The Compartmentalization of Surgery

For too many years medicine and surgery have been compartmentalized into small groups and even smaller subgroups. Early in this century a strong force that contributed to the fragmentation of medicine was the belief that one physician could not amass all the information necessary to provide complete patient care.

Specialization was promoted so that physicians would be available with in-depth knowledge of one body compartment or organ system. However, as de Duve observed,“Active science narrows the mind more often than it broadens it, the reason being the increased specialization of facts, concepts, and techniques. As we dig deeper, our scope shrinks.”¹

The development of focused medical and surgical disciplines led to isolation of these disciplines from one another. Because of this sequestration, knowledge and experience gained in one specialty were not readily transferred to another. Many examples of specialty isolation can be noted. However, none was so egregious as that which developed with laparoendoscopic surgery.

Laparoscopy was first reported in a living creature, a dog, by the German surgeon Georg Kelling in 1901. Kelling was attempting to develop a method for control of GI bleeding using increased intraabdominal pressure and wanted to determine how abdominal organs would react to the introduction of air. In his experiment, Kelling used a Nitze cystoscope to observe the in vivo status of the animals' abdomen during “lufttamponade” or pneumoperitoneum.²

Little interest was shown in closed cavity examination until the Swedish internist, Hans Christian Jacobaeus, reported his experiences with the technique in 1910. Jacobaeus showed that the laparoscope, actually a Nitze cystoscope, had great promise in diagnosing intraabdominal and intrathoracic disease.²

The specialties, however, were compartmentalized and knowledge did not easily diffuse from one compartment to another. With the exception of visionaries such as the German surgeon, Heinz Kalk, and U.S. internist, John C. Ruddock, little was done with laparoscopy for the first three decades of the 20th century.

Despite the hardships of World War II, the redoubtable French gynecologist, Raoul Palmer, developed innovative laparoscopic procedures and instrumentation in occupied France. After the war, many traveled to Palmer's clinic and trained with him. Most of the trainees, however, were gynecologists who practiced in Europe.

The compartmentalization of surgical knowledge continued, shielded by communication and geographical barriers.

General surgery remained isolated from gynecology and its leaders paid little attention to the novel approach of laparoscopic access. Content with the adage, “big problems require big incisions,” general surgeons did not heed the promise of intraluminal endoscopy or intracavitary laparoscopy.

It is likely that the status quo would have remained undisturbed, but for the intense patient demand for laparoscopic technique generated by “laparoscopic laser cholecystectomy.”⁴

During the 1990's, gynecological laparoscopes, instrumentation and techniques were adapted to cholecystectomy. Information and technological transfer to general surgery took place on an unprecedented scale. Huge numbers of “classically trained” surgeons were rapidly taught laparoscopic techniques. Development of the CCD chip camera and laparoscopic clip applier were powerful enabling tools that permitted general surgeons to operate in a laparoscopic environment.

Curiously, academic centers were not quick to recognize the benefits of laparoscopic intervention and laparoscopic training usually took place in non-university affiliated facilities. General surgeons, who had been isolated from other specialties, found themselves being taught by gynecologists, urologists and other specialists in the intricacies of image-guided surgery.

The early 1990's was a time of great excitement and intellectual ferment. There was a freshness about laparoscopic cholecystectomy that energized general surgery.

Recognizing that the use of image-guided laparoendoscopic techniques should cross specialty lines, the Society of Laparoendoscopic Surgeons (SLS) was formed to promote the communication and transfer of knowledge among laparoendoscopic surgeons. SLS has provided a forum for discussion and communication for all surgical specialties.

JSLS is the Journal of Society of Laparoendoscopic Surgeons and will be a multidisciplinary chronicle dedicated to the presentation of material from all physicians in the field of laparoendoscopic surgery. In any one volume will appear articles from general surgeons, gynecologists, urologists, thoracic surgeons, vascular surgeons and others who perform laparoendoscopic surgery.

It is the aim of this journal to help breach some of the barriers between surgical specialists. There is potential for great good in a multidisciplinary approach to surgical problems. Each specialty offers a unique perspective to the management of surgical disease and we can learn from one another.

Dr. William Mayo, in inaugurating another surgical journal, stated that “To the physician, patients represent medicine in practice, books on medicine represent stabilized medical opinion, and medical journals, the very breath he breathes, represent medicine in the making.”⁵ It is the goal of JSLS to represent medicine in the making for image-guided laparoendoscopic surgery.