History

Since ancient times, medical men desired to inspect human body cavities and passages to understand their complexity and to treat their diseases. Easily accessible body cavities like the mouth, rectum or even the vagina were already inspected in the ancient times with the help of speculums.

Accounts of catheters and rectal speculums are handed down from Hippocrates II. The Greek, born on the island of Kos and known for the Hippocratic oath, inserted in the vagina, tampons with threads using hollowed kalabass. However, the Greeks did not dare to use a speculum to view the rectum or inspect the vagina.
Erasistos, born in 320 BC.in Keos was first to describe anatomically correct curved catheters. Oreibasis, born in 325 B.C. in Pergamon invented the indwelling catheter at Rome in the times of Julius Caesar. He also dilated the urethra with a goose quill swathed in swollen parchment.
The origin of endoscopy can be traced back to a reference in Babylonian Talmud. The treatise describes a lead funnel with curved mouth, furnished with wooden outlet (Mechul). Both the parts were inserted in the vagina to show by retraction for the first time to human eyes, the cervical os as internal organ, to diagnose uterine bleeding and differentiate it from the vaginal bleeding.
A triple armed vaginal mirror and a rectal speculum were excavated in Pompei. The Syrian gynecologist, Archigenes from Apameia who practiced in Rome from 95-117 B.C., wrote a treatise on uterine bleedings. He used a cervical mirror for inspection and commented on various forms of gynecologic palpatory examinations as well as external and internal inspection.

The Arab, Abul-Qasim Khalaf Ibn Abbas Al Zahrawi is regarded as middle ages’ most eminent surgeon. Also known as Alsaha-Ravius or Albucasis of Cordoba (936-1009), he used a glass mirror to reflect light to view the inside of the vagina. He described his speculum as ‘ two rods, one lying on the top of the other, which is introduced in the cervix (probably meant vagina) to expand it with the help of screws.
The first endoscopic light source can be traced back to Gulio Cesare Aranzi (1530-1589). This Venezuelan used camera obscura (1587) to focus a ray of light to view the nasal cavity. He held water filled spherical glass bottle in front of a hole in a shutter in a darkened room and projected that focused light to view the nasal cavity. He recommended an artificial light source on rainy days.

The French gynecologist and surgeon, George Arnaud de Rosil (1698-1774) gave new significance to the vaginal speculum that was developed over of a century. Arnaud (1768) was the first to use endoscopic examination lamp making use of a covered lantern. The light source was a night lamp that was placed in a box painted silver from inside. Similar to camera obscura, light focused through a convex lens could be used to illuminate the vagina that was opened with a speculum.

Philipp Bozzini (1773-1809) who marks the turning point from the old to new medicine must unquestionably be mentioned for his contributions to the development of modern endoscopy. Bozzini studied in Mainz and Jena where he became acquainted with Christoph Wilhelm Hufeland who published the ‘Journal of practical pharmaceutics and art of wound healing’. In 1804 he published the first description of his instruments in a small Frankfurt newspaper. The equipment had optical part with illumination device and mechanical part that adapted itself to the anatomy of the body orifice. In 1806 he published a detailed account of his light guide.
In 1807 the national industrial Comptoir, Weimar published the monograph, “the light guide or the account of a simple device to illuminate internal cavities and passages of living animals”. Bozzini himself made the sketches and even engraved them in copper. Bozzini constructed an instrument for vagina, rectum and oral cavity including the throat. One could see and even operate on a modest scale with it. Even though the light source was too weak and the visual field too small, all further attempts at cystoscopy in the next seventy years were exclusively based on Bozzini’s illumination principle using extracorporeal light source to reflect the light. His principle of using artificial light source, reflection of the light towards the object to be examined as well as the light conduction and directing the reflection and re reflection to the observing eye, substantially influenced the international discussions on the development of endoscopes.

Antonin Jean Desormeaux (1815-1894) constructed the first portable endoscope and presented this historic development on 29. November 1843, for which received a part of Argenteuil prize from the Academie imperiale de Medicine. Desormeaux was first to clinically use Bozzini’s light guide for which many regard him the “Father of endoscopy”. His instrument was a system of mirrors and lenses with an open flame as light source. Skin burns were most frequent complication. The light guide was essentially used in patients with urological illnesses.
The most important development of endoscopic abdominal surgery is connected with photography and television. Theodor S. Stein (1868) started it in Frankfurt. In 1874 he introduced his “photo endoscope” .

Gynecology was the so to say initiator of the development of operative endoscopy. Apart from Desormeaux (1865), Aubinais (1864) and Pantaleoni (1869) must be also mentioned for their attempts to inspect the uterine cavity, that is today’s hysteroscopy. The technical development of endoscopy to perfection was left to cystoscopy. The plausible cause is: the Mignon filament (Edison) at the tip of the cystoscope by Nitze and Leiter (1879a, 1879b) posed no danger of burns because the urine in the urinary bladder ensured appropriate cooling.

In 1881 Johann Mikulicz (1850 -1905) and Leiter adopted the principle of rigid optic system developed by Max Nitze and successfully constructed the first clinically usable gastroscope. Mekulicz carried out several clinical examinations at Billroth’s surgical clinic in Vienna.
Between 1890 and 1900 George Kelling (1866-1945) of Dresden worked on anatomy and physiology of the stomach ‘to determine the size of the stomach’. He gained experience in oral air insufflation (1892) and worked on the pressure ratio of the gastrointestinal tract and the abdominal cavity. Simultaneously he worked on improving the techniques of examination of the gastrointestinal tract, which resulted in application for a patent (1897).

Kelling’s know-how of gastric and oesophageal endoscopy and his knowledge of air insufflation were the foundation of the future attempts to carry out therapeutic and diagnostic examinations in closed body cavities. The brilliant idea of connecting his air insufflation apparatus to the Fiedler trocar and Nitze cystoscope led to the birth of laparoscopy.
On twenty-third of September 1901, George Kelling gave the historic lecture on ‘Tour of the oesophagus and stomach by flexible instruments’ to natural history scientists and doctors’ seventy-third meeting in Hamburg. He also introduced his new procedure that he called ‘Coelioscopy’. Kelling had used his oral air insufflation apparatus for the intra-abdominal insufflation together with a Nitze-cystoscope for illumination to see the abdomen of a dog, in animal experiment for the time.

“I question myself, how the organs will react to the air introduced in side? To find out, I have developed a method to introduce the endoscope in the closed abdominal cavity (Coelioscopy)

After an interval of a century and considering the status of endoscopy today, one can evaluate Kelling’s endoscopic work of as follows:

• Contradicting the spirit of times, Kelling had favored the endoscopic procedure to exploratory laparotomy (1898)
• With far sight Kelling challenged the stage wise treatment of malignancy and for this purpose sent repeated reminders for the primary use of endoscopic procedure (1898)
• Kelling was the first to assemble all the basic instruments for laparoscopy with insufflation needle (Fiedler trocar), insufflation apparatus (Air pump by Politser), optic trocar and telescope (Nitzes cystoscope) and described the method (1901)
• Kelling, for the first time in 1901 formulated indications and contraindications for coelioscopy/laparoscopy.
• Kelling demonstrated for the first time the possibility of intraabdominal diagnostics by endoscopic inspection and palpation (1901)
• In 1901, Kelling advised –clearly foreseeing the problems in training young doctors, to practice endoscopic procedures on cadavers. A hundred years ago, dummies were not available to the pioneer of endoscopy
• Kelling, a visionary, had predicted use of endoscopic interventions particularly, laparoscopy as day care procedures (1901).
• Ahead of his time, Kelling had recognized the profitable economical aspects of endoscopic surgery (1923)

In 1911 internist Hans Christian Jacobaeus (1879-1937) from Stockholm introduced the term, ‘laparothoracoscopy’. He was first to view thorax and abdominal cavity by endoscopy and recommended endoscopic technique to view other body cavities. In contrast to Kelling, he inserted the trocar directly without creating pneumoperitoneum. Jacobaeus began like Kelling by breaking down the adhesions under thoracoscopic vision.
Bertram M. Bernheim (1880-1958) of Johns Hopkins Hospital introduced endoscopic surgery in USA in 1911. He called the procedure ‘organoscopy’. His instrument consisted of half-inch proctoscope and a simple light.

Constant improvements in the laparoscopic methodology smoothened the way for its wider operative use. The important steps in the process were, the use of the harmless carbon-di-oxide (CO2) for pneumoperitoneum by Zollikofer in Switzerland (1924), the coagulation of adhesions by Fervers in Germany (1933) and the intra-abdominal use of monopolar current by Ruddock in USA (1934).
Boesch, from Swiss Aarau reported in his paper on laparoscopy about ‘wonderful perspective of the feminine, not deformed genitals of woman and about the exposure of hidden organs, e.g. the ovaries with an elevator (palpation probe)’ (1936). He noted further: ‘with the laparoscope we have obtained a way to carry out the tubal sterilization for the given indication with out laparotomy. With a suitably insulated coagulation clamp, the tubes can be coagulated at multiple places in 3-5 minutes under endoscopic vision’ . Frank H. Power and Allen C. Barnes (1941) developed the same technique in USA, however they used a peritoneoscope for tubal sterilization.
The insufflation of abdominal cavity by instruments was problematic for a long time. Kelling carried it out with the Fiedler trocar, which had a blunt “mandrin” to avoid injuries; Otto Goetze (1886-1957) who coined the term “pneumoperitoneum”, in 1918 produced a similar instrument with spring mechanism for air insufflation for contrast radiograms.
In the year 1938, the Hungarian, Janos Veress (1903-1979) developed a special canula with spring mechanism –with the aim to create pneumothorax and consequently to treat tuberculosis which was prevalent at that time. With little modifications the Veress needle is used still today to create pneumoperitoneum for laparoscopy. Its special mechanism prevents injury to the internal organs during needle insertion through the anterior abdominal wall.
In the sixties of the twentieth century, gynecologist first began small operative interventions. However, the French gynecologist Raoul Palmer had already carried out laparoscopy in the Trendelenburg position in 1944. In this position the intestines were displaced out of the pelvis and consequently could be better assessed during the operation. Additionally, he required continuous gas insufflation, which was controlled automatically. Palmer also carried out the first laparoscopic sterilization in Paris.
The piercing of the umbilicus for the laparoscope by Raoul Palmer in 1946 was a groundbreaking procedure in gynecology. Like Kelling, he called the endoscopic diagnostic procedure ‘Coelioscopy’ and developed several methods to insert endoscope. The abdominal access involved many technical difficulties because of mainly blind insertion technique through the anterior abdominal wall. Decker, an American introduced the laparoscope transvaginally, through the vaginal fornix (Decker 1946, 1949, 1951). He called this procedure Douglasscopy or Culdoscopy. Douglasscopy from diagnostic perspective was insufficient. This technique that was initially prevalent in America later lost its importance. In 1998 it was team of Gordts (Brosens et al.1998; Gordts et al. 1998a, 1998b) that brought about a Renaissance of this procedure as transvaginal hydrolaparoscopy for the diagnosis of sterility.

Hans Frangenheim (born in 1920) and Kurt Semm (born in 1927) helped in a special way to develop laparoscopy in Germany after the Second World War.
In 1950 Hans Frangenheim began his training in gynecology at the National Gynecological Hospital at Wuppertal with Anselmino and in 1951 came in contact with laparoscopy for the first time. He was called to the medical clinic in Cologne where a lower abdominal tumour was diagnosed during hepatoscopy and further line of treatment had to be decided. Looking back he wrote:
‘I sensed there, that a new aid had presented itself for the field of gynecology and so began to look into literature. A remark made by Kalk in a textbook had impressed me the most, which said, it is certain that gynecology would open a big field of indications for laparoscopy’.
After his appointment in October 1955 to the post of assistant medical director of the National Gynecological Hospital at Wuppertal, Frangenheim attended lectures by Palmer in Paris and realized that laparoscopy was clearly superior to culdoscopy, which was still practiced in Germany. Then he concentrated on regulating uncontrolled gas insufflation, developing new instruments and photographic documentation of endoscopic findings. He had difficult time with German endoscopy firms. Finally, with modified anaesthesia equipment from Drager, he succeeded in reducing the gas pressure from the customary 50 mm Hg to 15 mm Hg. and restricting the carbon-di-oxide gas flow to maximum of 5 liters per minute. Frangenheim even defined indications for the diagnostic laparoscopy in extrauterine pregnancy, chronic lower abdominal pain, sterility and ovarian tumours.
His monographs, ‘Laparoscopy and Culdoscopy in Gynecology’ (1959), ‘Laparoscopy in gynecology, surgery and paediatrics’ (1976), ‘Diagnostic and operative laparoscopy in gynecology- atlas with colour illustrations’ (1980) as well as countless publications and lectures contributed to further spread of the method.
In 1966 he was the medical superintendent of the Gynecological clinic at Konstanz and European congress for endoscopy was held under his presidency in Konstanz at Lake Constance and from that event laparoscopy received further impetus. In 1982 Frangenheim received the First order of the Federal Republic of Germany for his outstanding work. On the occasion of his eightieth birthday Semm praised Frangenheim for his contribution with these words: ‘today the name, Frangenheim is inseparably associated with the gynecologic laparoscopic methods. His achievements for Germany and for the world are epoch making and will go down in the annals of history’.
The Kiel University clinic for women under Semm (born in 1927) is regarded as the birthplace of modern endoscopic surgery. Semm collaborating with Richard Fikentscher (1903-1993) developed a new universal insufflation equipment (Fikentscher and Semm 1955,1959,1970), for the diagnosis of tubal patency i.e. blowing through the fallopian tubes by Rubin (Semm 1964). Befitting his knowledge of tubal insufflation, Semm developed an apparatus called “CO₂ Pneumo” for insufflating CO₂ gas during laparoscopy to minimize operative risks of endoscopy (Semm et al.1967). The instrument was in use from 1964 onwards at the second university clinic for women in Munich and created pneumoperitoneum automatically (Semm 1967). The cold light (extracorporeal light that shone across a bundle of fibreglass) was simultaneously developed. Together, they eliminated intestinal burns and gas embolus that were the main dangers of gynecological laparoscopy. In spite of all the progress, world over the gynecological diagnostic laparoscopy was universally rejected. So, Semm selected the word Pelviscopy to project that a new technique was developed. Starting 1965, within three years, this new method spread quickly within Germany as a diagnostic procedure of female infertility. In 1976 Semm developed an electronic version of CO₂ - Pneumo”- with the quadrotest for operative Pelviscopy (Semm 1876).
After Semm demonstrated the “CO₂-Pneumo” at the congress of the American Fertility Association in Washington in 1969, Cohen published a book on this procedure in 1970. In USA, the acceptance of this new method of pelviscopic procedures in gynecology was phenomenal. Even though the method was used a million times, it was employed in 95% of the cases only for tubal sterilization, unlike in Europe (Semm 1976b), where Boesch already accomplished this 35 years before. The ignorance about the laws of physics while using the high frequency energy in closed body cavities was the cause of many grave accidents causing burns to the internal organs like intestines and ureter. Such incidents once more deeply incriminated this method.
Fascinated by the idea, that pelviscopy can be used not only for sterilization but also for other operative purposes (Hulka et al.1973), Semm introduced in his new regimen for haemostasis in New Orleans in 1974 (endocoagulator®). The use of high frequency current for creating destructive heat was not required in endocoagulation. The human body did not come in contact with the electrical energy. Optimal controlled haemostasis takes place at 110 oC. Between 1970-1980, the high frequency current in the mono and bipolar techniques using inadequately covered apparatus led to uncontrollable burns, today, in clinical endoscopic practice also, it is ensured that the electro energy used under vision does not lead to burns. The modern coagulation and cutting equipments which work on mono and bipolar current have control mechanisms that minimize the risk of unintentional burns. Bi and monopolar instruments have a controlled, restricted coagulation zone (Semm 1972).
Semm, who produced his own instruments, as he was a skilled instrument maker himself, built an automatic CO2 insufflator in 1963, introduced thermo coagulation in 1973 and used for the first time the Roeder loop to stop arterial bleeding. For the laparoscopy he developed special suction irrigation equipment and an electronic insufflator. Difficult interventions were possible because of the methods of haemostasis (endosuture with intra and extra corporeal knots) developed by Semm and his range of instruments. However, many physicians, gynecologists as well as surgeons criticized Semm for his vehement use of the so-called “key hole” surgery. They were of the opinion that due to the modern anaesthetic techniques, big operations by laparotomy posed no problems and Semm had exaggerated the problems with subsequent adhesions. Some treated the news of the new spectrum of operations (oophorectomy or the removal of complete uterine appendages, treatment of tubal pregnancy) with disbelief and concluded that Semm has started his operation as laparoscopy and then ended it as conventional operation by laparotomy.
Semm was exposed to the most intense hostility of the German gynecologists (and endoscopic surgeons) when he carried out the first laparoscopic appendectomy in 1983.The surgeons especially saw no need to abandon the established operative method and to replace it with technically more difficult one. Semm’s first attempt at publishing his method therefore met with rejection. The fact that a gynecologist wanted to show the surgeons, how an operation should be carried out was simply unthinkable at that time. Semm had crossed the limit that was till then considered as sacrosanct. But he knew that endoscopic surgery had enormous potential not only in gynecology but especially in surgery and therefore continued with his endeavors in laparoscopy, unperturbed towards the goal, of reducing the surgical trauma to the patients. Two German surgeons, Friedrich Gotz and Arnold Pier followed Semms’s intent and provided a wider base to laparoscopic appendectomy. In the early nineties they had already carried out hundreds of appendectomies in this way and perfected the technique, which they could now use even in acute appendicitis.
In 1977 a 10mm morcellator (Semm 1977) was produced for pelviscopy purposes. However, in today’s operative pelviscopy where even fist size myomata are removed from the uterus with little blood loss, this instrument is not very effective. So in 1988, the manually operated SEMM (Serrated Edged Macro Morcellator) of 15to 20mm diameter was introduced. The instrument could reduce a myoma of about 5cm.size to small pieces within few minutes. The posterior colpotomy for removal of myoma or even a small abdominal incision was not required any more (Semm and Mettler 1980). Since the introduction of horizontal morcellation (Semm 1997), the morcellators are motorized and are available in 10mm to 24 mm diameters.
Just like laparotomy, intra-abdominal irrigation equipments are necessary in laparoscopy also to guarantee good view. The aquapurator of 1974 gave way to CO₂- aquapurator in 1990.Today the aquapurator biotherm has removed many problems of hypothermia-even in operations of longer duration. In 1994, insufflation of preheated CO₂, was introduced to preserve isothermia.
In September 1985 a surgeon from Böblingen, Erich Mühe, (born in 1938) performed laparoscopic cholecystectomy for the first time in the world using Semm’s instruments. In 1987, Mühe reported 97 successful laparoscopic operations. In the year 1989, Reich et al. described the first laparoscopic assisted vaginal hysterectomy. In 1991 Mouret carried out the first cholecystectomy by video laparoscopy.
In the 70s and 80s most of the surgeons simply ignored the development of laparoscopic operations because of introduction of new medicines, the impressive results of intensive care and the innovations in anaesthesia that facilitated extensive surgeries. The basic concept, that a big problem (disease) requires a big solution (abdominal incision) was so deeply rooted in surgeon’s thinking that there was no place for “keyhole surgery”. This is why the surgical fraternity refused to accept and modify gynecological instruments for their use.
However, contrary to the general development some surgeons accepted the challenge and accelerated the introduction of laparoscopic techniques in surgery. A group of German surgeons was particularly active in this process and in December 1976 started CAES (Surgical Association for Endoscopy and Sonography) in Hamburg. In USA the society of American Gastrointestinal Endoscopic Surgeons (SAGES) was set up five years later. In the following years both the organizations laid the foundation for the introduction of endoscopy in clinical practice.
Prompted by Dr. Bernd Manegold, a surgeon from Manheim and one of the founders of the CAES, the first edition of the scientific journal ‘surgical endoscopy’ was published in 1987 under the direction of many leading endoscopists. Just the following year ‘the first world congress for surgical endoscopy’ was held in Berlin which was a great success where 500 experts from all over the world participated. This finally led to the acceptance of endoscopy in surgery.
In 1983, the British urologist John E.A. Wickham (born in 1927) used the concept “minimally invasive surgery” for the first time. The concept attracted attention in 1987 after Wickham published his visions of extensive endoscopic treatment in the famous British Journal of Urology. In spite of the strong criticism it mirrored the general trend of the 80s as the minimally invasive techniques had greatly fascinated the doctors and their patients.
This development was further accelerated by crucial technological innovations. The introduction of new light sources (Palmer 1953), the Hopkins optics (1960) and the cold light source had already improved the illumination in endoscopic operations in the 60s. The video technique was also important. The new video camera was much smaller and therefore easier to manage than its predecessor and the videocassettes also were simpler for every day use than the 8mm or 16mm film. In the 80s more surgeons used video cameras, but even the latest and smallest of the camera together with endoscope proved unwieldy because it altered the balance and made precision work difficult. Electronic minicamera brought the breakthrough: a 4 mm optoelectronic transducer (CCD) converted the view from inside the body cavity to electronic impulses and transferred them to the monitor. The combination of optic trocar and video camera opened new possibilities for the surgeons because now with both the hands free, they could operate ambidextrously and simultaneously follow on the monitor what was happening along with the entire team.
The years that followed were moulded by a lively exchange and reciprocal stimulation. The video laparoscopy of cholecystectomy in 1987 in Lyon by Philipe Mouret (born in 1937) and his presentation of the procedure in the SAGES meeting in Louisville triggered a down right boom in France and also encouraged surgeons in the entire world to tread this path further.
When Semm presented his laparoscopic appendectomy in Baltimore in 1988, J.B. Mckernan and W.B. Saye took it up and in June 1988 they reported the first laparoscopic cholecystectomy in USA using Semm’s instruments and combining the procedure with laser technology. As a result many successful endoscopists visited both the protagonists in Nashville to learn the new technique. At the same time, Sung Tao Ko from Chicago upheld the laparoscopic appendectomy by Semm and brought his instruments to America.
The news about these sensational methods reached even the media in USA. During a TV talk show it was made public with the help of gall bladder operation. After that the Nashville surgeons received hundreds of calls not only from the patients but also from doctors.
As in October 1989, Douglas O.Olsen and Eddie Joe Reddick announced their courses casually at the congress of the ACS (American College of Surgeon) for laparoscopic cholecystectomy, they were booked in the shortest of time and new courses had to be planned. Many American observers felt that laparoscopy has pervaded the entire surgical fraternity in USA. In the following weeks a wave of enthusiasm about this new technique passed through the nation and training courses sprung like mushrooms. The industry was confronted with an abundance of orders so that the waiting period rose up to six months. In the beginning the leading endoscopists tried to chanalise the development and to warn about the risks of injudicious use but soon they realized that it was not possible. No one had thought before 1989, that one of the most established operative method in surgery, cholecystectomy, would change so radically within just a few months. Even the surgeons who had substantially contributed to this development were surprised by the speed. Literally thousands of surgeons had to retrain themselves. The OP-courses were booked for months and the shortage of instruments was an unheard of phenomenon in the western medicine. In the following years with the spread of laparoscopy, as the experiences increased, new operative methods quickly developed in many operative specialities.
The production of endoscopic instruments in the industry showed an upswing and the interaction and interest of the various medical specialities –surgery, urology and gynecology, increased. Today the interest of the industry, doctors and patients worldwide is reflected in a common endeavour, betterment of surgery in many aspects through modern technology. That is reflected in further developments in the use of digital picture control, robotic instruments, computers and tele surgery. The numerous specilities which have emerged and which deal increasingly with the oncological fields also reflect these efforts. That is why in 1965 the German Society for Gynecologic Endoscopy and in 1971 the American Society for Gynecologic Endoscopy were founded. The World Society for gynecologic surgery (1986), the European Society for Gynecologic Endoscopy (ESGE, 1990) and the International Society for Gynecologic Endoscopy (ISGE, 1991) came into being with yearly or two-yearly meetings.
The development of hysteroscopy and fallopioscopy must be mentioned here. After Lindermann (1971) and Semm (1974) established the CO₂ hysteroscopy, the real breakthrough in the operative hysteroscopy came after 1980 (Hamou 1981; Campo et al. 1990)-basically as fluid hysteroscopy. Today hysteroscopy is a routine procedure and one cannot imagine diagnostic and therapeutic interventions without it.
From today’s point of view, the ideal entry for viewing the tubal lumen is by hysteroscopy, through a transcervical and transuterine catheter with 0.8 mm thick telescope on flexible falloposcope. (Kerin et al.1990; Rimbach et al.1997).
When one compares the gynecologic endoscopic surgical work of the 80s, primarily the sterilization, conservative operations on the adnexa and the enucleation of myoma were described. As against that, from 1989 the publications on adhesiolysis, appendectomy (Semm 1982, 1983), lymphadenectomy and laparoscopy assisted vaginal hysterectomy in different variations frequently appeared. In surgery, besides gall bladder resection, fundoplication and hernia operations, extensive splenectomies, bowel resections and great advances in surgical oncology and the neurosergery are described. In orthopedics, the operations on knee are improved further. In urology, there are reports on nephrectomies (Rassweiler et al. 1998a; 1998b; 1998c) and the first robotic prostatic resection. (Wickham and Daniel 1995). In gynecology, robotic optic holders (Mettler et al.1198) and instruments are employed.
The worldwide evolution for improvement of endoscopic surgery has begun; its end is still not in sight. The aim of this surgery is to achieve at least the same, if not better results as with conventional operative techniques.
In conclusion, it must be stressed that the history of laparoscopy and its introduction in the surgical practice is a story of many researchers, who for years battled against prevalent general thinking and partly against rejection of their brainchild of performing ‘gentle operations.’ Many of the pioneers were ignored, called dreamers or regarded as crazy. It is only through their persistence, tenacity and their strong personalities they could stand firm in the face of adversities.
The history of laparoscopy is a unique mixture of various trends in different fields, spurred by the activities of established societies as well as opportunities of their publication and influenced by the world congress. The influence of industry, which has kept pace and actively supported this development for years, should not be forgotten. Without suitable technology, this dissemination would not have been possible.