Honorary Chairman's speech: The Society of Laparonendoscopic Surgeons and the future of endoscopic surgery worldwide

CHAIRMAN’S SPEECH 16th International Congress, Society of Laparoendoscopic Surgeons(SLS), San Francisco, USA, September 2007. It is an honour to be asked to be the Honorary Chairman for the 16th SLS Congress, and I strongly feel that our SLS is the leader of multi-disciplinary endoscopic surgery worldwide. In fact endoscopic surgery is practically feasible and offers many advantages including better exposure of the operation field, magnification and adequate panoramic view, and operating very close to the affected tissue1. During the latter part of the 20th Century, endoscopy revolutionised surgical practice so much that clinicians who do not practice advanced endoscopic techniques would be losing an important dimension of contemporary surgical practice 2. With the early introduction of endoscopy in surgical disciplines, it was not uncommon to perform diagnostic endoscopy to diagnose a pathology; followed by a laparotomy to affect definitive treatment 3,4. “Conversion” to laparotomy has known complications 5. While conventional surgery will continue to be a part, albeit diminishing, in professional training programs 6,7, endoscopy is the “gold standard” approach to manage the majority of surgical problems both in elective and emergency situations 8-15. This immeasurable improvement has eventuated as a result of continuous upgrading of endoscopic surgical skills and knowledge, technological advances at diagnostic and operative spheres, improved instrumentation and better interdisciplinary co-operation between active clinicians practicing relevant fields of endoscopic surgery 16-21and hence the valuable role played by multi-disciplinary endoscopic societies notably Society of Laparoendoscopic Surgeons. As the future is a continuum of the past and present and without ideas there is nothing; without ideas and without innovation there is nothing to test 22. It may be relevant to consider some historical aspects of endoscopy. As a gynaecologist, I shall discuss the rocky paths of laparoscopy and hysteroscopy. For centuries, physicians aspired to inspect different body cavities by the use of visual aid 23. In Laparoscopy Many innovations took place in the world of gynaecological endoscopy, and one has to mention with admiration the creative work of the leading pioneers. Attempts at visualising the contents of the abdominal/pelvic cavity were made approximately 1000 years ago as reported by the Arabian physician, Abukasim (936 – 1013 AD) 24. However, the details of this apparently primitive attempt were not clear . In 1901, Kelling made the first attempt to inspect the peritoneal cavity with insufflation. He called it “Koeliskopie”. He reported the abdominal organs were much smaller than normal. That was because he created a very high pneumoperitoneum pressure of 50-60mm Hg and once even 100mm Hg. He employed air to distend the peritoneum 25. In 1910, Jacobaeus from Stockholm coined the term laparoscopy. He did not use pneumoperitoneum as most of his patients had ascites 26. In 1927, Korbsch suggested that the use of carbon dioxide (CO2) instead of air to a pressure less than 15 cm H2O. Unlike air which contains about 79% nitrogen, CO2 is readily absorbed within the body 27. In 1937, Ruddock published his series of 2500 laparoscopic sterilisation. He designed his own telescope, trocar, and pneumoperitoneum needle 28. His contemporary, Hope, suggested the use of laparoscopy in the evaluation of ectopic pregnancies 29. In 1944, Decker and Cherry introduced culdoscopy to visualise abdominal contents. It was performed with the patient under local anaesthesia and in the knee-chest position30. Culdoscopy dominated pelvic endoscopy in the United States for over 20 years. Concerned about the number of unnecessary laparotomies, the late British gynaecologist, Steptoe (1913 – 1988), the father of IVF (in-vitro fertilisation), travelled to Boston and New York, USA, in 1958, to learn about culdoscopy. Unfortunately, Steptoe left America disappointed with the practical value of culdoscopy 31. In 1963, Semm, a German gynaecologist from Kiel University, developed the automatic insufflator “CO2 - Pneu” that allowed more complex laparoscopic procedures to be performed. In 1979, Semm perfected his apparatus, creating an electronic insufflator; fully monitored pneumoperitoneum became possible 32. Semm was one of the world’s leaders of gynaecological endoscopy. However, the path was not all easy for him; but he overcame by persistence. In the seventies, his colleagues suggested only a person with brain damage would perform laparoscopic surgery, and they persuaded Semm to have a brain scan 33! In 1983, Semm reported the first laparoscopic appendicectomy 34. The American Journal of Obstetrics and Gynaecology rejected Semm’s paper on laparoscopic appendicectomy. One of the reviewers questioned the ethical aspect of this procedure 34 ! In 1985, Muhe of Boblingen, Germany, performed the first laparoscopic cholecystectomy. The German Surgical Society rejected Muhe in 1986 after he reported his pioneer operation, and the society considered the operation to be unethical. As he was ahead of his time, he received their highest award in 1992 35. In 1989, Harry Reich of Pennsylvania, USA, reported the first laparoscopic hysterectomy, a procedure that had new concepts and dimensions36,37-; but, again, was not well received in its infancy especially by those physicians who could not perform the operation. And we have just heard the story of struggle of our good friend Professor Hary Hasson and his excellent technique of Open Laparoscopy38 and many other patents that have been proudly adopted and practiced worldwide by many high profile Endoscopic Surgeons. The invention of a rod lens optical system by Hopkins in 1959 and the addition of fibre-optic light transmission by Storz in 1960 have been vital for modern endoscopy. Similarly, an important milestone in laparoscopy was the development of a video computer chip in 1987; that allowed magnification and projection of images onto television screens 39-42. In 1987,C.Nezhat published a much awaited report about the use of videolaparoscopy in Advanced Gynaecological Endoscopic Surgery. This was an important milestone in the development and successful practice of not only minimally- invasive gynaecological operations, but, also, many other disciplines and sub-specialities of surgery42,43. The techniques of video laparoscopic surgery became integrated into general and specialised surgery alike, and were vital for purposes of training, teaching and involving all operating theatre personnel in the following of surgical procedures. In Hysteroscopy Similar to laparoscopy, the modern operative hysteroscope evolved through many stages of development. The uterine cavity, like any other cavity in the body, is empty and dark and is a potential (not a real) cavity. In 1807, Bozini described a vase-shaped lantern made of tin and covered with leather to examine the uterine cavity. Interestingly, he declared that “adhesions, polyps and tumours will be operated upon under direct vision” 44. In 1869, Pantaleoni wrote on “endoscopic examination of the cavity of the womb” in which he stated that invention of the ophthalmoscope and laryngoscope led to the invention of the endoscope45. The problem was how to throw sufficient light into an internal dark cavity. However, later on in the nineteenth century, Dr Cruise of Dublin introduced a light and prevented the instrument from becoming heated by light 46. In 1908, David, Paris University, wrote “sheaths and hysteroscopes of different sizes were made to meet anatomic variations in size, length and degree of cervical dilatation” 47. After these early contributions, illumination systems changed from candle-light and reflected light and were replaced by the electric bulb and distal lighting, proximal lighting, halogen, and xenon light systems and, most recently, fibre-optic systems 48. The initial attempts led to a long process of continuous improvement that allowed the gynaecological surgeon to perform complicated hysteroscopic and laparoscopic procedures without resort to laparotomy. Recent advances in fibre-optic technology have been the cornerstone of adequate visualisation of the operation field, which is the essential prerequisite of any operative procedure anywhere in the body 49-51. In essence, clinicians learned from their mistakes as well as their colleagues in different specialities of medicine. They all had great obstacles to overcome; nevertheless, they rose to the challenge and proved that success is an ongoing journey. At this point in time, clinicians and patients are cashing in on the benefits of the work of our predecessors. However, today’s challenges are by no means simple. Training and quality assurance are important issues 52-54. The surgeon must pass through a learning curve to acquire and maintain new skills and special expertise, and to avoid, recognise and manage complications of advanced endoscopic surgery 55. In fact, the learning process has to be closely tied with a vigorous system of quality assurance. A balance has to be struck between the ethical obligations to benefit patients while avoiding harm, and the professional expectation of continued learning, and this has to be maintained and expanded as long as surgical practice continues so that surgeons will be able to successfully follow the ever moving horizon of endoscopic surgery. The development and continuous progression of endoscopic surgery is a cumulative effort of internists, gynaecologists, urologists and surgeons alike. Hence, multi-disciplinary societies of minimally invasive surgery, notably the Society of Laparoendoscopic Surgery, play a leading role in the 21st Century. A/Professor Mark Erian, MD(University of Queensland),FRCOG,FRANZCOG,CAGE(USA) Senior Consultant Obstetrician and Gynaecologist, University of Queensland / Royal Brisbane and Women’s Hospital, Herston Q 4029,Australia E-Mail Address: M.Erian@uq.edu.a