilized in the old way, with endoscopists peering awkwardly through the scope. A similar attachment, called a “multiple tube medical television camera,” highlighted in a 1977 AAGL conference entitled “Endoscopy in Gynecology,” also demonstrates this well-entrenched trend.

In other words, while some of the technological rudiments to support videolaparoscopy had been in existence for at least forty years in some cases, the most crucial missing link was not technological in nature, but rather was an issue of missing imagination. The conceptual idea of combining these technologies and using them in an entirely different way had been entirely overlooked until Nezhat’s unique contribution.

A Paradox – Poor Resolution Almost Foils the Thought
All of this background review has missed one vital but paradoxical point; even with these newly emerging optic and video technologies, Nezhat’s idea was actually still too advanced for the era’s technologies to support. At the time of Nezhat’s awakening to the magic of operating upright, operating off the monitor was barely feasible because the early generation optics and video systems (before digital was perfected) still did not produce the level of high pixel resolution that we have become accustomed to today. And despite the superior illumination afforded by the latest fiber optics and Hopkins lens systems, the quality of light had not advanced to a level where images could be efficiently split toward the monitor. As recently as 1977, Berci made a point to mention the inadequate nature of light sources, stating that “Illumination sources are in a chaotic state.” These combined technical deficiencies meant that the images shown on the monitor were so grainy that, for most they proved to be indiscernible; definitely not clear enough to support the notion of operating off images. This is why so many were against the idea initially, since it was quite disorienting to view barely discernible images emanating from a low-resolution, two-dimensional screen positioned several feet away from both surgeon and patient!

Backlash to Laparoscopy for Second Time in the 20th Century
As if these obstacles were not enough, gynecologic laparoscopy in America was actually experiencing another season of discontent, just beginning to surface in the late 1970s [2]. Of course, as usual with the story of laparoscopy, this is completely paradoxical, for the discipline did experience some very dramatic leaps forward during this era, at least symbolically. For example, by the mid- 1970s training in laparoscopy had been added to “all major gynecologic residency programs” in Europe. And by 1981, the American Board of Obstetricians and Gynecologists followed suit and made laparoscopic training a required component of U.S. residency programs. The number of procedures being performed annually also skyrocketed. By about 1973, some sources state that between six and seven million endoscopic procedures were being performed annually in the US alone [3]. Other reports show that from 1971 to 1976, laparoscopic sterilizations increased from a mere 1% to an astonishing 60%. Though such statistics on the quantity of surgical procedures are notoriously difficult to verify, based on our research these numbers appear to be reasonable estimates.

Yet at the end of the day, the majority of operative procedures were still limited to only simple tasks, a fact that translated to millions of female patients continuing to be subjected to multiple laparotomies for even mild cases of endometriosis. This stall in the progression toward more advanced procedures was in part caused by growing concerns over complication rates associated with outpatient laparoscopic sterilizations, a procedure which had rapidly grown in popularity in just a few short years.

A growing backlash toward all things laparoscopic developed in earnest and articles forewarning of high complication rates began to seep into the literature. One of the first such articles of this kind to gain national attention was published by the well-respected founder of the AAGL, Jordan Phillips, whose 1977 report outlining in stark detail the estimated complication rates associated with laparoscopic tubal sterilizations struck a raw nerve within surgical communities and served for a time to temper enthusiasm. Indeed, failed sterilizations became the second leading cause of lawsuits for ob-gyns in America, only after those associated with pregnancy complications [4].

Another example of the ambivalence over the scope’s role in more advanced operative procedures can be found in one of AAGL’s most memorable meetings, in which Semm had been invited to demonstrate the types of operative procedures he envisaged for his “pelviscopy.” “Kurt Semm’s pelviscopy presentation struck people in that meeting as going too far,” recalls Soderstrom, one of the founding members of AAGL. The title of this debate, called “Laparoscopy is replacing the clinical judgment of the gynecologist,” also captured perfectly the unease about allowing the scope to advance beyond diagnostics.

Soon thereafter, urgent congressional hearings and other governmental advisory panels were being called into session to address concerns about the rapid technological changes affecting endoscopic medical devices in particular and medical technologies in general. Symbolic actions were taken against laparoscopy, beginning most conspicuously with the Congressional Health Device Act passed in 1976. Later, in 1981, the CDC in Atlanta issued a very strong public rebuke over patient deaths apparently linked to unipolar laparoscopic sterilization procedures [5]. Since the medical community tends to err on the side of caution, such adverse reports– whether exaggerated or not- were nearly the death-knell for laparoscopic innovation in those days.

The Frozen Tundra of Buffalo – This is Your Brain on Imagination
Necessity knows no law except to conquer.
–Publilius Syrus, Maxim 553

And thus it unfolded that, for the second time in the 20th century, interest in laparoscopy had soared to the heights of unfathomable popularity, only to plunge back down to earth once its inherent limitations were revealed after the veil had been lifted. An epoch tale indeed was in the making, as it seemed our laparoscope’s once rising star of shiny, happy brilliance was on the verge of being reduced to a garish glare. The revivalist hey-day that American laparoscopists had so enjoyed during the 1965-1975 timeframe had been nearly neutralized by the end of the 1970s. In other words, the timing could not have been worse to introduce such a radically new concept as that of advanced operative video-laparoscopy!

All the same, Nezhat remained imperturbable. These heavy realities were no match for his hidden reserves of moxie; he boldly pushed past the raucous ramble of naysayers, forcing a reckoning with minimally invasive surgery as the new reality.

So, how did it all begin?

Amidst the frozen tundra that is Buffalo, New York in mid-winter, there was a kindling mind, ablaze with great visions that soon would take the surgical world by storm. But how did videolaparoscopy develop from the imagination of this young physician just starting his residency? And by the way, what audacity! How did he find the courage to disagree with senior surgeons– at risk to his own just- blooming career– and take on the entire surgical world?

Very gracefully, of course.

More than anything though, the how came from the why; Nezhat was driven to help ease the pain of his patients, who had been forced to endure 6 to 12 inch incisions into their abdomens for even the mildest of pathologies. In witnessing the extreme pain and suffering of his patients, their long convalescence, and the serious and numerous complications arising out of laparotomies, Nezhat believed that with just minor alterations almost all of this unnecessary suffering could be averted. It seemed clear to Nezhat that one of the most significant hindrances was the positioning of the surgeon in relation to the scope. The whole contraption left him contorted in the most unnatural of positions; bent-over sideways, with an assistant blindly holding the scope and other instruments in place while the surgeon tried in vain to verbally direct its positioning.

He knew that if only he could find a way to circumvent the physical limitations posed by peering through the scope’s singular eyepiece that the scope’s surgical capabilities could then be extended into more advanced operative procedures. Practicing in the lab late at night, he realized that one might be able to perform surgery standing upright by watching the monitor.

With the concept now firmly in his head, Nezhat began the art of rigging together whatever equipment he could find to make this vision come true. Initially he operated directly off the monitor using a single tube camera by Medical Dynamics, model Synvision- with low light level.

Nezhat recounts those early days:

“Early on, vascular and neurosurgeons had had success using cameras for micro surgery. So, hoping to learn from their successes, I approached my colleagues in these disciplines. Their willingness to spend time demonstrating this technology was very fruitful. Of course, we ran into unusual logistical dilemmas trying to adapt this technology. Many strange configurations were attempted before achieving any degree of success. [Eventually though], we were able to convert an old camera used in their disciplines into an awkward but nevertheless functioning addition to the scope.”– Camran Nezhat, Presidential Speech, September 2005, JSLS

Despite this precarious start, Nezhat was able to collaborate with other disciplines, a factor which became crucial in developing these ideas even further. Nezhat attributes this multi-disciplinary facet as having been a vital source of endless inspiration. Endometriosis especially led him to work with other specialties, since it commonly affects many different organs, especially the GI and GU tracks. The contributions of Dr. Earl Pennington, a pioneering colorectal surgeon, and Drs. Rottenberg and Green, both urologists, were especially noteworthy, as they guided Nezhat through very challenging procedures which had never been achieved laparoscopically before. Nezhat recalls, “Colorectal surgeon, Earl Pennington and urologist, Howard Rottenberg, were always at our side.” Also, patients with endometriosis have high rates of endometriomas which sometimes can have the appearance of malignancy. Therefore, from the very beginning, contributions from colleagues in gynecologic oncology were of critical importance. In this area, the guidance of Drs. Benedict Benigno and Matthew Burrell was absolutely invaluable. Through their vision and willingness to share their expertise, a better understanding of how to recognize and manage malignancies laparoscopically was achieved.

As for new suturing methods, only a few modifications were needed. For the most part, Nezhat was able to convert the same microsurgical techniques for open surgeries as were taught by pioneers in treating endometriosis such as doctors Robert Frankling of Houston and Ron Batt of Buffalo. Prior to switching to video-laparoscopy, suturing laparoscopically was a feat extraordinarily difficult to achieve while hunched over the scope. In fact, this factor was one of the main hindrances which had made earlier attempts at operative laparoscopy so awkward, unsuccessful, and ultimately, unpopular.

Forever-scopy
Operative video-laparoscopy was certainly not without its flaws. And we wouldn’t want to delude the reader by providing only the pretty pictures of its past. Indeed, one of its least attractive features initially was the extra time it took to perform some of the advanced procedures. As Nezhat recalled, “they used to call laparoscopy ‘forever-scopy’.” For instance, laparoscopic ectopic pregnancy surgeries were taking 4-5 hours initially, while Nezhat recalls that his first- and also the world’s first- radical hysterectomy with paraeortic and pelvic lymphadenectomy by video-laparoscopy actually took seven hours. This added time factor wasn’t helping to convince anyone that the video-laparoscopic method was better or safer than open. Of course, even some laparotomies took up to seven hours. But, the new method naturally was judged more harshly than classical standards.

Because of this time factor stemming from the very long learning curve, the effectiveness of video-laparoscopy was difficult to assess at first. Early reports showed laparoscopy to have higher complication rates than laparotomies, though these result were attributable mainly to inexperience.

Collaboration with Instrument Makers
In order to overcome these inherent deficiencies standing in the ways of the new technique, Nezhat began a fruitful relationship of collaboration with Karl Storz and other surgical instrument companies. Using those same old clunky cameras borrowed from the neuro and vascular surgeons, Nezhat was able to show the company representatives that operating off the monitor could in fact work. After hours in the OR, eventually Storz and other company reps were also convinced of the scope’s greater potential and they began producing new cameras and light sources customized for operative video-laparoscopy.

These days, working together with companies in this fashion might be discouraged. Yet, without this early support and free-spirited exchange of ideas between engineers and surgeons, poor visualization and other technological hindrances certainly would have persisted as formidable conceptual and technological divides.

Delays in Publications
Despite collecting verifiable clinical proof to the safety and efficacy of video operative laparoscopy, at first no one would accept Nezhat’s early manuscripts on the subject.

It took a few years, but finally his debut articles on these never-before-seen laparoscopic surgeries were published in 1986. From this point, Nezhat was able to continue to demonstrate– this time to a larger audience- that other complex surgeries were finally possible. Indeed, between the years of 1984-1989, Nezhat forced a reconsideration of all that was thought possible when he and his colleagues became the first to successfully perform such complex surgeries as: the first laparoscopic treatment of multi-organ, extensive, stage IV endometriosis, affecting the GI and GU, the first laparoscopic bowel surgery & resection with Pennington, the first laparoscopic ureter resection, ureterouretrostomy, with H. Rottenberg, and B. Green, the first laparoscopic radical hysterectomy with paraortic and pelvic node dissection with M. Burrell & B. Benigno, the first laparoscopic bladder resection with H. Rottenberg, the first laparoscopic vesicovaginal fistula repair with Batista, the first laparoscopic rectovaginal fistula repair with Basida, the first laparoscopic ovarian cystectomy in second and third trimester of pregnancy, the first laparoscopic- assisted surgery (laparoscopically assisted myomectomy), the first laparoscopic Burch procedure, the first laparoscopic treatment of ovarian remnant with E. Pennington and H. Rottenberg, the first laparoscopic sacral colpopexy, the first laparoscopic treatment of diaphragmatic endometriosis lesions with H. Brown, the first laparoscopic management of a leaking inferior mesenteric artery with C. Zarins, the first laparoscopic coronary reanastomosis in a porcine model, the first laparoscopic management of dermoid cyst.

Acceptance and publications on these firsts by Nezhat and his colleagues often faced numerous rejections and/or lagged three to five years after the initial procedures were performed, due to either resistance from journal editors to such new-fangled ideas, or for preference to publish the work of those in academia rather than those in private practice.

In any case, before the dawn of 1990, Nezhat and his colleagues had already performed laparoscopically practically all the major procedures involving the bowel, bladder, and ureter, which in the past had only been accomplished via laparotomy.

“Agony in the Garden” – The Era of Abject Antagonism
Scandal has ever been the doom of beauty.
–Book II, Properties

Like a rite of passage, the quintessential pioneer story wouldn’t be complete without an element of abject suffering to startle us out of our reverie. Like Semm, Muhe and others, Nezhat endured many years of doubt before his ideas became accepted. In terms of endoscopy’s long history, this was not surprising. There had always existed an element of resistance since the time of Bozzini, if not earlier. Resistance to operative video-laparoscopy was especially fierce for it forced surgeons- for the second time in the 20th century- to lose two vital sensory mechanisms: tactile and direct visualization. These changes seemed to be the tipping point which drove the final stake into ancient surgical practices, bringing to the fore a 21st century approach which few were actually ready to embrace. Indeed, so suspect was the new surgical revolution that Nezhat and his brothers actually had their academic integrity called into question.

Even from just a few years ago, in 2002, a lay media frenzy went so far as to label Nezhat’s work as “bizarre,” “barbaric, and akin to “medical terrorism.” Forced now to answer to this misinformed media frenzy, Stanford University was essentially left with no choice but to act in the most politically expedient manner by launching a highly publicized, formal investigation of Nezhat’s work, issuing in the process a temporary suspension of his professorship to appease the public outcry [6]. After lengthy investigations– and to the surprise of no one in the know- Nezhat’s work was found to be free of any misconduct whatsoever, cleared by the highest authorities from Stanford University, the U.S. State Supreme Court, and the California and Georgia State Medical Boards. How ironic it is today that, quietly, all the studies are pouring forth which confirm Nezhat’s initial impressions of the advantages of operative video laparoscopy. Those same procedures pioneered by Nezhat and his team considered so controversial just a few years ago, are now encouraged to be performed by the most prestigious journals. A 2004 editorial from the New England Journal of Medicine states, “Surgeons must progress beyond the traditional techniques of cutting and sewing…to a future in which …minimal access to the abdominal cavity [is] only the beginning.”

Conclusion
History may be servitude, history may be freedom.
–from “Little Gidding,” TS Elliot

Sometimes history can become an unbearable weight. Operating off the monitor and inventing the accompanying advanced procedures were the crucial links which allowed our discipline to be set free from hundreds of years of history of peering directly through a tube, specula, or scope. By demonstrating the scope’s boundless potential, Nezhat hit the groundbreaking grand slam that drove laparoscopy home toward its true operative potential.

Other Significant Pioneers and Events of the Late 1970s
John Wickman, a urologist, had been at the forefront of endoscopic discoveries since the 1970s. Wickman was using newly created lithotripter on kidney stones in ‘80/’81, and also performed the first removal of gallstones endoscopically in ’86, using a nephroscope. Wickham is credited with coining the phrase “minimally invasive surgery” in 1983. Wickham was criticized greatly for what were considered “outrageous and nonsensical claims of a new surgical movement.” Muhe of Germany and Mouret of France, 1985-1987, were the true pioneers for laparoscopic cholecystectomy in Europe M.A. Bruhaut of Clermont- Ferrand, and his team in France was on the cutting edge of operative laparoscopy for the 1970s. In 1979, Bruhat et al. used the CO2 laser for laparoscopy. Yona Tadir of Israel independently accomplished the same also in approximately the same time period. In 1980 Bruhat et al. also launched one of laparoscopy’s first prospective and comparative studies between microsurgery and laparoscopy for the treatment of tubo-peritoneal infertility. Their findings demonstrated that the laparoscopic method gave more advantages. Hubert Manhes worked with Bruhat early on, and came up with several new instruments and advanced operative procedures, including the conservative (laparoscopic) treatment of ectopic pregnancy as early as 1973. H.M. Hasson’s 1971 introduction to “open laparoscopy,” allowed for direct visualuation of trocar-entrance. Since introduction of the trocar was and still is one of the main chances for error, this feature allowed for less experienced surgeons to gain a sense of mastery over laparoscopy and mimicking the open method somewhat. Lisolette Mettler in 1976 reported on the laparoscopic diagnosis of stage IV endometriosis, which involved multiple organs. Henry Coutnay Clark was performing some of the earliest operative procedures from 1972 onwards in the Carribean and Canada, though many of his firsts were earlier unrecognized due to the controversy surrounding these new procedures. Victor Gomel reported good results with infertility patients undergoing corrective laparoscopic surgery.