The revolution in laparoscopic surgery began three decades ago when laparoscopic cholecystectomy (LC) was introduced. It did not take long for a consensus to develop and for the National Institutes of Health to pronounce LC as, “the treatment of choice for many patients with symptomatic cholelithiasis.” The procedure had immediate acceptance by patients and surgeons based on clinical experience, and became rapidly popular without randomized trials. Retrospective data shows LC to be safe and effective, and when compared to open cholecystectomy the advantages of LC have been described as, “obvious and compelling.”[2–5]
The laparoscopic revolution in general surgery can thank LC for much of it's initial success and popularity. The tremendous public interest enjoyed by the LC forced general surgeons who had neglected operative laparoscopy to take notice. By helping laparoscopy to get its “foot in the door” among general surgeons, LC has served as the igniting spark in the laparoscopic surgery explosion and has paved the way for the more complex laparoscopic procedure which have become commonplace. Where and when did this laparoscopic revolution start? Who ignited the LC spark? Answers to these questions are hidden by time and distance, and the question remains: Who did the first LC?
THE HISTORY OF LAPAROSCOPIC CHOLECYSTECTOMY
In contrast to its current prominence, laparoscopy initially found few advocates in general surgery. It was more warmly received by gynecologists, notably the German physician and engineer, Kurt Semm. Semm led a research team at the University of Kiel and began using the laparoscopic approach to treat gynecological disorders in the 1970s. He developed instruments and described techniques for ovarectomy, adnectomy and myomectomy. It was not until 1982 when Semm performed an “endoscopic appendectomy” that general surgeons began to take notice. The German surgeon Erich Mühe. responded, “I had the overwhelming feeling that we [general surgeons] had already lost traditional surgical fields like polypectomy, papillotomy, and now even endoscopic appendectomy was discussed. I was convinced that if we passed up [laparoscopic surgery] internist and gynecologist would again take away a piece of our competence.” Inspired by Semm's success, Mühe became interested in the possibility that cholecystectomy could be performed laparoscopically; however, he was concerned that he would be unable to remove a gallbladder full of stones using Semm's instruments. Collaborating with Hans Frost, then an employee of the German manufacturing company WISAP, he worked out the details of an operative laparoscope that could accommodate the delivery of a diseased gallbladder. This effort resulted in the construction of the “Galloscope,” a unique instrument complete with optics, instrument channels, a light conductor, and valves that could maintain pneumoperitoneum when the instrument was in place. Mühe introduced the Galloscope on September 12, 1985 during a planned cholecystectomy. He obtained pneumoperitoneum with a Veress needle and introduced the Galloscope at the patient's umbilicus. He introduced a Weck-Reynolds pistol grip hemoclip applier and scissors either through channels in the Galloscope or through small portholes in her lower abdomen in order to dissect the gallbladder. Then, in the course of roughly 2 hours, Dr. Mühe performed an early version of LC.[9–11]
Mühe continued to perform cholecystectomies laparoscopically and found himself amazed at the rapid recovery enjoyed by those undergoing this new alternative to open surgery. He was, however, not completely satisfied with the technique of the LC. He felt the arrangement of the Galloscope at the umbilicus and the portholes in the lower abdomen made for an awkward working arrangement. He noticed the right costal margin created a “roof” above the gallbladder creating straight-forward access to the gallbladder fossa. He postulated that introducing the scope at the costal margin would eliminate the need for pneumoperitoneum and optic guidance. Initially, Mühe removed the pneumoperitoneum from the procedure and developed what he referred to as “gasless LC.” He then decided that the optical instrument was unnecessary since he was now operating directly over the gallbladder and began working through the trocar sleeve alone. In a final series of modifications, Mühe attached a proctoscope light cable to a simple metal tube he procured from the hospital supply closet and began performing “open tube” cholecystectomies. Of the 94 LCs in Mühe's initial series, the first 6 were done in a “traditional” laparoscopic fashion with pneumoperitoneum and working ports, and the remaining 88 were performed by “LC without pneumoperitoneum and/or without optical guidance.” He preferred the later method because he felt it could be done more quickly and through one skin incision rather than the three to four incisions necessary for LC with pneumoperitoneum and optical guidance. He also felt these modifications would make the technique more attractive to general surgeons and as a result be more readily accepted by the surgical community, supplanting the innovative laparoscopic approach with a technique similar to rigid transanal proctoscopic surgery done today. Mühe first presented his experience at the Congress of the German Surgical Society (GSS) in April of 1986. His presentation was met with skepticism and ridicule. Mühe's procedure was described as “Mickey Mouse surgery” while others remarked “small brain - small incision.”
At the same time, on the same continent, a French surgeon in Lyon, Philippe Mouret, also became interested in applying the endoscopic technique to general surgery. Mouret shared his practice with a gynecologist and saw first hand how laparoscopy improved patient satisfaction and led to increased diagnostic capabilities.
In March of 1987 Mouret was scheduled to perform “laparoscopy, gynecological adhesiolysis, and cholecystectomy” for a 50-year-old woman with vague abdominal pain. According to his personal accounts, this lady requested that Mouret perform the operations at the same time, which he agreed to do if possible. After performing the pelvic phase of the procedure, Mouret reversed the Trendelenburg position and explored the gallbladder area with the laparoscope. He dissected the gallbladder antegrade with a hook dissector as he grasped the gallbladder fundus with forceps inserted directly through the abdominal wall. He cauterized the cystic artery and clipped the cystic duct with a clip applier introduced through the left rectus muscle. Video was not available at this time so Mouret was forced to lie on the patient's right thigh as he peered through the laparoscope and controlled his instruments. In the course of 2 ½ hours, Mouret performed his first LC. He left the case feeling both physically and mentally exhausted as he pondered the “weight of medico-legal responsibility for having innovated in a classic operation, which had reached a stage of near perfection.” The benefits of the laparoscopic approach became obvious to Mouret when he made postoperative rounds on this patient and found her fully dressed and ready to leave the hospital, angry because she did not believe Dr. Mouret had removed her gallbladder!
In the late 1980s François Dubois of Paris, was performing cholecystectomy by “mini-laparotomy.” This technique was popular in France because it called for a very small incision and required no drains. As a result, it led to a shorter hospital stay than the more traditional cholecystectomy. Dubois was proud of his “one-day cholecystectomy,” and shared his enthusiasm with a new scrub nurse, Claire Jeaupitre. She was not impressed by the small size of the incision as she had seen Mouret perform LC in Lyon. When she recounted the LC tale to Dubois, he angered considerably, believing this to be impossible and contacted Mouret. Mouret met Dubois in Paris in December of 1987, and showed him a video of his LC. Dubois performed his first LC in April of 1988.
LC was advanced on a third French front in Bordeaux. Professor Jacques Perissat heard Dubois speak on laparoscopic appendectomy in July 1988. Perissat had been utilizing intracorporeal lithotripsy and had laparoscopically introduced the ultrasonic lithotripter into the gallbladder. Perissat became intrigued by the idea of LC either in conjunction with, or as an alternative to LC with intracorporeal lithotripsy. By early 1989, Perissat was treating most cases of cholelithiasis with intracorporeal lithotripsy followed by LC.
WORD OF LAPAROSCOPIC CHOLECYSTECTOMY SPREADS
The French were successful in reporting their work, and news of the LC and the “French Connection” (Mouret, Dubois, and Perissat) spread quickly. This was in part due to the introduction of video technology with broadcasting of new laparoscopic procedures. In 1989, Perissat presented his video at the American Gastrointestinal Endoscopic Surgeons (SAGES) meeting in Louisville, KY. He attracted great attention because a great surgical ideal was presented in an ideal location. His display booth was located adjacent to the men's restroom, thereby attracting a steady stream of visitors. Months later Dubois's paper “Coelioscopic Cholecystectomy” was published in the Annals of Surgery and found a large American audience. American general surgeon Barry McKernan and American gynecologist William Saye performed LC in the United States in 1988. Then, through collaboration with McKernan and Saye, Nashville surgeons Eddie Reddick and Douglas Olsen began performing LC routinely.
When reviewing the literature on early LC, Mühe is notably absent. In the early 1990s, a few surgeons spoke out in an effort to secure Mühe some of the credit they felt he deserved. In 1992, German physician Geza Garaguly of Austria wrote a letter to the editor of a book on laparoscopy that credited Mouret as the inventor of the LC. Garaguly wrote “much to my amazement, I read in the chapter on LC that you…claim that Philippe Mouret of Lyon was the first to perform LC in 1987. Interestingly, Mouret and Perissat are listed as the first to perform this by German authors in their works as well. At the 1986 German Congress of Surgeons in Munich, I myself heard a paper by a Dr. Mühe where he presented the first cholecystectomy through a laparoscope, which he performed for the first time in September 1985.” He goes on to write, “…he deserves to be mentioned in such prominent works as yours. Perhaps his name escaped your literature search.”
Later that same year, 7 years after his first LC, the German Surgical Society recognized the significance of Mühe's work by awarding him the GSS Anniversary Award. Then in 1999, the SAGES officially recognized Mühe's LC and he presented “The First Laparoscopic Cholecystectomy: Overcoming the Roadblocks on the Road to the Future” in San Antonio, TX in 1999.
THE REJECTION OF LAPAROSCOPIC CHOLECYSTECTOMY
When considering the extraordinarily positive influence LC has made on general surgery, it is difficult to imagine why this innovative procedure was met with such strong opposition. Litynski views the resistance as multifactorial.
The 1970s and early 1980s were a time of great excitement and public interest in the development of non-surgical therapies for cholelithiasis. There was a better understanding of bile and bile salts, and it was anticipated that this knowledge would lead quickly to the chemical dissolution of gallstones. Moreover, external lithotripsy machines were being developed that initially yielded promising results. Traditional laparotomy with cholecystectomy became known as the “old-fashion” approach to gallbladder disease and surgical referrals for cholelithiasis began to wane. With these non-surgical “cures” on the horizon it seemed unnecessary to investigate this new gallbladder surgery as many general surgeons felt that internist would eventually take over the management of cholelithiasis.
LC was being introduced at a time when abdominal surgeries were becoming extensive operations. Bigger and bolder open surgical techniques were being developed regularly. The idea that big problems required big operations led to rejection of minimally invasive surgery. Litynski reports a personal letter written by the editor-in-chief of the Journal of the Society of Laparoendoscopic Surgeons (JSLS), Michael Kavic, “General surgical thinking was oriented to the concept that big problems required big incisions, and that incisions healed side to side, not end to end.” So while complex and radical surgeries were being performed, there was little interest in wasting time changing the surgical management of an operation with a mortality rate as low as that of cholecystectomy.
Most importantly, there were serious reservations about the safety of laparoscopic surgery. This is well-illustrated by the harsh criticism hurled at the early pioneering work of Perissat. Skeptical opponents described laparoscopic surgery as, “a futureless technique, circus surgery, [and] the mediatized show of a tight-rope dancer totally careless of the risks for the patients.
To lead a surgical revolution one has to not only make but promulgate and populatize the innovation. Mühe's pioneering work was hindered because he targeted the German audience almost exclusively. Only seven of his 342 publications appeared in English. Prior to in the introduction of laparoscopic and endoscopic surgery, surgeons held a mindset that surgical innovation belongs to the university surgeons so the fact that Mühe was a private surgeon contributed to the dismissal of his LC. Mouret would later comment that the endorsement and worldwide education given by Professor Perissat, a highly respected and renowned gastrointestinal surgeon, helped LC gain credibility. Mouret credits Perissat and Dubois as holding an equal share in the success of the LC.
THE LAPAROSCOPIC EVOLUTION
The excitement generated by these early champions of laparoscopic surgery was immense. Kavic wrote, “The progenitors of the laparoscopic revolution were few… but they were articulate, and the public was receptive. They preached the new gospel that gallbladders could be removed laparoscopically with less hospitalization, and dramatically less pain. Word spread quickly.” The media also had quite a bit to do with the growth of operative laparoscopy. As reports of “band-aid surgery,” spread, public interest grew rapidly and ultimately the explosion of LC was largely patient driven. The pioneers of operative laparoscopy set up training centers and courses across the country to teach their newly acquired techniques to other general surgeons. Of these innovative men and women, Kavic writes, “They believed they were part of a historical watershed in surgical thought and waged a crusade for laparoscopic general surgery.” “Laparoscopy was not just a different method of access, but represented a different mindset on how to approach a general surgical problem.” If the gallbladder could be approached laparoscopically with such exceptional results, who's then to say laparoscopy could not be used in other surgical procedures like splenectomy, hernia repair, or colectomy? In this way, the LC helped to persuade the surgical community to recognize and ultimately embrace the field of operative laparoscopy.
“Who did the first LC?” As in most surgical innovations the answers are debatable. Who did the first pancreatoduodenectomy? Whipple? Kausch? Codivilla? Who did the first gastrectomy? Billroth? Pean? Surgical and scientific innovations are more accurately described as evolutionary, not revolutionary. Many scientists and physicians were involved in the development of LC, and it was not the result of an individual creator. Although it is human nature to prefer revolution to evolution, nature chooses the latter. The evolutionary biologist and scientific historian Stephen J. Gould describes how Civil War General Abner Doubleday has long been credited with the invention of American baseball. Gould documents that baseball has no single inventor as it evolved from any number of stick and ball games played long before Doubleday was born. As a society we prefer to think of origins in terms of creation rather than as products of evolution, so that in this way we can choose heroes like Mouret, or Mühe or Perissat. LC was not invented one day in the operating theater, rather LC is the dynamic product of years of collaboration and innovation among generations of scientist and physicians. No one individual did the first LC, LC evolved through the efforts of these and many other ingenious surgical heroes and champions.
We extend special thanks to Dr. Tom Theruvath for kindly translating Dr. Mühe's articles printed in German.
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Conflict of Interest: None declared.