Over 13 million laparoscopy procedures are performed globally every year, as minimally invasive surgery gradually replaces open surgery. Video laparoscopy was used from the 1980s onwards while the 21st century has seen advances in surgical robotics.
All this is to benefit the patient: less pain, quicker recovery, lower infection and complication rates, and neater scars. It is now routine for cholecystectomy, nephrectomy, hernia repairs, the removal of tumours from the head, neck, lung, bladder and uterus, and a host of other procedures.
The background to this is interesting. Georg Kelling (1866-1945) is credited as a pioneer of minimally invasive surgery. Born in Dresden, Germany, he studied medicine initially at the University of Leipzig and later – on foot of his military service – at the University of Berlin. Achieving his doctorate in 1890, he acquired a post as a surgeon at Dresden Hospital where his specialty was gastrointestinal conditions. In 1901, he performed the world’s first laparoscopy – a procedure he called ‘celioscopy’. In an unsuccessful attempt to control gastrointestinal haemorrhage by insufflation of the abdomen with air, he discovered however that this was a good way to create working space within the abdominal cavity. Using the technique of insufflation to inflate the canine’s abdomen, he inserted a tube with a magnifying lens and an electric light through the abdominal wall. He called this tubular device a cystoscope.
In a sense minimally invasive surgery is very old indeed. In the Neolithic period, small burr holes were drilled into the skulls of countless patients in a procedure known as trepanning. The writings of Hippocrates suggest that the ancient Greeks used tools to inspect the innards of patients in the fourth century BC. But there was little progress made in any of this until 1806, when the German army surgeon Philipp Bozzini invented the Lichtleiter. This device was essentially a tube made of aluminium, containing a candle and a mirror. It was cumbersome and prone to overheating and consequently Bozzini never saw it used, but the French surgeon Antonin Desormeaux resurrected it in 1853, made alterations to its design and renamed it the endoscope. But it was still prone to overheating and thus ended up on the shelf until 1878, when the German urologist Maximilian Nitze incorporated an electric light and greater magnification while using it to examine the inside of a patient’s bladder. It was this more-modern cystoscope that Kelling eventually used in 1901 on his dog. Finally, in 1910, the Swedish surgeon Hans Christian Jacobaeus performed the first actual laparoscopic surgery on a human.
As we know, the incision need only be large enough to insert the endoscope and some small surgical tools; usually, 0.5-1.5cm will do the trick. Modern endoscopes are long, thin, flexible tubes with a miniature light, a small camera and something to collect biopsy samples. When technology allowed it, the obvious source of light would be via a fibre-optic cable. Thus video laparoscopy became the everyday procedure it is today.
Not a bad legacy for Georg Kelling who perished with his wife in the St Valentine’s Day bombings of Dresden in 1945 – the city of his birth and the birth of laparoscopic procedures.
- St John A, Caturegli I, Kubicki NS, Kavic SM. The rise of minimally invasive surgery: 16 year analysis of the progressive replacement of open surgery with laparoscopy. JSLS: J Soc Laparoscopic Robotic Surg 2020; 24(4):e2020.00076