Five thousand years of minimal access surgery: 3000BC to 1850: early instruments for viewing body cavities.

Surgeons and their patients recognise that one of the major advances in surgical technique over the last 20 years has been the growth of minimal access surgery by means of laparoscopic and robotic approaches. Partnerships with industry have facilitated the development of advanced technical instruments, light sources, recording devices and optics which are almost out of date by the time they are introduced to surgical practice. However, lest we think that technological innovation is entirely a modern concept, we should remember that our predecessors were masters of their craft and able to apply new technologies to surgical practice. The history of minimal access surgery can be traced back to approximately 5000 years ago and this review aims to remind us of the achievements of historical doctors and engineers, as well as bring more modern developments to wider attention.This review will comprise a three-part series:Part I 3000BC to 1850 Early instruments for viewing body cavitiesPart II 1850 to 1990 Technological developmentsPart III 1990 to present Organisational issues and the rise of the robots.

Hans Christian Jacobaeus: Inventor of human laparoscopy and thoracoscopy.

Hans Christian Jacobaeus performed the first clinical laparoscopic surgery in Stockholm. This pioneering procedure was based on the animal experiments of Georg Kelling (1866-1945), a German physician from Dresden, who performed the first laparoscopic intervention in 1901 using a Nitz cystoscope in a dog. In 1910, Jacobaeus published his initial experiences with laparoscopic surgery in the Münchner Medizinischen Wochenschrift under the title "The Possibilities for Performing Cystoscopy in Examinations of Serous Cavities." He used this technique for diagnostic purposes in undefined abdominal complaints and functional impairment. Jacobaeus was the first who pointed out the possibility of injuring organs, especially the intestines, by inserting the trocar. In 1910, Jacobaeus recognized the immense diagnostic and therapeutic possibilities of laparoscopic surgery, as well as its difficulties and limits. He also was the first to realize the need for initial endoscopic training in animals and corpses. He promoted the development of special laparoscopic instruments to optimize and simplify the procedure.

[Georg Kelling (1866-1945): the man who introduced modern laparoscopy into medicine]. / Georg Kelling (1866-1945): Der Erfinder der modernen Laparoskopie.

On 23 September 1901, Georg Kelling (1866-1945) from Dresden performed a celioscopy with a Nitze cystoscope on a dog in Hamburg. This was the beginning of the era of laparoscopy.His doctoral thesis already reflected his early interest in the anatomy and physiology of the gastrointestinal tract. This experience, together with his knowledge on air insufflation of the abdomen, enabled him to be the first to develop the procedure he named "celioscopy." During this pioneer time of laparoscopy, he developed various basic principles that are still valid today and demonstrated astonishingly visionary skills. Although his pioneering achievements have hardly been acknowledged to this day, modern laparoscopy has confirmed Kelling's visions and scientific work in almost all aspects. His name and achievements have most definitely earned a place in the history of endoscopy.

George Berci: past, present, and future.

Dr. George Berci's contributions to the art and science of endoscopy and laparoscopy have continued unabated for nearly half a century. Fundamental advances in optics, illumination, television application, instrumentation, and operative radiology were either fostered or initiated by him, culminating in the advanced state of the technology as it is known today. As a creative force and catalytic influence, he has been a true pioneer.

From the lumen to the laparoscope.

Throughout the ages, the issues that have defined the management of disease processes have been particularly exemplified in the gastrointestinal tract. The use of gas lamps and candles with reflectors by Bozzini, Segalas, Cruise, and Fisher (19th century) allowed for some ingress into both the upper and lower gastrointestinal tract. Von Mikulicz, Leiter, Nitze, Kelling, and Jacobaeus contributed to the development of rigid instruments that could be used endoscopically or laparoscopically. Endoscopic efforts were amplified and extended by Rosenheim, Sternberg, Wolf, and, finally, Schindler, who not only introduced novel lens systems but also for the most part overcame the problems of flexibility and illumination. Bernheim, Ruddock, Veress, and Palmer made significant technical and clinical contributions to abdominal cavity exploration. The subsequent application of Hopkins and Kapany's work on optics, and the development by Hirschowitz and Curtiss of the flexible fiber optic endoscope, enabled the design of instruments that would allow the appropriate illumination and vision of both the farthest reaches of the bowel as well as the interior of the abdomen. Thus, the same endoscopic instruments coupled with a surgical interest in diagnostic laparotomy allowed for the evolution of minimally invasive surgery along a similar timescale. The cycle whereby diagnostic laparotomy in the early part of the century was supplanted by endoscopy and laparoscopy has now attained full circle whereby laparoscopy has evolved from a diagnostic procedure into one with major therapeutic applications and is perceived as the state-of-the-art technique for a wide variety of operations, including appendectomy, cholecystectomy, hernia repair, fundoplication, splenectomy, colectomy, and gastrointestinal anastomoses.

Eugen Bircher (1882-1956) the first knee surgeon to use diagnostic arthroscopy.

Eugen Bircher was a strong advocate of diagnostic arthroscopy as shown in several papers on the topic of internal derangements of the knee published between 1921 and 1926. During that time, he performed about 60 endoscopic procedures, which usually preceded a meniscectomy. We believe that this was the first time arthroscopy was used in a large scale for clinical purposes. Bircher was the head surgeon of the busy provincial Aarau General Hospital, a right-wing politician, and a highly ranked army officer. His interest in knee surgery was supported by his friend Fritz Steinmann, who was the "man of the pin" and an early promoter of skeletal traction for fracture treatment. Bircher believed in the early surgical treatment of meniscal lesions and, later, in the reconstruction of cruciate ligament lesions. He used the Jacobaeus thoracolaparoscope for arthroscopy, but it had poor endoscopic qualities. The electric lamp at the tip of the optical device was not mechanically protected and was therefore endangered by every manipulation within the joint space. Also, the 90 degrees optical system delivered a dark image. By the late 1920s, Bircher had developed the technique of double-contrast arthrography, and he gave up endoscopy by 1930. In 1935, he left surgery and took a military command in the Swiss army; later he was a representative of the Farmers Party in the National Parliament until his death.

The first laparoscopic cholecystectomy.

Prof Dr Med Erich Mühe of Böblingen, Germany, performed the first laparoscopic cholecystectomy on September 12, 1985. The German Surgical Society rejected Mühe in 1986 after he reported that he had performed the first laparoscopic cholecystectomy, yet in 1992 he received their highest award, the German Surgical Society Anniversary Award. In 1990 in Atlanta, at the Society of American Gastrointestinal Surgeons (SAGES) Convention, Perissat, Berci, Cuschieri, Dubois, and Mouret were recognized by SAGES for performing early laparoscopic cholecystectomies, but Mühe was not. However, in 1999 he was recognized by SAGES for having performed the first laparoscopic cholecystectomy-SAGES invited Mühe to present the Storz Lecture. In Mühe's presentation, titled "The First Laparoscopic Cholecystectomy," which he gave in March 1999 in San Antonio, Texas, he described the first procedure. Finally, Mühe had received the worldwide acclaim that he deserved for his pioneering work. One purpose of this article is to trace the development of the basic instruments used in laparoscopic cholecystectomy. The other purpose is to give Mühe the recognition he deserves for being the developer of the laparoscopic cholecystectomy procedure.

History and instrumentation of laparoscopic surgery.

Equine surgery continues to benefit from advances in endoscopic surgical techniques. Much of what we have learned in equine endoscopy comes from techniques used in humans. Descriptions of the normal anatomy of the standing horse and advances in instrumentation have improved our ability to perform laparoscopic surgery in standing and dorsally recumbent horses. This article describes the history of laparoscopy and available instrumentation.