Laparoscopy, From Kurt Semm to Robotic Systems

Contents

1. Looking inside before the electric lamp
2. The diagnostic era, from Kelling to Jacobaeus
3. Gynecologists and the operating scope
4. Operating against resistance
5. The robot as a new way to hold the instruments
6. Where conventional laparoscopy stands
7. A short glossary

Laparoscopic surgery sits in Candace Cooley’s surgical experience beside vaginal and abdominal hysterectomy, cystoscopy and hysteroscopy, and it belongs to a field where two things are routinely run together. Laparoscopy is a way of reaching the inside of the abdomen through a few small openings, with a camera and long slender instruments. Robotic surgery is not a separate route at all. Reporting on the hysterectomy research describes the robotic operation as close to the conventional laparoscopic one, except that the surgeon sits at a console away from the table and moves tools mounted on mechanical arms with hand and foot controls.³ The opening is the same. What changed is who, or what, holds the instruments.

Looking inside before the electric lamp

The word endoscopy comes from Greek and means viewing the inner spaces of the body. A review by Ibrahim Alkatout and colleagues in Frontiers in Surgery traces the wish to look inside back to the speculum Hippocrates described, and identifies light as the persistent obstacle.¹ In 1806 Philipp Bozzini, a Frankfurt doctor, published his light conductor, an optical tube with lighting for the vagina, rectum and mouth. Antonin Jean Desormeaux built a portable endoscope in 1843 that burned an open flame, and its heat caused burns. Only after the electric bulb could Maximilian Nitze, in 1877, put a light source inside a cystoscope, the instrument that laid the ground for clinical endoscopy.¹

The diagnostic era, from Kelling to Jacobaeus

The idea of looking into the abdomen with a scope took hold at the start of the twentieth century, a short history from Lublin notes, and its growth later made it the standard way of treating many diseases.² In 1901 Georg Kelling, a Dresden surgeon, inflated the abdomen of a dog with filtered air, looked in with a Nitze cystoscope and called the technique coelioscopy. Nine years later the Swedish internist Hans Christian Jacobaeus reported his experience of the earliest examinations in people.¹

The decades that followed refined the basics. Otto Goetze coined the word pneumoperitoneum for the gas filled abdomen, Richard Zollikofer switched from air to carbon dioxide in 1924, and the Hungarian internist János Veres introduced a spring loaded needle that is still used to inflate the abdomen safely.¹ For most of this period the scope only looked; it did not operate.

Figure

From a lit tube to an operating scope

1. 01
   1806Philipp Bozzini describes his light conductor for looking into body openings.
2. 02
   1901Georg Kelling inspects the air filled abdomen of a dog with a cystoscope and calls it coelioscopy.
3. 03
   1910Hans Christian Jacobaeus reports his experience of the earliest laparoscopies in people.
4. 04
   1924Richard Zollikofer replaces air with carbon dioxide to inflate the abdomen.
5. 05
   1963Kurt Semm builds an automatic carbon dioxide insufflator.
6. 06
   1985Erich Mühe removes a gallbladder through the laparoscope with Semm's instruments.

Gynecologists and the operating scope

The change came largely from gynecology. The review credits gynecologists with the earliest minor operations through the scope in the 1960s, and names Raoul Palmer in Paris and Hans Frangenheim in Germany among the pioneers.¹ Optics improved at the same time: the rod lens system that the British physicist Harold Hopkins developed in 1961 transmitted far more light and gave sharper images. Until about 1970, though, the work stayed mostly diagnostic, because there was no reliable way to stop bleeding through a scope.

Kurt Semm, who led the department of obstetrics and gynecology at Kiel, set out to solve that. He had trained as a precision mechanic before medical school and built much of his own equipment: an automatic carbon dioxide insufflator in 1963, thermocoagulation in 1973, the Roeder loop for tying off vessels, a suction irrigation device, an early morcellator and methods for knotting sutures inside and outside the body. He called his technique pelviscopy, to set it apart from the internists’ examinations of the upper abdomen.¹ In 1985 he built the pelvi trainer, a box for practicing the hand movements, and the Kiel school of gynecological endoscopy followed in 1990.

Operating against resistance

Semm’s colleagues were not persuaded. Critics argued that modern anesthesia had made open abdominal surgery a small matter, and some answered his reports of tubal and ovarian operations with open disbelief.¹ On 13 September 1980 he removed an appendix laparoscopically at his department. Journals turned the report down, and it appeared only in 1983. By his own account, surgeons and gynecologists alike were angry with him, and a colleague later recalled that he was sent for a scan of his skull to show he was well.¹

The resistance gave way within a decade. Erich Mühe used Semm’s instruments for a laparoscopic gallbladder removal in 1985, Reich and colleagues described laparoscopic hysterectomy in 1989, small electronic cameras arrived in 1987, and the urologist John Wickham gave the movement its name, minimally invasive surgery, the same year.¹ A video camera feeding a monitor let the surgeon work with both hands while the whole team watched, which is still the arrangement in a modern hysterectomy or a look inside the uterus.

The robot as a new way to hold the instruments

Robotic systems extend the same approach. Three dimensional views and wristed instruments with seven degrees of freedom let surgeons work without tremor in tight spaces, while the drawbacks are cost, longer early operating times and a fresh learning curve even for experienced laparoscopists.¹

For routine hysterectomy the evidence has been sobering. A JAMA study of more than 260,000 patients found a median hospital cost of $8,868 for robot assisted surgery against $6,679 for laparoscopy, with no significant difference in complications or transfusions, while robotic use grew from 0.5 percent to 9.5 percent of hysterectomies between 2007 and 2010.³ A separate analysis in Obstetrics and Gynecology put the robotic premium near $2,500 per patient with similar perioperative outcomes.⁴

Figure

Laparoscopic and robot assisted hysterectomy

	Conventional laparoscopy	Robot assisted
Where the surgeon works	At the table, holding the instruments	At a console some distance from the table
How the tools move	Directly by hand through small incisions	On robotic arms, by hand and foot controls
Median hospital cost	$6,679	$8,868
Complications and transfusions	No significant difference	No significant difference
Stays longer than two days	More likely	Less likely

In 2013 the president of the specialty’s national college said that robotic surgery was neither the only, the best nor the most cost efficient route to a minimally invasive hysterectomy, with vaginal operations the least invasive and least costly and laparoscopy second on both counts, MDedge reported.⁵ He allowed that complex cancer operations needing lymph node removal might benefit, and cited work suggesting surgeons need 50 to 90 robotic hysterectomies before matching their results with other minimally invasive methods, Fox News reported.⁶

Where conventional laparoscopy stands

Plain laparoscopy has not stood still. A 2025 series of 150 total laparoscopic hysterectomies by one surgeon in North India reported a mean operating time of 39 minutes, a mean blood loss of 25 mL and an average stay of about two days.⁷ The same paper notes that in the United States the laparoscopic share of hysterectomies fell from 15.5 percent in 2006 to 8.6 percent in 2010, partly as robotic operations rose.⁷ Newer variants aim to shrink access further, through a single port or through natural openings.² Which approach suits one patient is a question for her own surgeon, weighed against her anatomy and diagnosis. The longer story of how operations became easier to recover from is told in the history of anesthesia and recovery.

A short glossary

Coelioscopy. Kelling’s and later Palmer’s word for looking into the abdominal cavity with a scope.

Pneumoperitoneum. The gas filled abdomen that gives the surgeon room to see; Goetze coined the term.

Insufflator. The machine that delivers and controls that gas; Semm automated it in 1963.

Veres needle. The spring loaded needle used to start inflating the abdomen.

Pelviscopy. Semm’s name for operating laparoscopy in the female pelvis.

Rod lens. Hopkins’s optical system of 1961, which brightened and sharpened the image.

Robot assisted surgery. Laparoscopy in which the instruments ride on mechanical arms steered from a console.