Techniques allowing the examination of internal organs without large incisions predate the clinical efforts to lower case costs and recovery times that are minimally invasive surgery's chief draws today. In fact, the roots of endoscopy, laparoscopy and related procedures reach back to ancient times.

Dawn of endoscopy
The first minimally invasive procedure on record dates to approximately 400 B.C., when the Greek physician Hippocrates described the use of a rectal speculum to examine hemorrhoids. The excavation of the Roman city of Pompeii, buried by a volcanic eruption in 79 A.D., revealed a vaginal speculum, and instruments closely resembling laparoscopic trocars were found in other Roman ruins.

The reason for these devices? Natural curiosity.

'Just the thought of, 'If I can look through a tube and see something that's otherwise inaccessible, I can make a decision without cutting the body open,'' says Jeffrey Ponsky, MD, chairman of the department of surgery at Case School of Medicine and the University Hospitals of Cleveland in Cleveland, Ohio.

Minimally invasive surgery was built on an incremental history of inventions and improvements. The first step was just seeing clearly.

'The major issue was not the forceps, but vision,' says George Berci, MD, FACS, FRCS, emeritus director of Los Angeles-based Cedars-Sinai Medical Center's surgical endoscopy division, which he founded in 1970. 'To see deeply located organs without exploration.'

Developing tools
Centuries of efforts to reflect and focus light into internal cavities met success in 1806, when Philipp Bozzini of Germany created a 'light transmitter,' a rigid aluminum tube fitted with mirrors that sent candlelight into the body and carried an image out. Dr. Bozzini's professional peers viewed this early endoscope with some skepticism, but it established the founding principles of modern endoscopy.

Dr. Bozzini's device influenced French surgeon Antoine Jean Desormeaux, who used a similar device for urological views in the 1850s, as well as German physician Adolph Kussmaul, who hired professional sword swallowers as subjects for rigid scope examinations of the esophagus and stomach in 1868. Since Dr. Desormeaux's scope used an alcohol-turpentine flame as a light source and Dr. Kussmaul's a gasoline lamp, the risk of burns was a very real possibility and limited the scopes' use. In 1877, however, Maximillian Nitze modified Thomas Edison's light bulb to provide electrical illumination for scopes.

The first decade of the 20th century saw minimally invasive pioneers such as George Kelling in Germany and H.C. Jacobaeus in Sweden using small incisions and insufflation to introduce scopes into animal and human subjects. Their rigid scopes limited access to the gastrointestinal tract, however, requiring the invention of a flexible instrument - and a way to illuminate it.

Assembling the pieces
Building on the earlier use of rigid quartz rods to carry and focus light and the idea that a bundle of rods could be used to transmit a signal, researchers in the 1950s developed fiber optic technology, the contained transmission of light through long, flexible glass or plastic threads. This allowed an external light source to project light and return a clear image without the threat of heat damage to tissue.

German gynecologist Kurt Semm's mid-1960s development of an automatic insufflator that was able to monitor intra-abdominal pressure resulted in greater patient safety. By the mid- to late-1970s, gynecological surgeons worldwide used laparoscopy not just for examinations but for such procedures as suturing and tubal ligation as well.

In 1977, surgeons conducted the first laparoscopically assisted appendectomy, and by 1981 the American Board of Obstetrics and Gynecology made training in laparoscopic techniques a required component of surgical residency.

The laparoscopic revolution
While fiber optic technology provided images from the surgical site, a scope's eyepiece only allowed one person to see them, or perhaps a second observer if a teaching attachment was used. The development of the first solid-state, or chip, camera for laparoscopy in 1982 changed that. Light carried in by fiber optics was now signaled out electronically for a video image.

Dr. Berci, who was instrumental in the early development of the miniaturized video camera, notes three advantages that video images held over an eye to the eyepiece. Human vision, binocular by nature, is weakened when reduced to one, monocular eyepiece, but camera and monitor images remain sharp. A camera lens can magnify an image. And video images can be captured and reproduced.

Plus, more than one pair of eyes can watch a video image at the same time. 'The advent of TV meant you could involve more than one person in a procedure,' says Gerald Marks, MD, FACS, director of the Culshaw Colorectal Research Unit at the Lankenau Institute for Medical Research in Wynnewood, Pa.

'Everybody in the OR could assist,' adds Dr. Ponsky. 'This enabled people to participate. It was so dramatic, it fired the imagination of everyone else,' challenging them to reproduce the results and improve upon them.

One such challenge was the first laparoscopic cholecystectomy, performed by French surgeon Phillipe Mouret in 1987. It, and demonstrations that followed, are regarded to have kicked off the laparoscopic revolution.

Dr. Marks describes Jacques Perissat's lap chole presentation at the Society of American Gastrointestinal and Endoscopic Surgeons' 1989 annual meeting as a procedure 'finding the proper audience.' He could magnify and illuminate the critical area, the neck of the gall bladder. 'Under conventional methods, this might have been a deep and dark hole,' recalls Dr. Marks.

As a procedure, video laparoscopy soon found applications in nearly every specialty. By the late 1990s, it was done through smaller incisions and even with the assistance of robotic consoles.

'It was just a matter of time before creative experts approached the other organs,' says Dr. Marks, 'and showed that virtually every organ could be operated on endoscopically.'