Chapter 23 - Society of Laparoscopic & Robotic Surgeons

Chapter 23


Déjà vu all over again.
-William Keye regarding the 1980s

The 1980s represent what are arguably the most controversial years in laparoscopy’s entire history. As developments in laparoscopy became more advanced and widespread, and with its popularity souring. Some of the earliest intense debates were revolving in particular about the increasing application of laparoscopy into more advanced operative procedures. By 1975 a huge heated debate had been brewing about whether or not the removal of ectopic pregnancies was indicated for laparoscopy and also tubal ligation by laparoscopy. Apparently there were some unexpected complications rates with the earliest procedures. As a result, laparoscopy was the target of intense scrutiny in the 1980s. In 1981, rules and requirements to perform laparoscopy were adopted by many hospitals and surgical societies. Meanwhile, the FDA got involved and in 1980 published safety standards for gynecological laparoscopy. The CDC also in 1981 reported about deaths from tubal ligations and made stern reprimands.

Yet, aside from these brewing debates about certain issues, the laparoscope was at the same time finally accepted as an important part of everyday practice. By this time the American Board of Obstetrics and Gynecology made laparoscopy training a required component of residency training.

Imaging diagnostic procedures were also beginning to work as complimentary components of endoscopic procedures. By 1981, surgeons could portray for instance bladder tumors via sonographic imagery with transurethral scanners. K. Matouschek was one of the first to do so.

As for attempting to grasp the various strands of endoscopic history in the 1980s, we divide the subject into two distinct periods: 1) before 1987 and 2) after 1987’s laparoscopic cholecystectomy. Although Muhe actually was responsible for the true revolution in gall bladder surgery that began in this era, with his 1985 work, we still must use the year 1987 as a dividing point, due to the unfortunate lack of attention that Muhe’s work received at the time.

Unfortunately at the same time in the early to late 1980’s, there was significant resistance in the United States against operative laparoscopy. It took 5 years before Dr. Camran Nezhat was able to present his laparoscopic treatment of extensive endometriosis in 1985. This was at the combined Canadian and American Fertility Society in Toronto, Canada. His paper was finally published in 1986 in Fertility and Sterility. At that time he reported laparoscopic treatment of Stage IV Endometriosis. As Dr. Camran Nezhat was not able to publish his work, he started teaching operative laparoscopy on his own beginning September of 1983. Over the years, more than 10,000 physicians from all over the world have attended his workshops. In collaboration with colorectal surgeons and urologists and GYN oncologists he was performing procedures far more challenging than cholecystectomies in the mid to late 1980’s.

The 1980s
In the late 70s and early 80s operative laparoscopy for the mild pelvic pathology like ectopic pregnancy, ovarian cysts, oopherectomy, pregnancy, small myoma and adhesions were routinely performed by different surgeons world wide like Semm in Germany, Muhes and Bruhat and his group in France and Gomel in North America. Like the first introduction of laparoscopy in the form of looking through the scope directly, there was an equally exciting explosion of innovation following the introduction of operative video- laparoscopy.

1985 – Erich Muhe
Erich Muhe, of Erlangen, Germany, was years ahead of the pack when in 1985 he audaciously re-imagined a way to surgically remove diseased gallbladders. Using an instrument he designed himself, which he dubbed the “galloscope,” and relying on the monitoring systems and other instrumentation from Semm’s, Muhe completed the world’s first ever completely laparoscopic removal of a gallbladder in less than two hours. By 1987, Muhe had performed almost 100 endoscopic laparoscopic cholestectomies, giving Muhe himself reason to call the procedure “magic.”

However, that’s not what the German Surgical Society thought. Muhe’s 1986 presentation to the Congress detailing what he had achieved was met with great skepticism and even scorn. Indeed, his work was so misunderstood at this time it was called into question by German authorities, which eventually led to a full blown censure by the courts stemming from a lawsuit against him which alleged “improper surgical action.” Muhe’s work was then ignored for the next several years. It was only in 1992 that the German Surgical Society exonerated his work. The excellent and extensive research about Muhe by Litnski uncovered an excellent quote by the Congress’ President from 1993, apologizing to Muhe:

“I am especially pleased that your pioneering effort received clear recognition at the Congress of German surgeons in Munich… this is without a doubt one of the greatest original achievements of German medicine in recent history.”

Conclusion Muhe
Muhe’s surgical skill was in the category of virtuoso. Yet his engineering genius was equally impressive. The scope he custom made especially for the gallbladder surgery had been improved considerably. It featured a laparoscopic opening of 30 mm and improved circular illumination. Muhe’s technique different from Mouret’s in the use of video cameras, which Muhe chose not to use at the time since that technology was in its developmental stages. There is some question in the record recently about whether Muhe or antoher laparoscopist named OD Lukichev of Russia was the first to perform a laparoscopic cholecystectomy. While Lukichev came close to achieving this procedure in 1983, ultimately he was not able to actually perform the entire operation laparoscopically. Therefore, Muhe is still confirmed today as the first ever to laparoscopically remove the entire gallbladder.

Mouret gained worldwide preeminence in 1987 by performing the first video-assisted laparoscopic cholecystectomy. The effects of this one day reverberated throughout the entire field of surgery, medicine, and beyond. In the aftermath of this revolution, not only had every single discipline of endoscopy been affected, but most astonishingly, the entire field of general surgery was transformed right down to its very core.

Indeed, we had arrived at the ultimate turning point in the history of laparosocopy. There is simply no other singular moment that encapsulates all that the minimally invasive movement had been leading toward all those years.

Mouret’s surgery took place in Lyons, where a team of French surgeons had been working for some time on early laparoscopic development. Indeed, even before 1987, in 1983 Mouret had actually hit another milestone by becoming the second person in history (after Semm) to perform a laparoscopic appendectomy. And his earliest work began in the late 1960s and early 1970s with using the laparoscope for diagnostic gynecological procedures.

For the 1987 laparoscopic cholecystectomy Mouret used standardized instrumentation (for gynecological laparoscopy), rather than designing his own instrument as Muhe had. It is astonishing to think that Mouret’s work was also not initially regarded as a crucial contribution, possibly as a consequence to his choosing not to publish, or perhaps because he was a private surgeon as opposed to one affiliated with a university.

Conclusion Mouret
The remarkable moment in laparoscopy history, brought to life by Mouret’s dedication to the discipline, launched countless other developments since that time. Through years of friendly collaboration, the French team of laparoscopists from Bordeaux came to learn just about all there was to know about endoscopic affairs at the time and as Mouret himself would agree, this environment of exchange played a significant role in bringing about the events of 1987. And what appeared to unknowing eyes as something that came from out of nowhere, Mouret’s achievement was actually the culmination of centuries of struggles to develop technologies which could catch up to the great idealism that had imagined for the world the minimally invasive philosophy.

The French Team
After Mouret’s debut, his efforts as well as those of Dubois and Perissat led others to refer to them as the “the French connection.” Apparently, it was not until the mid-1990s that these pioneers got the full recognition for what they had accomplished.

Francois Dubois
Dubois had been advocating the method referred to as mini-cholecystectomy, which had been popular in France since the early 1970s. Yet after hearing of Mouret’s method, he contacted Mouret to start to learn as much as he could about the procedure. After practicing in the lab, Dubois performed his personal first laparoscopic cholecystectomy in 1988.

Jacques Perissat from Bordeaux, France
During the same time period as Dubois and Mouret, Perissat had his attention on the extracorporal shock wave lithotripsy that had been all the rage at the time, long before the laparoscopic cholecystectomy. At some point he decided to experiment with an intra-corporal method and choose the laparoscope to facilitate this new idea. Perissat had already been exposed to the work of Palmer and had gained clinical experience with Palmer’s methods.

1988 – The Americans and Their First Laparoscopic Cholecystectomy
Within a year of Mouret’s show-stopping surgery, a heightened pitch of promise was in the air for general surgeons. These moments represented unprecedented change for the medical community in general, causing a raucous swing-vote shift toward the minimally invasive mindset. It was like rock star fever had entered the operating theater. General surgeons flocked to weekend crash courses on operative videolaparoscopy, which had sprung up seemingly overnight. The year 1988 turned out to be the great flashpoint of change for American general surgeons. In 1988, the first US laparoscopic cholecystectomy was performed by J. Barry McKernan and Saye of Marietta, Georgia.

McKernan was Chief of Trauma surgery, and Saye was head of the Department of Obstetrics and Gynecology. Saye was also deeply influenced by seeing the work of Nezhat at post graduate endoscopic gynecology seminars and a live surgery demonstration in Atlanta where Nezhat presented a video presentation on his video laparoscopic treatment of extensive endometriosis. After these first moments of awakening, the rest is simply history. McKernan apparently purchased on his own credit the entire set of new instrumentation needed for his OR. Shortly after McKernan and Saye’s first laparoscopic cholecystectomy, Eddie J. Reddick and Olsen (Nashville, Tennessee) performed theirs. Their work however was said to be more influential in popularizing and refining the procedure. Reddick and Olsen made significant new developments in technique, including a refined technique of laparoscopic cholangiography. Reddick earlier had been teaching courses in laser surgery. By the end of the 1980s, Dubois (Paris), Perissat (Bordeaux), and Nathanson and Cuschieri (Scotland) had performed laparoscopic cholecystectomy at their respective institutions.

Intro to Late 1980s
By the late 80s, the laparoscope was mainly a gynecologist’s tool, and from this discipline, audaciously re-imagined innovations poured forth from a superstar slew of uber-surgeons, which kept the newsreels rolling about the new sci-fi surgery, which continued to keep the world enthralled. By the late 1980s, new technologies were being developed which would allow for advanced operative procedures. Semm was spectacularly productive in the 1980s, introducing severeal new morcellators, which could morcelate fist-sized myomas. These developments continued to pave the way toward what was now the inevitable operative frontier. Nezhat and Semm were invited to a debate in Amsterdam, Holland in which Nezhat argued for operating on the monitor using video and Semm argued for operating directly through the laparoscope. This was a friendly debate which the then young turk Nezhat won against the established Semm.

CO2 Laser
A key element in this pioneering orchestra of surgical collaboration and operative technique is the CO2 laser beam. Bruhat et al. (1979) in France and Tadir et al. (1981) in Israel initially used the CO2 laser laparoscope. Later different surgeons across the world including Dan Martin, Bill Kelley, Jim Daniel in the U.S., Chris Sutton in England, Jack Donnes in Belgium and others were among the pioneers in Gynecology whom in their own countries used advanced laparoscopic operative techniques.

1989 – The Second International Symposium in Atlanta Georgia
The second international conference for endoscopic surgery, this time held in Atlanta, was described as a boat-rocking success and represented the moment in which, finally, general surgeons became convinced of operative laparoscopy as the future of surgery. As mentioned previously, before the introduction of laparoscopic cholecystectomy, gynecologists were performing some of the most advanced laparoscopic procedures. For example, in 1985, ’86 and ’89, Dr. Camran Nezhat and his colleagues reported laparoscopic treatment of Stage IV Endometriosis involving the bowel, bladder and ureters which he had been routinely performing for years. Through his collaboration with colorectal surgeons and urologists, he was able to reveal through seminars all over the U.S. and Europe, years before the laparoscopic cholecystectomy, that even the most extensive pathology (including GI and GU resections) can be managed laparoscopically.

Conclusion 1980s
The 1980s was a time of great transition, which naturally causes a sense of disruption to the comforts of tradition. On the one hand, there was no question that laparoscopy was here to stay. By 1986 laparoscopies were in fact the most frequently performed procedure by Ob-Gyns in North America. Yet, simultaneously, some of the most heated debates began to simmer in the 1980s. Nothing elicited fiercer debating than whether to move laparoscopy into more advanced operations. It’s a debate that takes place even today. An example was the removal of ectopic pregnancies, which had been achieved by 1975. Despite the proof that they could be removed, even some of the most influential textbooks of the era did not advocate this method. For instance, Wheeless’ 1988 textbook advises the open method to remove ectopic pregnancies.