By Nisha Lakhi, M.D., and Ceana Nezhat, M.D.
The history of endoscopy is a story inextricably bound by the human energies of character and charisma, persistence and insistence. Over the course of several centuries, many great thinkers and visionaries have established the rudimentary foundation that minimally invasive surgery stands upon today.
However it was the Persian physician-philosopher Ibn Sina (980-1037 C.E.), commonly known to westerners as Avicenna, who has been credited for one of the most crucial turning points in the history of endoscopy – the use of reflected light (1). Ibn Sina’s endoscopic techniques are generally considered to be the first documented instances of using reflected sunlight and polished glass mirrors to examine internal cavities of the human body.
Several obstacles had to be overcome before endoscopy could be accepted as a legitimate form of surgery. The technical challenges included 1) creating or expanding entrances to the interior of the human body, 2) safely delivering enough light into the interior body cavity, 3) transmitting a clear magnified image back to the eye, and finally 4) expanding the field of vision. Although Ibn Sina was able to overcome the first two of these challenges with his use of reflected sunlight, the world waited several centuries before further technical innovation would shape modern endoscopy.
Endoscopy as a Philosophy
Perhaps the most unique aspect of the history of the endoscope lies in the issue of categorization. Just what is endoscopy anyway? Is it an instrument or technique? Revolution or evolution? Many have come to understand the meaning of endoscopy as merely that of a technology or instrumentation. Because its roots as an almost exclusively diagnostic tool are so recent, this limited conceptualization has been somewhat difficult to escape. A more accurate definition, however, places endoscopy firmly in the realm of a new philosophy, one rooted in what is now referred to as minimally invasive surgery.
One may also interpret much of the Hippocratic Corpus as predominantly advocating this minimalist approach, as can be inferred by the modern version of the Hippocratic ancient edict “First, do no harm.” Hippocrates specifically instructed physicians to avoid invasive methods as much as possible.
Sometime between antiquity and the late 19th to early 20th century, however, the favored form of surgical intervention transformed into one dominated by big incisions.
Yet, just like Newtonian physics, these classical theories of surgery would ultimately be challenged by the conceptual breakthroughs driven in part by the burgeoning field of modern operative endoscopy.
Great Leaps Forward
The next great leap forward took place in 1806, when Philipp Bozzini first looked into a human bladder with an apparatus called the Lichtleiter. This first known endoscope utilized a candle as the sole light source (1).
The scope consisted of a system of strategically angled mirrors that were positioned in such a way as to bring the image back to his eye while simultaneously conveying the distally placed candlelight into the interior body cavity. Thus the third challenge of reflecting images back to the eye was overcome.
With the advent of electricity, exponential growth in the development of endoscopic technology was seen through the 18th and early 19th century. Most notability in 1879, Maximilian Carl-Friedrich Nitze developed the first rigid endoscopic instrument with a built-in light source.
In 1902, the first laparoscopy was performed by the German surgeon Georg Kelling. He inserted a Nitze cystoscope into the peritoneal cavity of a live anesthetized dog and examined its viscera (1). Eight years later, Hans Christian Jacobaeus of Sweden performed the first laparoscopic operation on a human (1).
A Wave of Opposition
Other surgical specialties were resistant to using this new technology. Surgeons of this era equated “surgical might” with larger incisions (Big Surgeon=Big Incision). By the 1970s, laparoscopic techniques were almost exclusively in the repertoire of gynecologists. In addition, there were reports of deaths caused by insulation complications, electrocautery accidents and intraoperative hemorrhage.
Soon thereafter, urgent congressional hearings and governmental advisory panels were called into session to address these concerns. Symbolic actions were taken against laparoscopy. Most notability the Centers for Disease Control and Prevention (CDC) issued a very strong public rebuke over patient deaths that were apparently linked to monopolar laparoscopic sterilization procedures.
However, one of the most pressing challenges was the ergonomic difficulty inherent to the use of laparoscopic equipment. Until the 1980s, laparoscopy was a one-man, one-eyed, one-handed procedure. The operating surgeon would have to hold the scope with one hand and peer through it as he operated. Thus visualization was limited, and complex operative procedures were not possible.
The Birth of a New Era: Videolaparoscopy
Dr. Camran Nezhat is considered to be the founding father of operative videolaparoscopy (2). He used a conventional video camera, and ‘rigged’ it to an endoscope and a television monitor. This conceptual breakthrough revolutionized modern abdominal and pelvic surgery. Video-laparoscopy refined the endoscopic process by empowering the surgeon with the capacity to operate in a vertical position, to use both hands and both feet simultaneously and to observe an enhanced field of vision on the video monitor while operating directly through the laparoscope.
The foundation of a multi-disciplinary endoscopic approach to complex pathologies was established in Atlanta, at Northside Hospital. The Nezhat brothers, in collaboration with other surgical specialties, performed many complex procedures for the first time by a minimally invasive approach. In the field of urology, along with Drs. Howard Rottenberg, Fred Shessel, and Bruce Green, laparoscopic techniques for bladder and ureter resection were pioneered. Similarly, in collaboration with colorectal surgeons, Drs. Earl Pennington, Wayne Ambroze, Guy Orangio and later on Mary Ann Schertzer, some of the earliest laparoscopic bowel resections were performed.
The general surgeons also began to adopt this new technology. Several notable general surgeons in Atlanta, including Drs. John Harvey, David Ruben and Patrick Luke later joined by Dr. Iqbal Garcha, began applying laparoscopic techniques to various surgical procedures.
Nezhats partnered with renowned gynecologic oncologists in Atlanta, Dr. Benedict Benigno and Dr. Matthew Burrell, to began using laparoscopy for their oncologic procedures. And surgeons of different specialties from around the world have since attended minimally invasive surgery courses conducted since 1984 at Northside Hospital.
During this time, Atlanta became a mecca of laparoscopic innovation. The first laparoscopic cholecystectomy in the United States was performed on June 22, 1988 in Atlanta by Drs. J. Barry McKernan and William B. Saye (1). At the Second World Congress on Endoscopic Surgery held in March 1990 in Atlanta, general surgeons and gynecologists from all around the world came together. At this meeting, video laparoscopy was validated as a true surgical specialty (1).
The Age of Robotics
Although videolaparoscopy allowed more complex procedures to be performed laparoscopically, its uptake was limited to select individuals who possessed the necessary skill set and aptitude to carry out these technically challenging procedures working off a two-dimensional video monitor. In 2000, the Da Vinci Surgery System (Sunnyvale, Calif.) was the first robotic-assisted surgery system approved by the FDA for general laparoscopic surgery. The robotic platform offered many advantages, including 3-D vision, enhanced dexterity, tremor filter and articulated instruments. This technology bridged the gap, as it allowed more surgeons to offer a minimally invasive approach to their patients instead of laparotomy.
Thus the enthusiasm and demand for minimally invasive surgery surged. Patients became educated about the advantages of minimally invasive surgery and started requesting robotic and laparoscopic procedures. Due to this increased demand, more providers began to offer a minimally invasive approach to their patients. However, some surgeons were inexperienced and did not understand the principles of laparoscopy, electro-surgery and safe specimen extraction. This resulted in a new surge of fatalities and complications.
From January 2000 to December 2013, 144 deaths and 1,391 patient injuries were attributed to the Da Vinci Surgical System (3). Several of these complications were due to inadequate surgical expertise. Complications were secondary to unsafe abdominal entry techniques, improper use of electrosurgical instruments, insufficient knowledge of anatomy and lack of adherence to the principles of minimally invasive surgery (4). Principles of safe specimen extraction were also violated. Collateral injuries and even death were reported secondary to morcellator blades (3). Additionally, due to unsafe uncontained tissue extraction techniques and poor patient selection for this type of procedure, dissemination of malignant intra-peritoneal pathology also occurred.
In 2014, driven by a broad public campaign, the FDA released a strong warning against the use of power morcellators. This had devastating and far-reaching consequences, as many began to abandon laparoscopy all together (4, 5). Johnson & Johnson issued a worldwide recall of their morcelator.
Eight months after the FDA warning was issued, one Florida health system observed an 8.7 percent decrease in benign minimally invasive hysterectomies and a 19 percent decrease in minimally invasive myomectomies (5). It was the first time, despite the decades of innovation and progress that we were reverting back to laparotomy.
Inflection Point Reached
Minimally invasive surgery today has reached an inflection point. We are no longer trying to prove that these procedures can be done. Rather, we must focus on doing these procedures safely and with the proper use of technology. We cannot afford to take steps backward, nor can we revert back to laparotomy or risk abandoning minimally invasive surgery all together. Therefore, we must maintain high standards and keep the art of minimally invasive surgery in the hands of experienced surgeons who can perform these procedures meticulously. An in-depth understanding of surgical anatomy, abdominal entry, port placement, electro-surgical principles, energy devices and tissue extraction techniques is of paramount importance.
The Future
Laparoscopy has revolutionized the practice of modern surgery from simple diagnostic work to advanced operative procedures. In the pursuit of even less invasive means for surgery, mini-laparoscopes and instruments some 3 millimeters or less in diameter have been developed. Mini-laparoscopic technology is a step beyond traditional operative laparoscopy and robotic-assisted surgery in that incisions are even smaller. The benefits are abundant and include reduced incisional pain, less risk of hernia or wound hematoma, no visible scarring, faster recovery and reduced costs.
Northside Hospital is the first hospital in Georgia to offer the new mini-laparoscopy technology. With mini-laparoscopic instruments, we have been able to successfully treat complex diseases including deeply infiltrating endometriosis affecting the bowel, bladder and ureter; removal of mesh embedded in the surrounding organs; or lysis of extensive adhesions.
Offering Patients the Ideal Surgery
We aspire to realize the dreams of the pioneers who spearheaded the revolution in modern-day surgery. To accomplish this goal, we must use our talents and expertise to improve and expand minimally invasive surgery. Our patients desire IDEAL minimally invasive surgery. That is, surgery Individualized, Data-driven, Economical, Advantageous and that offers optimal Long-term results.
Although minimally invasive surgery offers our patients an IDEAL surgical approach, there is a caveat – the surgery must be performed to a high standard of excellence in the hands of a skilled surgeon. Surgical success is dependent upon the knowledge and skill of the surgeon, beginning with an accurate diagnosis and proper selection of patients, determination of surgical access route and, especially, recognition of the surgeon’s own limitations.
As technological advances in this field are rapidly increasing, practicing surgeons must become proficient with new instrumentation and new surgical approaches. Therefore, adequate training and continuing education are crucial for success and the prevention of complications. If we truly want to progress and to offer an IDEAL minimally invasive surgical approach to our patients, we must not forget that the safety of our patients is of utmost importance.
References:
1.Nezhat C. Nezhat’s History of Endoscopy – A Historical Analysis of Endoscopy’s Ascension since Antiquity (2nd edition). Endo:Press, Tuttlingen, Germany,2011.
2.Podratz, Karl, MD PHD. Degrees of Freedom: Advances in Gynecological and Obstetrical Surgery. Remembering Milestones and Achievements in Surgery: Inspiring Quality for a Hundred Years 19132012.Published by American College of Surgeons 2012.Tampa: Faircount Media Group; 2013.
3.Manoucheri E, Fuchs-Weizman N, Cohen SL, Wang KC, Einarsson J. MAUDE: analysis of robotic-assisted gynecologic surgery. J Minim Invasive Gynecol. 2014 Jul-Aug; 21(4):592-5.
4. Kimberly A. Kho, MD, MPH; Ceana H. Nezhat, MD Evaluating the Risks of Electric Uterine MorcellationJAMA. 2014;311(9):905-906. doi:10.1001/jama.2014.1093
5.Nezhat C. The Dilemma of Myomectomy, Morcellation, and the Demand for Reliable Metrics on Surgical Quality. JAMA Oncol. 2015 Apr;1(1):78-9. 6.Lum DA, Sokol ER, Berek JS, Schulkin J, Chen L, McElwain CA, Wright JD. Impact of the 2014 FDA Warnings against Power Morcellation. J Minim Invasive Gynecol. 2016 Jan 28.
6.Barron KI, Richard T, Robinson PS, Lamvu G. Association of the U.S. Food and Drug Administration Morcellation Warning with Rates of Minimally Invasive Hysterectomy and Myomectomy. Obstet Gynecol. 2015 Dec;126(6):1174-80.
