Historical advancements in surgical technology are often traced to roots in gynecology. From Hippocrates’ use of tin catheters and pomegranate pessaries to modern robotic-assisted procedures, surgical progress has been molded by the innovations of gynecologists.
Vaginal hysterectomies date back to 50 BC with Themison of Athens. Early hysterectomies were performed to fix prolapsed uteri or infection. In 120 AD, Soranus of Ephesus performed hysterectomies and revolutionized the understanding of the uterus and uterine cavity through human dissections. , While these procedures were often fatal or left patients with significant urogenital trauma, the teachings of Soranus of Ephesus guided gynecologic studies well into the 1600s ( Fig. 36.1 ). ,
The early history of endoscopy is also rooted in gynecology. Philipp Bozzini, a practicing obstetrician in 1806, created the first lighted endoscope coined the Lichtleiter . , The Lichtleiter utilized staggered mirrors inside an aluminum container to reflect candlelight into a single beam. Dr. Bozzini described the endoscope as a cystoscope useful for observing bladder stones and venereal diseases. , Unfortunately, the invention was largely undervalued and dismissed by physicians and educational institutes, and Bozzini was admonished for his work. , In following years, Bozzini’s endoscope was modified and adopted for use outside the field of obstetrics and gynecology, revolutionizing urologic procedures and examination of the digestive tract. ,
In 1809 Ephraim McDowell performed the first documented laparotomy in order to remove an ovarian cyst. Four years later in 1813, Konrad Langenbeck of Göttingen performed the first planned and purposeful modern day vaginal hysterectomy. Despite the achievement, Langenbeck was not believed by colleagues until 26 years later when his patient passed away and the postmortem exam revealed an absent uterus. In 1822, Sauter of Baden performed the first nonprolapsed vaginal hysterectomy with entry into the peritoneal cavity for the management of cervical cancer. Sadly, this patient ultimately died months later from complications arising from postoperative fistula formation. The first successful abdominal myomectomy with uterus preservation was performed by Washington and John Atlee in 1844, and the first successful vaginal myomectomy was performed by Washington Atlee a year later. Ten years later, in 1853, Walter Burnham performed the first documented and successful abdominal hysterectomy; unfortunately, it was not the intended procedure, with the laparotomy being performed to remove an enlarged ovary. , In 1856, the first successful abdominal hysterectomy in the United States with bilateral salpingo-oophorectomy was performed by William Baker, and, in 1895, the first radical hysterectomy was performed for the treatment of cervical cancer. Hysterectomies at this time were a gruesome experience for patients, and abdominal hysterectomies were condemned in Paris by 1872. By the 1920s, the mortality rate for both vaginal and abdominal hysterectomies had decreased to just 2% to 3%.
The next major advancement in endoscopy occurred in 1901 when the German surgeon, Georg Kelling, performed the first experimental laparoscopy. Using an animal model, Kelling pumped air into an incision in a dog’s abdomen to visualize the abdominal contents. Kelling understood the potential of laparoscopy and described how it might be used to stop hemorrhage in a ruptured ectopic pregnancy. The first human laparoscopic cases occurred from 1901 to 1911; however, these were largely accomplished by internists such as Hans Christian Jacobaeus and Bertram Bernheim to visualize the lung and abdominal cavity. , It was not until the 1930s and 1940s that the use of the laparoscope returned to the field of gynecology. , Despite this 20-year gap, gynecological surgeons were among the first surgeons to utilize and incorporate laparoscopic equipment in practice. In 1933, lysis of adhesions using laparoscopy was first described by gynecologist Karl Fervers, and, in 1936, a Swiss gynecologist named P.F. Boesch performed the first documented tubal sterilization with electrocauterization. In the 1940s, gynecologist Raoul Palmer first utilized laparoscopy to examine reproductive organs, diagnose gynecological and fertility issues, and terminate pregnancies. , , He is responsible for introducing Trendelenburg positioning and monitoring intra-abdominal pressure, still key components of today’s laparoscopic and robotic surgery. , Palmer also described his use of the laparoscope and electrosurgery in the management of infertility, contraception, and tubal ligation. , Through his teaching, his student Patrick Steptoe utilized laparoscopic surgery to retrieve oocytes for the first successful in vitro fertilization (IVF) in 1978. ,
In the same period of time, Kurt Semm, both a tool maker and physician, received recognition for his contributions to the field. Semm blended his knowledge of engineering, female reproductive tract pathologies, and surgery to develop laparoscopic tools corresponding to specific surgical steps. He developed laparoscopic needle holders, forceps, shears, knot tying instruments, electrocoagulation instruments, retractors, carbon dioxide insufflators, a tubal patency testing device, and other endoscopic tools. , , Versions of many of these devices are still used today. He also described manipulation and irrigation of the uterus, techniques in operative laparoscopy, and how a physician should approach a laparoscopic hysterectomy. , , He first performed laparoscopic gynecological procedures in the 1970s, well before he performed the first laparoscopic appendectomy in 1981 and Erich Mühe performed the first cholecystectomy in 1985. Semm claimed to perform over 3300 different gynecological surgeries to include oophorectomies and adnexectomies. He urged fellow surgeons to consider laparoscopic appendectomies and cholecystectomies but was met with resistance and even calls for the suspension of his practice.
By the 1970s, on the heels of Semm’s ingenuity, the field of gynecology adopted laparoscopy. In 1971, only 1% of tubal ligations were laparoscopic; however, this number grew to 60% by 1976. In this time period, Camran Nezhat, a gynecology resident in Buffalo, New York, had a breakthrough that would again revolutionize the field—the combination of a video monitor with a laparoscope.
Consistent with many minimally invasive surgery pioneers, Nezhat was met with widespread criticism and legal investigations. Despite the critics, video laparoscopy radically transformed the practice of most surgical specialties and is arguably one of the most important contributions to surgical history. In 1982, a real-time, high-resolution video camera was developed that could be attached to the endoscope. Prior to this innovation, the operating surgeon performed the case while in the ergonomically unsustainable position of leaning over the patient to directly peer into the scope. Now, a clear magnified image of the entire operating field was shown on the monitor that could be positioned as needed for surgeon comfort. This innovation also enabled participatory assistants to join the procedure. Beyond transforming the operations themselves, video laparoscopy enabled surgeries to be recorded and shared, revolutionizing surgical education.
Utilizing Dr. Nezhat’s innovation, in 1984, Semm first described a technique for laparoscopic assistance in vaginal hysterectomies. The adnexa were separated laparoscopically to simplify vaginal hysterectomies. Four years later, Harry Reich performed the first total laparoscopic hysterectomy in Pennsylvania. The ligaments and uterine vessels were coagulated with bipolar forceps and cut with scissors. The vagina was opened and closed laparoscopically. The total operating time was 180 minutes, the uterus weighed 230 g, and the patient was discharged on the fourth postoperative day. Harry Reich astonished viewers with his video of a laparoscopic hysterectomy at the annual AAGL Conference in 1988. Since then, an increasing number of surgeons have reported their techniques. Laparoscopic surgery now has well established benefits for both the patient and the surgeon. For the surgeon, modern high-definition video laparoscopy improves visualization of anatomy and pathology deep in the pelvis and allows for more surgical precision.
Five years after videolaparoscopy was born, the first laparoscopic cholecystectomy was reported in 1987, in Lyon, France. The following year, laparoscopic cholecystectomies were performed by surgeons in several regions of the world (France, Scotland, Germany, Switzerland, and the United States), and laparoscopic surgery became widely accepted after years of criticism. The next 5 years saw surgeons from almost every subspecialty applying the surgical principles found in these original surgeries. Laparoscopy became routine for colectomy, splenectomy, nephrectomy, adrenalectomy, appendectomy, small bowel resections, explorations, and more.
As laparoscopic techniques were being developed and perfected, surgeons also began to realize the limitations of conventional laparoscopy. Limitations of conventional laparoscopy include counterintuitive hand movements, two-dimensional visualization, and limited degrees of instrument motion within the body (particularly lack of articulation), as well as ergonomic difficulty and hand tremor amplification. The surgical robot was born of an effort to correct these deficits. Robotic surgery provides improvement in instrument dexterity, dampening of natural hand tremors, camera stability, three-dimensional visualization, and improved ergonomics. It provides the surgeon with instruments that mimic the natural and intuitive movements of the human hand while operating under a high-definition, three-dimensional view.
The history of robotics begins with the PUMA 560, used in 1985 to perform neurosurgical biopsies with greater precision. The first robotic system for laparoscopic surgery became available in 1994. AESOP (Automatic Endoscopic System for Optimal Positioning) had a voice-activated robotic arm used to operate the camera during laparoscopic surgery, thus freeing the surgeon’s second hand. AESOP was the predecessor to the ZEUS Robotic Surgical System (Computer Motion), the first fully integrated surgical system, which became available for investigational use in the United States in 1996. The ZEUS system included a 10 mm laparoscope controlled by a voice activated AESOP, in addition to two robotic arms each with 5 mm laparoscopic instruments. A surgeon sits remotely at the surgeon console, and the computer controller transmits the surgeon’s movements to the robotic arms and instruments. Dr. Tommaso Falcone performed the first United States gynecologic procedure using the ZEUS system, a robot-assisted tubal reanastomosis. A subsequent prospective trial was performed to evaluate pregnancy rates in ten patients who underwent laparoscopic tubal anastomosis using the ZEUS robotic system. A hysterosalpingogram 6 weeks after surgery demonstrated patency in 17 of the 19 tubes anastomosed, and the pregnancy rate at 1 year was 50%. No ectopic pregnancies occurred and there were no intraoperative or postoperative complications.
The da Vinci Robotic Surgical System (Intuitive Surgical, Inc.) was first introduced in 1999 and approved by the U.S. Food and Drug Administration (FDA) for human use in 2000. The da-Vinci was a rival to ZEUS and, in 2003, after several litigations, the two companies merged. The da Vinci system no longer used the voice-activated AESOP but instead included a robotic manipulator with three cart-mounted arms. The camera arm controls the three-dimensional 12-mm stereoscopic laparoscope, while the two instrument arms manipulate a variety of 8-mm surgical instruments. Unique to the da Vinci system, the laparoscopic instrument tips, called “ EndoWrist instruments,” provide articulated motion with a full 7 degrees of freedom inside the abdominal cavity, mimicking the flexibility of the human wrist.
The first successful surgery using the da Vinci surgical system was performed in Belgium in 1997, leading to a first series of successful robotic laparoscopic hysterectomies performed and reported by Diaz-Arrastia in 2002. The series included 16 patients ranging from age 27 to 77. Operative times ranged from 270 to 600 minutes, and blood loss ranged between 50 to 1500 mL with an average loss of 300 mL. The average hospital stay was 2 days. All cases in the series had the posterior colpotomy and ligation of cardinal and uterosacral ligaments performed vaginally.
Beste et al. reported their initial robotic-assisted laparoscopic hysterectomy experience with 10 total laparoscopic hysterectomies performed at East Carolina University’s Brody School of Medicine between November 2001 and December 2002. They used a KOH cervical cup and RUMI uterine manipulator to help displace the ureters laterally to protect from thermal injury, in addition to the cup providing a visual target to help make the colpotomy with the decreased tactile feedback found during robotics. Operative time varied from 2 hours 28 minutes to 4 hours 37 minutes with an average operating time of 3 hours 12 minutes. Uterine weight ranged from 49 g to 227 g, and estimated blood loss ranged from 25 to 350 mL. Patients were discharged home on the first postoperative day. One case was converted to open procedure (initially attempted on 11 women). Operative results were similar to those of conventional laparoscopic hysterectomy, with no additional complications. One cystotomy occurred in a patient with a history of a prior cystotomy and was unrelated to the robotic system. Lysis of adhesions, suturing, and knot tying were enhanced with the robotic surgical system.
In 2005, the FDA approved the use of the da Vinci surgical system in gynecological surgery. The da Vinci surgical system is now used by gynecological generalists in addition to subspecialists. It has proven to be especially useful for complex cases such as those with scarred or obliterated surgical planes. Additionally, cases with complex suturing such as the multilayer closure of a myomectomy potentially benefit from a robotic approach. In urogynecology, robotic-assisted sacrocolpopexy has been advantageous for dissection of the presacral space, positioning of the mesh, and intracorporeal suturing. In gynecologic oncology, staging procedures have proven to be amenable to robotic assistance with studies demonstrating higher lymph node counts with a robotic approach compared to conventional laparoscopy.
There are currently multiple laparoscopic robotic platforms approved for use in humans across the world ( Table 36.1 ). The following have been approved for use in gynecological surgery. The Senhance Surgical System (Asensus Surgical) was cleared for FDA use for laparoscopic gynecological surgeries in 2017. Asensus Surgical, Inc. (formerly TransEnterix, Inc.) received additional clearance for Senhance Surgical System use in general surgery in March 2021. Senhance uses augmented intelligence called digital laparoscopy, utilizing eye-tracking for camera control, in addition to reusable instruments and an open-platform architecture. Also, in March 2021, Memic received U.S. FDA De Novo authorization of their Hominis robot-assisted surgical system for use in single site, natural orifice laparoscopic-assisted transvaginal benign surgical procedures including benign hysterectomy.
