本田財団レポート No.１２２
第 28 回本田賞授与式 記念講演（２００7 年 11 月 19 日）「ラパロスコピー：
外科医のもう一つの眼

もう一つの手術を考える眼」

外科医師

フィリップ・ムレ博士

Laparoscopy:
Another means to see in surgery
Another means to appraise surgery
Commemorative Lecture at the Twenty eighth Honda PrizeAwarding Ceremony on the 19th November 2007

Dr. Philippe Mouret
M.D., General Surgery

フィリップ・ムレ博士
外科医師

M.D., General Surgery

Dr. Philippe Mouret■最終学歴
1966 年■職■UNIVERSITARY TITLES
Doctorate (Thesis Lyon 1966)
リヨン大学医学部博士課程（医学博士）

歴1. 病院勤務
1957 年
リヨン病院勤務医試験合格
1960 年
リヨン病院研修医試験合格
1964 年
リヨン病院研修医金賞候補
1966～1970 年 リヨン病院外科助手
1967～1970 年 救急外科医
元リヨン病院内勤外科医、
元パリ病院内勤外科医（指導教授 Bismuth 教授）
2. 教 職
1962 年
解剖学講師
1963 年
検死解剖医1964 年
法医学監督官1961～1964 年 勤務医および研修医向け講師
ほか、以下の各大学にて腹腔鏡手術の講義を担当
パリ、リヨン・サンテティエンヌ、ニース、
クレモン・フェラン(C.I.C.E)、トリノ（イタリア）
3. 個人開業
1968 年～2001 年 リヨン開業医
1981 年～現在
トリノ（イタリア・ピエモンテ州）の個人病院勤務
2000 年 4 月～2006 年 7 月
ハノイ・フレンチホスピタル（Ben Vien Viet Phap）嘱託勤務
ほか、実践教育プロジェクト「Into The Field」の一環として Krishna Hospital in Arnad（インド・ガジャラト州）に出向
■学会活動
フランス外科学会会員、リヨン外科学会会員、フランス
外科医師会会員、
フランス内視鏡外科学会（S.F.C.E）創立者・初代会長、
フランス腹腔鏡外科学会（S.F.C.L）会員■表彰歴
1992 年
1993 年
2000 年
2002 年
2006 年

Delannoy Robbe 賞（フランス国立医学アカデミー）
Bullukian 賞（リヨン外科学会）
湖南大学（現・中南大学湘雅医学院、
中国・湖南省長沙市）名誉博士号
アメリカ腹腔鏡学会賞（アメリカ・ニューオリンズ）
フランス外科医師会名誉会員■軍 役
フランス医療予備隊軍医大佐■HOSPITAL TITLES
Lyon’s Hospitals « Externe » (Competitive examination 1957)
Lyon’s Hospitals « Interne » (Competitive examination1960)
Lyon’s Hospitals « Gold medal Interne » (nomination 1964)■HOSPITAL FUNCTIONS
Lyon’s Hospitals Assistant Surgeon from 1966 to 1970
Emergency Surgery’s Surgeon from 1967 to 1970
Former Attached Surgeon of Lyon’s Hospitals
Former Attached Surgeon of Paris’s Hospitals Service of Pr.
Bismuth■TEACHING FUNCTIONS
Anatomy’s Instructor 1962
Anatomy’s « Prosecteur » 1963
Anatomy’s « Chef de travaux » 1964
Lecturer for « Externat » and « Internat » from 1961 to 1964
Participation to Universitary teachings of Surgical Endoscopy
Paris, Lyon Saint-Etienne, Nice, Clermont-Ferrand (C.I.C.E.),
Torino (Italy)■PROFESSIONAL ACTIVITIESPrivate activity from 1968 to 2001 in Lyon
Private activity in private hospital in region of Piemonte (Torino,
Italy) since 1981
Private activity in time share in Ha Noï Ben Vien Viet Phap, Vietnam from April 2000 to July 2006
Missions of practical teaching « into the field » (Krishna Hospitalin Arnad, Gujarat’s province, India)■SCIENTIFIC SOCIETIESMember of ACADEMY OF SURGERY
Member of Lyon’s Surgical Society
Member of French Surgical Association
Founding Member and First President of French SurgicalEndoscopic Society (S.F.C.E.)
Member of French Laparoscopic Surgery Society (S.F.C.L.)■DISTINCTIONS and AWARDS
Prize winner of National Medical Academy (Delannoy Robbe’s
prize 1992)
Prize winner of Lyon’s Surgical Society (Bullukian’s prize 1993)
Honorary Professor of Hunan Provincial People’s Hospital
University of Changsa (Hunan,China )2000
Award from American Society of Laparoendoscopic Surgeons(New Orleans,United States) 2002
Honorary Member of the French Surgical Association 2006■MILITARY SITUATION« Médecin Colonel » in Reserve corps

このレポートは、2007 年 11 月 19 日 東京、帝国ホテルにおいて行われた第 28 回本田賞授与式記念講演の要旨をまとめたものです。
This report is the gist of the commemorative lecture at the twenty eighth Honda Prize Awarding Ceremony on the 19th November
2007 Imperial Hotel, Tokyo.

Laparoscopy:
Another means to see in surgery
Another means to appraise surgery

Fig 1〈Fig 1〉Laparoscopy, before it became a new means to operate, was (and still is) a new wayof seeing in surgery. For me it has been a new way to appraise surgery although I don’t
exactly know even today what was the cause and effect of it. I’ll try to give an answer at theend of this lecture.

Fig 2〈Fig 2〉I have today an exceptional opportunity to expose the concept of laparoscopy as I
feel it, and to tell the history of laparoscopic development as I have lived it. Much more I
have in front of me an audience from various fields who are not specialized in surgery; and it−32−

is lucky for me because the surgical world has very long been reluctant to accept the concept
which has driven to the birth of laparoscopy, though the patients themselves, those to whomsurgery is dedicated, understood immediately the benefits of my research.
Besides, if I have had the opportunity to participate in the birth of laparoscopy, it is due to thefact that I received a multidisciplinary training at the time when it was still possible to do it.
However, laparoscopy has today become a surgical specialty, and it’s necessary to talk about
it with words as plain as possible to explain it clearly.
The global knowledge of human beings reminds me of the shape of a sea urchin. While more
people participate in the body by their general knowledge, specialists go into their specialty,
and narrow their space of mind as much so they improve their specialized knowledge.

Fig 3〈Fig 3〉And finally it becomes almost impossible to communicate directly from one
specialty to another.

Fig 4

−33−

〈Fig 4〉To make certain information understandable, you must transit through the body ofknowledge. It’s for that reason that I’ll use analogical thinking widely in my lecture.

Fig 5〈Fig 5〉The first question I’ll try to answer is: What is surgery?
But, before going in the technical aspects, I must ask the fundamental question which may
provoke so much emotional resonance: Is surgery a good thing or not?
The question may be considered preposterous coming from a surgeon! In fact, I have about
surgery a very ambiguous feeling. As far as I remember, I have always had that ambivalent
appraisal: I like, or better I am madly in love with, my job, still I hate its aggressiveness, andhate the fact that its aggressiveness is considered often by surgeons (and patients) as thenormal price to pay for healing.
To approach the appraisal of surgery, we must remember the situation of the mankind before
the advent of surgery.

Fig 6

−34−

〈Fig 6〉Suppose a young person. His life passes without any identified risk...

Fig 7〈Fig 7〉Then suddenly an access of acute appendicitis, a dreadful event, occurs to him. In
less than one week, this subject in perfect health is dying without any possible remission.

Fig 8〈Fig 8〉Then surgery appeared and has made possible the cure of that dramatic pathology;
and in the majority of cases, the recovery was, almost simply, obtained in few days.
Considering the importance that the problem of appendicitis has had in the birth of digestive
laparoscopy, I’ll take a moment to tell the story of appendicitis treatment.
It was at the end of the 19th century. Some surgeons in U.S.A., in the region of Boston, had
the intuition that the starting point of those dreadful abscesses of iliac fossa, which were
found at the autopsy of those (generally young) patients, was the vermicular appendix.
That appears obvious for us today because we know the solution, but at this period, only the
autopsy was able to show the anatomic lesions. And on a patient dead from appendicitis, all−35−

the iliac fossa was destroyed by gangrenous abscess and a so little and delicate structure likeappendix completely disappeared. So it took a genius to understand that appendix might beresponsible, and to be audacious to purpose the removal of the appendix at an early stage ofpathology. The removal was done and promised to succeed.

Fig 9〈Fig 9〉As such, we may draw the diagram of that miraculous surgery which really saves
lives. Without any possible contestation, surgery must be considered as a good thing… . And
it was the same for a lot of very severe and acute pathologies, which were tackled at the same
period. But…

Fig 10〈Fig 10〉As surgery is expanding and taking in charge of less spectacular processes, or lessacute pathologies, the appraisal might become different. When the surgery, with the aim ofbringing to the patient only an improvement of his health condition, more security in his life,
or at least a preventive technique, becomes more ambitious, the balance between advantages−36−and drawbacks is less obvious.
But so much impressed by the previous successes, everybody has continued to apply to thewhole surgery a Manichean judgment. The appraisal for surgery for opportunity remains thesame as for surgery for necessity: if surgery does it, it is necessarily good because surgery is agood thing.
As such it appears to me that surgery is not always so intrinsically good. Errors of diagnosis
exist. Of course in such an event, surgery cannot be the appropriate answer! In that case it
cannot be good.
During the operation itself or during the hospital stay, everybody knows that there is somevital risk. It’s a reality. But fortunately that risk is exceptional. It conceals the real drawbacks
of surgery which are of two types:• First, complications resulted from the surgical act and its follow up. These complications

may occur during the operation itself or the hospital stay. Some cases necessitate a newsurgical act and create a vicious circle.
• There is another type of drawbacks. Surgery may entail after effects, and especiallyserious are long term after effects.
These are at the crux of the surgical issues that gave birth to laparoscopic discovery and its
success. I’ll try to explain that concept because it is in that field that the laparoscopic
approach of surgery has mainly brought possibilities of significant improvements.

Fig 11〈Fig 11〉Laparoscopy, which was first an exploration, may be performed in somecircumstances not usually met in surgery, and never responsible for death. And we have toremember that all our knowledge about pathologic situations comes from autopsy
examinations (anatomo-pathologic method of discovery) or more recently from the surgicaldiscoveries. Laparoscopy may be considered in this context as an autopsy on living being!

−37−But, to explain why and what laparoscopy has brought to us, I need first to develop my story alittle bit into what laparoscopy is, what surgery is, and what surgery by laparoscopy is.
When I prepared this lecture, I wanted to know the level of information available for the great
public about laparoscopy, and what kind of explanations was given. I went on the Net andwas surprised, while there is a lot of information about what can be performed by laparoscopy
or not, the advantages and disadvantages of the method, the risks, and so on, to find nothing
about the basics. I had the impression that somebody who wants to know what a plane is andhow it flies can only have the list of the companies and the schedule for Los Angeles, Tokyoor Sidney!
So I’ll try to explain laparoscopy with my personal means, which are drawings on one hand,and analogical comparisons on the other. I have prepared two series of diagrams of the middle
part of human body.

Fig 12〈Fig 12〉One represents a longitudinal section, showing the situation of abdominal cavity,
separated from the thorax in high by the diaphragm; and in continuity with the pelvis region
down. The imaginary limit between pelvis and abdomen is the bone circle of pelvis bones:
pubis at the front, and sacrum at the back.
What is important to see is the notion of peritoneal cavity which is the field of direct
laparoscopic access. It is difficult to see it on the drawing because this cavity contains nothing(virtual) in the normal state.

−38−

Fig 13〈Fig 13〉At the beginning of a laparoscopic exam, the surgeon just brought to the fore theperitoneal cavity by gas insufflation and made its space real. This space was necessary to havevision and to maneuver instruments.

Fig 14〈Fig 14〉I should note that insufflation, which is presented as the necessary means to create
enough space for laparoscopy, can be replaced by a mechanical device which gives the same
space: the abdominal wall suspensor. This mean that I invented in 1988 is not widely used,
except in Japan, where several devices for abdominal suspension were created.
I think that it’s too bad because I am convinced that those devices might be a very cheapmanner to diffuse laparoscopy in developing countries. The reason is that it avoids airtightconditions for all the instrumentation, and authorizes the mixing of laparoscopic means withconventional techniques and instruments.
But, saving up is not a common industrial and commercial aim. Is it the reason of thereluctance? Perhaps… , as industry has taken great control of surgical thinking by its
involvement in laparoscopic training.

−39−

Fig 15〈Fig 15〉The second series of diagrams is a transversal section, as is seen on a scanner
image, that shows the virtual peritoneal cavity here and on the following diagram.

Fig 16〈Fig 16〉This is the space for vision and actions which is permitted by the abdominal wall
elevation (pneumatic or mechanical).

−40−

Fig 17〈Fig 17〉Traditionally, laparoscopy was used by gynaecologists for the pelvic examinationof the patients. The main idea to make possible the vision of the pelvic organs was the inclineof the table to make the mass of the bowel falling in the upper part of the abdomen. Of course,
by doing so, all the organs of the upper part of abdomen are hidden. And that position is
specific for the pelvis examination.

Fig 18〈Fig 18〉That I consider as “my invention”was only to inverse the decline of the table to
make the upper organs accessible for examination! I was able to do it because I have had theluck to work with a skillful and intelligent anaesthetist, who accepted those intraoperative
movements of the table that anaesthetists usually do not like and even refuse.

−41−

Fig 19〈Fig 19〉To explain the different concepts of practice between laparoscopy and classic
surgery, I have drawn a series of diagrams showing the approach to the removal of a tumor on
bowel.

Fig 20〈Fig 20〉In classic surgery, the abdominal wall is opened widely while the lesion is
exposed by a retraction of the wall.

−42−

Fig 21〈Fig 21〉You note that a lot of things go through this unique access in laparotomy:• The light• The vision of surgeons and his assistant(s)• The instruments in his hands and in the hands of assistants

It is obvious that the size of the incision must be large enough to make surgery comfortable(and safe).

Fig 22〈Fig 22〉The bowel bearing the tumor is resected and removed by the same unique access.

−43−Fig 23〈Fig 23〉The bowel is sutured and the abdominal wall closed. The operation is finished, but
the works of nature starts, because it’s the nature which makes the healing definitive, notthe surgeon.
Surgeon is convinced more or less that he achieved the operation. Wrong! He only prepares
the operation of the Nature! His first duty is to not hinder its works.

Fig 24〈Fig 24〉The idea to respect the works of nature has appeared step by step; and the firstidea to reduce the aggressiveness of surgery was the reduction of the size of laparotomy. It
was the phase of “minilaparotomy”which reached its peak at the end of the 1980’s.
My friend François Dubois was perhaps the world champion in this field. I must say that I
was challenging in the same direction, but I thought that the possible limits were reached, andthat it would be dangerous to go forwards.
In fact, in the minilaparotomic approach, it becomes difficult to have a correct vision because
the operative field becomes narrow. And as you go deeper, the difficulty increases so much−44−

that it’s impossible to see with the two eyes. You actually operate in a funnel-shaped field.
And if the surgeon keeps a little bit of vision, the assistant doesn’t see anything more. The
head of surgeon hides the light; and his operation of one or more instruments becomesacrobatic with parallel vision which makes difficult the control of the instrumental action.

Fig 25〈Fig 25〉It’s the reason why it has been said in the surgical world that “Great incisions aremaking great surgeons,”meaning that it is necessary to be comfortable to operate well, notthat the great surgeons are making great incisions, which would be the summit of theauthorized aggression!

Fig 26〈Fig 26〉This diagram shows the idea of Erich Mühe who in 1985 hit on a technical idea toincrease the minimalization of the minilaparotomy for gallbladder removal.
He introduced a special tube in a ‘record’minilaparotomy. Inside that tube, a laparoscopic
device was embedded to provide light and vision; and he operated by the laparoscopic−45−

instruments in the same tube.
The idea to use a laparoscope to provide vision and light was a stroke of genius and I consider
that he did the half part of the invention. Unfortunately, he remained disabled by the “oneway access”concept of surgery (the same one which was limiting the minimalization of
laparotomy).

Fig 27〈Fig 27〉This shows the laparoscopy of today. The multiple accesses by trocars haveresolved the problem of simultaneous vision and surgical manipulations.
Of course the gestuality, the indirect vision on screen, and the appraisal of space and relief are
all amazingly disturbing. It necessitates a complete and long training.
It is the reason why the majority of surgeons have been destabilized by that novelty andconsider that laparoscopy is a new surgery.
Having lived the phenomenon from its beginning, and witnessing its progressive shift, I
consider, on the contrary, laparoscopic surgery as a different means to perform surgery but
absolutely not as a new surgery. This is the reason I prefer to talk about “surgery bylaparoscopic approach”rather than use the term of laparoscopic surgery. But the common use
prevails over all.

−46−

Fig 28〈Fig 28〉To resume the problem of gestuality in surgery, here is the diagram of classic
surgery with a great liberty of way of access, surgery by minilaparotomy where all the accessbecomes straight, and surgery by laparoscopy which open widely the fan shape of accesses. In
term of gesture and visual control, laparoscopy is equivalent to the largest laparotomy.
Moreover, when the operating site is very deep, even in classic surgery, the operating field
becomes narrow and uncomfortable irrespective of the size of the laparotomy. Laparoscopic
approach has not this limit and the space appears much wider, in return of some tricks, thanthe open access. This phase was obvious for the surgery of the posterior organs of theabdomen (those we call retroperitoneal organs such as kidneys or adrenal glands).

Fig 29〈Fig 29〉The meeting of laparoscopy and surgery has been neither easy to do nor easy to
accept. It was not a “love story”! Far from it! It was really a cultural shock. It was the meetingof two separate worlds which were unaware of each other.
On one hand the laparoscopy itself is a branch of endoscopy; and on the other the surgery is−47−

traditionally jealous of its independence from medicine. This fact may seem superficial, but I
am convinced that it was a reason for the long reluctance of surgery with laparoscopy.
Yes, endoscopy has been always in the field of medicine. The concept to look inside the bodywithout overstepping the limits of the body (that is to say, non-invasive technique) is
essentially a medical concept. I have always thought that it is clearly a concept of spying!
Surgery on the opposite side is an invasion, a violent action, which constrains the body bypower to give its access and secrets.
This way, it’s easy to understand why I feel medicine as a peaceful relation with the patient,
medical treatment as a kind of negotiation, and endoscopy as an act of “intelligence”, while
surgery as something comparable to a military action. Even if diplomacy and army arenecessarily complementary, as much as medicine and surgery are, both sides do not work thesame way.
We may push very much forward the comparison. I’ll let you do by yourself the analogy with
the international relations which is not my field; I am convinced that you can do it by yourself,
since you agree with the analogies; and I’ll talk mainly about the progressive mixing of thetwo spheres.
Medicine and surgery, although conceptually and technically very different, have always
encroached one on the field of the other.
At the beginning, the strictly non-invasive endoscopy, limited to the exploration of superficial
cavities, wanted to go deeper inside. Its first target was the bladder. But, the gestures being
somewhat risky required some skillfulness were mainly performed by surgeons and not bypractitioners. All the more, it was giving access to the stones of the bladder which were a veryfrequent disease a century ago.

Fig 30〈Fig 30〉Using the same instruments as those for urinary exploration, some surgeons hit on
the idea to insert them in the peritoneal cavity through the wall of the abdomen (by a minimal−48−

invasion). The only difference was the injection of gas and not of water.
From that period, and following the cultural tradition of endoscopy, surgeons andmanufacturers remained with an idea that everything might be done by a unique access as if
there was a fictitious channel of urethra around the port of insertion. At the origin of theendoscopic practice were the two mixed specialties, urology and gynaecology, where
medicine and surgery overlap each other.

Fig 31〈Fig 31〉The main role in the development at the beginning was taken by gynaecologists,
and more precisely by an exceptional humanist, lover and admirer of the women, Raoul
Palmer.
All has started from his revolt against the explorative laparotomy which was the only way to
explore the tubar women infertility. It was at the end of the war, where the problem was acutewith the ravages of tuberculosis and septic abortions. In the majority of cases, the answer tothe patients after that surgical exploration was: “nothing to do”! Palmer considered that it wasan excessive aggression for such a result!
He got the same results without opening the abdomen: the laparoscopy in its clinical use wasborn.
In few years a lot of students came from the whole world, and laparoscopy became a routine
exam in gynaecology. Instead of that, some ones remained reluctant for a long time. It was at
this step of routine gynaecologic exam that I learned the method from colleagues, students ofPalmer. I have not personally met Raoul Palmer, so I understood only many years later thephilosophy which has driven Palmer in his research. However, there was sufficient technical−49−heritage to get started, and his surgical philosophy was still living in the technique.
I learned there was the interest of extending the exam to the digestive field. My first step was
to use it in place of explorative laparotomy in emergencies. I followed in the digestive field
the same reasoning that Palmer followed 20 years before in the gynaecologic one.
But my own merit was poor because the laparoscopy was yet employed for the diagnosis of avery acute gynaecologic emergency that general surgeons (like me) had to treat the ectopic
pregnancy.
My first target was to confirm or invalidate the diagnosis of appendicitis in the event of
abdominal pain. I was convinced that a lot of appendectomies were not useful (I say “a lot of”,
but in my humble opinion “the majority of”). And the perversion was really a French evil. My
reasoning was simple: More than 300,000 appendectomies were performed in France, and a
French person had 50% chances to keep his appendix all lifelong. If all those patients have
had a so heavy affection than appendicitis in the remote past before the surgical era, thehumankind would have disappeared! The result of the “laparoscopic attitude”in my personal
activity was absolutely incredible, reducing to 20% the number of cases operated by a year!
So, first, the mixing of laparoscopy and surgery must be strategic where laparoscopy comes
first, and laparotomy follows only if it is positive. I have had the opportunity to make thoseobservations because appendectomy under laparoscopy was not yet available. That experience
will remain unique.
It appeared the mixing of the two worlds could go forward step by step: The laparoscopy partprovides a tactical assistance for the surgical part as manipulations under laparoscopic control,
such as liberation of adhesions and beginning of dissection and liberation, becomes routine.
The most conceptually simple operation, consisting only of liberation of adhesions andcutting of the band and the treatment of acute occlusion of the bowel (which is however far
from easy!), became very soon possible to perform, and it was, to my sense, the firsttherapeutic action performed by laparoscopic approach. It was in March 1972.

−50−

Fig 32

At the same period, my friend Hubert Manhès〈Fig 32〉in Vichy and Maurice-Antoine
Bruhat in Clermont-Ferrand (in the center of France) were active in their gynaecologic
discipline.

Fig 33〈Fig 33〉And Kurt Semm in Kiel in Germany started to operate ectopic pregnancy ovariancyst and resection of adnexas. In 1980 Kurt Semm performed for the first time in the world anappendectomy by a completely laparoscopic way. When he attempted to publish it, he was
asked to be suspended for surgical activity as he had walked over the limits of his specialty.
He has not yet published its technique when I performed my first appendectomy in 1983 by
my personal concept of mixed technique that I recommend still with insistence for developing
countries for its safety, cheapness and easiness to learn.
Hubert Manhès who is my friend and Kurt Semm with whom I had friendly relations have
had a conceptual idea of the performance of laparoscopy which is somewhat different of mine.

−51−

For some reasons, they, though different somehow from each other, consider that alaparoscopic procedure must be performed as completely as possible by laparoscopic access.
To the contrary, I consider that the research of less aggressiveness is not exclusively theprivilege of laparoscopy, and the association with minimal access does not seem to me
detrimental to this aim. My activity in the third world reinforced this view because it is lessdependent on instruments, and by that way much more cheap.
I think sincerely that the two ways are to follow and one must not exclude the other. The two
ways do not concern the same field, and the same countries. The majority of surgeons follow
this “Manhès and Semm thinking.”I do not worry. For a long time I have been sofamiliarized with being the opposite of the consensus!

Fig 34〈Fig 34〉Moreover, a lot of complex procedures necessitate (mainly for the extraction of
the specimen) the involvement of laparotomy (usually called minilaparotomy). Many
surgeons are then talking about “a laparoscopic technique assisted by minilaparotomy.”And I
continue to think that laparoscopic surgery is not a different surgery, and it is the laparoscopy
which gives assistance to surgery, not the inverse.

−52−Fig 35〈Fig 35〉To put it another way, there are two possible conceptual diagrams of the relation
between laparoscopy and surgery:• In the first case, laparoscopy swallows the surgery. But it’s necessary to think that classic

surgery cannot be entirely abandoned whatever the improvements and progress there may
be. Without classic surgery, transplantations and treatments of large open wounds, forexample, would be impossible.
• In the other case, surgery as it evolves will give more and more place to laparoscopy to

perform the same gestures by similar operating principles. This is clearly the conceptual
opinion of which I’m in favor for today and for the future.

Fig 36〈Fig 36〉To resume the beginning of laparoscopic story, I’ll give you some historic data.
It’s necessary to correct some worldwide inaccuracies and pay homage to some courageous
pioneers who did not receive the gratitude they deserve, or who received it when it’s too late.

−53−• First… No!.. Laparoscopic surgery was not born in 1987 by my first operation of thegallbladder. It has been revealed and discovered by surgical community at that time; it’sdifferent!
• No!.. Laparoscopic digestive surgery was not created from the gynaecologic surgical

technique. These two fields were contemporary, and laparoscopic digestive surgery wasborn completely independent of gynaecology. There was no affiliation between the two
fields.
• In any way, the birth of laparoscopic therapeutic procedures was in the years between

1972 and 73, and not the end of the 80’s.
• Yes!.. Kurt Semm performed before me a laparoscopic appendectomy, but he was

reduced to silence by his Scientific Society, which asked for his suspension. Kurt wasfamiliarized with that kind of ‘scientific’reactions because some years before, his coworkers wanted him to undergo a scanner examination being suspected, in their view, ofbrain disorder! The Inquisition in the 15th century had sentenced Galileo Galilei who
insisted the earth rotates. Nothing new under the sun!
Due to that reluctance of surgical corporation, I never heard about the Semm’s
performance, and my technique is essentially different.
• Yes!.. Erich Mühe performed cholecystectomy with the help of a laparoscope before me,

and the persecutions he underwent are absolutely unbearable. I have had the objective tomeet him last year and pay homage publically to him; unfortunately I can do it only
today… . posthumously.
I would have done it so much gladly that, if I’m proud of something, it is to have done thefirst therapeutic gesture under laparoscopy 15 years before, not for my first laparoscopiccholecystectomy.
• Yes!… The origin of all is the laparoscopic exploration in gynaecology due to Palmer

genius. But Palmer was a gynaecologist, and more a Parisian gynaecologist. The poorconsideration that general surgeons had at that time for gynaecology, and the rivalry
between the capital and Lyon, the second-largest city in France, need to be taken inconsideration.
For me, working in Lyon had me plunged in complete loneliness for almost 20 years. It
was really terrible, and instead of the fact I was convinced to be right considering thestate of the patients and the results, I had some doubts, of which main concern was thatthe technique would be impossible to teach. Until the first cholecystectomy there was nocamera, so no direct vision, and a very poor capacity of communication. (Only the secondcholecystectomy was recorded.) Most of friendly colleagues who heard about mytechnique were all saying that the technique was impossible to reproduce.

−54−

Fig 37〈Fig 37〉Yes, I travelled through a desert; and often I said it, delighted with the drawing ofa famous French comics trip Lucky Luck which ends all the volume of the series.
But as in a desert, one sand hill behind, there is always someone who is travelling as you doin a parallel trail. I met those travelers only when I reached an ‘oasis,’that is to say, whenlaparoscopy was emerging in general knowledge at the end of the 80’s.

Fig 38〈Fig 38〉I want to introduce these “travelers”I met. A majority of them is here on thephotography:• François Dubois, to whom I shown some videos and who was able to perform his firsthuman cases four month later after a brief experimental training. But he was trained inlaparoscopic exploration many years before.
François Dubois was the first surgeon to publish about laparoscopic cholecystectomy inprofessional press, but he never put himself forwards and has had always the scientifichonesty to recognize my priority.
−55−• Jacques Périssat who has made me the favor of coming here in Japan. He deserves thefriendship I have for him and the tribute I pay to him for several reasons: Our first meeting was in the first Congress in Paris, where I was speaking aboutlaparoscopic surgery (April 1988). After my video projection, I was almost
reproached by the representatives from a great Parisian institution, shouting that it
was disgraceful to show such horrors. (Nobody asked for me a scanner examination,
but I think that is only because they did not have such an idea!)
Two persons stood up for me, a young friend university surgeon from Lyon, Jacques
Baulieux as whiteness of morality, and Jacques Périssat, whom I did not know andwho did not knew me. He said that in his hospital they were working for somemonths about approach to the gallbladder by laparoscopy. His university position
was a serious help for me.
His approach to the gallbladder was original about which I should mention a few
words:The tendency in this time, for gallbladder stones management was the ultrasonicbreaking of stones, a non-invasive technique which was not so well working than for
kidney’s stones. So Jacques adopted an idea to use laparoscopy to introduce directlyin the gallbladder the device for stone breaking, and let in place the gallbladder as the
medical custom wanted.
He was a little bit like a pickpocket who wants to rob the money and leave the purse
inside. I was a better pickpocket than him. I rob the purse itself just because it waseasier to do! And only for that I arrived first!
 And the third reason which is more directly related to this Honda Prize is thefollowing:
Reading the reasons for being awarded, one of the most determinant reasons was alecture done in Singapore in 1993. I was a guest of honor of that Congress. But at thelast moment, I was not able to come by myself and it was Jacques who made me thefavor of reading my lecture!
There are many more reasons to share with you the honor which I receive today.
Thank you Jacques!
• The others participants on that slide are Jean Mouiel, a friend from our first hours, and apioneer in gastric ulcer treatment.
• You see also the two gynaecologic pioneers Manhès and Bruhat, and my friend EdmondEstour who leads for almost 20 years the “Journal de coelio-chirurgie”and his English
editing which are to my mind, the most invaluable publications for practitioner surgeons
in laparoscopy.

−56−

Fig 39〈Fig 39〉As I said, the meeting came later; and I worked in a complete isolation,
reinforced by the refusal of press to publish such stupid mistakes. But loneliness has had somevery important advantages:• In return for no assistance I received, I was not disturbed by external pressures, orsuggestions, or academic scientific committees which would have limited my liberty ofthinking.
• From1968 to 87, about 6,000 of laparoscopic procedures were performed, mainly for

explorations. It has concerned mainly gynaecology and emergencies. But soon, thelaparoscopic examination was applied to some difficult problems of abdominal diagnosis
in a time where complementary means of exploration were not so developed as today.
This experience has been unique and will remain unique in the future because
laparoscopy, having become a main surgical access, is almost no longer used today only
for an explorative aim.
• It is from this period that I draw some precious lesson from that practice that I have called

an “autopsy on living being”:
 First, I conceived the notion that previous surgery strongly disturbs the beautiful
anatomic organization of the abdominal cavity, even if it’s not perceived by thepatient. I had the feeling there is an aggression against ecologic harmony: theimpression that nature has been desecrated by surgery. Gradually I became
increasingly suspicious about innocuousness of surgery and unfond of inutile surgery.
Even the most common and supposedly light surgery, such as appendectomy in cold
surgery, was sometimes responsible for great disorders. The performance oflaparoscopy itself was reinforcing the idea which has had directed its use at the
beginning.

−57− Second, I conceived the notion (in cases where I was driven to perform iterative
coelioscopic examination) that laparoscopy (without gesture) was almost innocuous.
And even that the limited gestures of liberation of adhesions were less aggressive
than the open surgery.
Saying that does not signify that laparoscopy is perfect, but only that it is lessimperfect than the classic approach. (“Mini-invasive”does not signify “noninvasive”.)
 Third, I really learned the fundamental role of peritoneum in all the pathologic
process of the abdominal cavity. Surgery itself may be considered as a pathologic
process. The peritoneum answers to all pathologic processes (including surgery) bygluing and making adhesions whatever aggression it may receive. That phenomenon,
limiting the diffusion of infectious contamination has been really (and is still today)
the essential auxiliary of surgeon.

Fig 40〈Fig 40〉The same adhesion process can threaten the life of the patient in long time
follow up of surgery by acute occlusions.
It was during that period that I followed the strategy of progressive conversion of
laparotomic gestures into laparoscopic gestures; and I did this without expensive
devices and without accidents. (If I would have any, in the context of that time, I am
sure that I would have finished my life in prison!) The cheap access to laparoscopythat I followed may be followed in developing countries. But my isolation in that
period (which has been occulted by the worldwide surgical community) makes it
difficult even today to communicate the complete message.
My experience was and will remain unique. It is not considered scientifically correct because
today only multicentric experiences are considered serious. It’s the result of the introduction−58−

of scientific rules in surgery which, however, is not a science.

Fig 41〈Fig 41〉Of course the worldwide diffusion of laparoscopy gave me great satisfaction, andparticularly having the honor to be here today. But I have regrets in exchange of mysatisfaction:• The fact that surgeons everywhere (and even in the countries where they cannot do it) are

more interested in the “advanced”surgery than in the basic one.
• The fact that the “all laparoscopic”performances prevail more than more adaptable

mixed techniques.
• The unavoidable tendency to favor technologic improvements more than technicalimprovements in gestuality and skillfulness.

Fig 42〈Fig 42〉To conclude, I’ll ask the question which preys on my mind since the diffusion of
the laparoscopy: Is laparoscopy really an improvement of surgery or not? Or you can−59−subsidiarily ask: Is it for all surgeries? For all surgeons? And, if laparoscopy is really an
improvement, in what proportion is it so? Without any pretention of mathematic rigor, I’ll
give you my view in the form of curves:

Fig 43〈Fig 43〉I suppose the estimated aggressiveness of surgery by traditional access (red curve)
and that of laparoscopy (in blue) correspond to the level of complexity of operation performed.
At the level 0 (only the access), it’s obvious that laparoscopy is a reduced aggression. As thelevel of complexity increases, due to the difficulties and unavoidable risk of imperfections
involved, it’s probable that aggressiveness increases faster in laparoscopy than in laparotomy.
The curves are crossing at a level whose position is the crux of the problem. I represented ithere on the middle section.

Fig 44〈Fig 44〉Left there is some benefit, and right no benefit. It’s the level of complexity which
can be excessive at this moment for the surgeon to whom this curve is dedicated, because… .
−60−

Fig 45〈Fig 45〉… it’s obvious that for an expert in laparoscopic surgery, the curve is lower, and at
least the two curves do not cross each other.

Fig 46〈Fig 46〉More, we may dream! Is it the future? But… .

−61−

Fig 47〈Fig 47〉… for a nonexpert learner, the crossing of curves comes earlier and worse…

Fig 48〈Fig 48〉In the case of malpractice due to a mistake in the laparoscopic settings, itsaggressiveness can be greater than the simple laparotomy (for a vascular or visceral injury, forexample). And even if the surgeon returns by the so called “conversion,”the aggressivenessof the two attempts is cumulative! It is preferable to know his limits than to convert in forced
conditions!

−62−

Fig 49〈Fig 49〉Whether or not laparosurgery is more useful at the middle level of complexity anddifficulty represented by the dotted line completely varies according to the level of expertiseof the surgeon: While laparosurgery may be easier for an expert, and beneficial for a trained
surgeon, it could be more aggressive than laparotomy for a learner, and it cannot be
performed at all in the extreme situation. Laparoscopic technique, like any other novelty, isquite operator dependent.
You may consider my vision of laparoscopy too pessimistic, but I am sure that the future will
improve the situation, if surgeons and industry manage with prudence their ambition and stop
to consider only the vertical development of more and more complex, more and more difficult
procedures. The research of feasibility must not be the unique aim of development.
And in sympathy with the direction of the dream of Mr. Soichiro Honda, let me takemotorbike for example to illustrate my message about the usefulness and necessity ofhorizontally spread development.

Fig 50 REPSOL HONDA RC212V MotoGP2007〈Fig 50〉It’s fantastic to win in a “grand prix”motorbike racing. It demonstrates the−63−

maximal capacity of that which is feasible. I think such sophistication is necessary to bepresent in this field and I am enthusiastic about that… .

Fig 51 HONDA SUPER CUB C100 1958

〈Fig 51〉… but without the basic devices it would be a sterile purpose.
Basic devices are not so glorious but how much useful they are!
I think it may be the same in surgery!

■ This report can be viewed in the Honda Foundation’s website.
You may not use the proceedings for the purposes other than personal use without theexpress written consent of The Honda Foundation.

−64−発行責任者
Editor in chief

伴俊 夫
Toshio Ban

104-0028 東京都中央区八重洲 2-6-20 ホンダ八重洲ビル
Tel. 03-3274-5125

Fax. 03-3274-5103

6-20, Yaesu 2-chome, Chuo-ku, Tokyo 104-0028 Japan
Tel. +81 3 3274-5125
Fax. +81 3 3274-5103

http://www.hondafoundation.jp