Chapter 24

1990’s

Introduction
STOP…pretending you don’t want me.
–On a t-shirt, somewhere in L.A.

The 1990’s witnessed wide acceptance of laparoscopic surgery. This resulted in dramatic explosion of its applications: Patrick O’Regan and Nezhat, advanced the use of laparoscopic appendectomy. Edward Phillips and Jean Dulucq developed a peritoneal laparoscopic hernia repair. Videolaparoscopic nephrectomy was first reported in 1992 by Ralph Clayman and repair of the ureter by Gomel. Videolaparoscopic ureterouretrostomy, ureteroneocystatomy, and psosas-hitch procedures were reported by Nezhat. Bladder resection was reported by Nezhat in 1991. Dallemagne, in 1991, performed the first laparoscopic truncal vagotomy for treatment of peptic ulcer disease. Harry Reich reported on laparoscopic hysterectomy and Jack Donnez along with Harry Hasson and Tom Lyon on laparoscopic supracervical hysterectomy. Phillip Konick, Peter Mohr, David Redwine, Paul Devroy, Ivo Brosun, Jorge Keckstein Arnold Wattiez, Michele Nisolle, Shlomo Mashiah and Daniel Seidman were among physicians who reported about the laparoscopic management of extensive endometriosis. A large body of work on pelvic floor disorders was reported T. Vancaille, CY Lu and William Saye and others. Nezhat, Jacobs, Redwine, Wexler, and others, reported laparoscopically assisted colectomy. In 1992, Goh described the first laparoscopic Billroth II gastrectomy, adrenelectomy, and laparoscopic splenectomy Pelvic lymphadenectomy was reported first by Daniel Dargant, and Querlo in France and paraortic lymphadenectomy by Nezhat and Childers in this country. Nezhat and colleagues, in this country, and Cainis in Clearmont, France, first reported radical hysterectomy in the late 1980s and early 1990s; M.A. Pelosi introduced novel laparoscopic techniques of single port laparoscopy; GA Vilos advanced hysteroscopic techniques; Anton Langebrekke made significant contributions for advanced operative procedures; Jacques Donnez and Hasson performed one of the first laparoscopic supracervical hysterectomies.

Dazzling technological advances took center stage during this era. The first laparoscopic robotic procedures were performed by T. Falcone, J. Goldberg, A. Garcia-Ruiz, H. Margossian, L. Stevens, a procedure which was called “full robotic assistance for laparoscopic tubal anastomosis.” In 1996, the first live telecast of laparoscopic surgery performed remotely via the internet was achieved (robotic telesurgery).

Society of Laparoendoscopic Surgeons (SLS) – 1990
The growing international popularization of endoscopic surgery raised the need for organized communication among those who were experts in their field and those who wanted to gain entry into the endoscopic fold.

Stop: There was someone out there optimistic enough to think he could convince surgeons from different disciplines to come together- in the same room?! Indeed, there are miracles in medicine after all and Team SLS proved it. It was Paul Wetter, along with Janis Chinnock, and other colleagues, who envisioned with remarkable foresight the need for a multi-disciplinary approach to advance endoscopy even further.

Yet transforming this movie from someone’s head into a living force is where grit and glory came into play. It would take the transmutation of Warren Buffett’s business brain, spiked with a garnish of Gandhi, Picasso and Patrick Henry (for peaceful, artistic audacity) to get this baby off the ground. And it did. And it has served to inspire us ever since. And the un-believers stood stunned to tatters. Just ten years from its 1990 debut, SLS had achieved an international following of nearly 10,000 members, organized wildly popular conferences throughout the world, and launched the most widely circulating journal ever focusing exclusively on all things endoscopy.

Ultimately, this organizational innovation proved to be one of the most crucial factors for driving forward the collective success of endoscopic development in general, for it encouraged us to come together so that we could gain insight from one another as we embarked into the great unknown.

Backlash, 1990s Style
The mid-1990s witnessed another era of resistance, perhaps of a more virulent strain. The advanced operative procedures that were just coming into their own at this time were disparagingly referred to as “experimental surgery,” which had no data to support their efficacy. An article written in 1994 sums up the concerns succinctly when the author stated:

“An increasing number of endoscopic procedures have been described in recent years, developed largely with the goal of providing less invasive and more cost- efficient surgical treatments than are currently available by more traditional approaches. However, this growing subspecialty of endoscopic surgery has largely been developed and advocated by a relatively limited number of vocal proponents, supported by an eager and aggressive medical instrumentation industry….But have they accomplished the goals of less invasiveness and more cost efficiency? More importantly, what happens when large numbers of less- skilled and less-experienced surgeons begin performing these procedures?” – D. Smith et al, A hospital review of advanced gynecologic endoscopic procedures, 1994

The point about less-experienced surgeons was not without merit in some respects. The training efforts couldn’t always keep up with the rapid development of new procedures. One of the latest, laparoscopic-assisted vaginal hysterectomies, was the subject of especially heated debates. In this 1994 study, laparoscopic-assisted vaginal hysterectomies for instance were found to have up to a 60% complication rate. A prominent Wall Street Journal article in 1999 was published, highlighting the fact that “keyhole” surgery had backfired for heart surgery, sending another wave of incertitude to be unleashed concerning the laparoscope’s perceived shortcomings.

After some of these and other negative reports came out, laparoscopy was on its heels, defense tips in tow. This became the moment in time when lap was deemed practically the antithesis of science and sanity, when it seemed that teams of frenetic forensic investigatiors would raid the literature hoping to catch a laparoscopy in the middle of a complication. The critics bemoaned that this so-called wild band of “free wheeling laparoscopists” were out loose, roving about looking for an opportunity to insert their tiny incisions.

Conclusion History of Laparoscopy
The dream of reason produces monsters; imagination deserted by reason creates impossible, useless thoughts. United with reason, imagination is the mother of all art and the source of all its beauty.
–Goya

It is rare that in our lives we can become the products- as well as pioneers on occasion– of a scientific movement that has come to be seen as one of the most important developments of 20th century medicine. This journey toward the new order of things, shifting as it did between peril and promise, was not a painless transformation.

Perhaps of even more lasting significance, the painful transformation from the old ways of open surgery to minimally invasive modalities set off an intense scientific and philosophical debate about just where the upper bounds- if any- of operative laparoscopy should end. It forced a reconsideration of the entire field of surgery, a change that called for every aspect of surgical methodologies to be thoroughly scrutinized. And it wasn’t just strictly the category of surgery that was reevaluated. Rather, questions arose having to do with a wide range of aspects concerning medicine, patient rights, and disease-states. New concepts relating to pain management for patients emerged as one of the most important changes to have come about due to the minimally invasive movement. As well, an eventual rethinking in expectations about surgical outcomes arose. Complications once considered unavoidable in the days of open surgery were suddenly reevaluated and revised in the minimally invasive era.

Still, as laparoscopists, our advocacy work to perfect and promote minimally invasive surgery is not done. There are still too many patients who are enduring needless open procedures. For example, in 1997 66.8% of hysterectomies performed in the U.S. were still done via laparotomy. Statistics from 2004 estimate that more than 7 million laparotomies(in all disciplines of surgery vs. 2.5 million laparoscopies) are performed for benign conditions in the US each year, with abdominal hysterectomies accounting for 500,000 of those cases, and another 500,000 accounting for unspecified cases (excluding the 1 million Cesarians).

Nevertheless, humankind is closer than ever to the ideal of performing the most advanced operative surgeries through the least traumatic incisions. For this reason, the nearly complete triumph of minimally invasive surgery has turned out to be one of the greatest achievements of 20th century medicine. More than that, it transformed into one of the world’s most important human rights movements, a change which touched the lives of millions of patients who had suffered too long in the shadows of silence.