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impactful on the world of General Surgery. In Urology, the only role for laparoscopy then was in Pediatric Urology, looking for undescended testicles. I had been gifted a laparoscopic set for the laboratory by one of the representatives from Karl Storz, Cynthia Drake. I had no idea what to do with it. It sat on my floor literally for at a year. Getting laparoscopic equipment in those days was very, very difficult. At that time Nathaniel Soper, who was on faculty in General Surgery here at Washington University, had an interest in laparoscopic cholecystectomy. Dr. Samuel Wells, who was the Chair of Surgery, brought the two of us together. Me because I had the equipment and the laboratory and Nat because he had the clinical interest to test the use of electrocautery in a pneumoperitoneum field for doing laparoscopic cholecystectomies. At that time, a lot of laparoscopic work was being done typically with a CO2 laser. Accordingly, Nat, Lou Kavoussi and I began the gallbladder studies in our laboratory. Nat would come in and work on the porcine gallbladder. Louis Kavoussi and I would assist Nat as he was doing the cholecystectomy. During these procedures, it became very clear, that you could see the kidney. Pigs aren't fat. When you look at the pig’s liver, you're also looking right at the kidney. The line of Toldt in the pig is medial to the vessels, as opposed to in the human, where it's lateral to the kidney. As such, we were looking at the kidney the whole time while we were doing the cholecystectomy. Finally, either Lou said to me or I said to him: "Do you think we could take the kidney out laparoscopically?". From there came the laboratory work, where we started doing laparoscopic nephrectomies in pigs. Then, came the question: "Ηow do we get this kidney out?". It didn’t make sense to do the entire nephrectomy
laparoscopically via the 5-10 mm ports and then make a 3–4-inch incision at the end of the procedure rather than making the same incision at the beginning of the procedure. From that realization, came the concept of organ entrapment and from organ entrapment came the concept of morcellation. Both of these technologies, the entrapment sack and the high- speed tissue morcellator, were then developed for us by COOK Medical thanks to the work of Mr. Fred Roemer, Mr. Paul Thomson, and Mr. Ed Pingleton. Once perfected, you could take the entire kidney out from a hole no bigger than the 10 mm port. This is where the lack of humility is always a problem, because we thought that because we were able to dothisinthepig,weoughttobeabletodothisina patient. If we had thought more and had a bit more humility, we would have said: "Hey, before we go to a patient, let's do this in a couple of cadavers." We, unfortunately in my mind, did not do that. We went straight to a patient. We went through the Institutional Review Board (IRB). Bill Catalona suggested that we had to do so and he was right. We got permission from our IRB to do a laparoscopic nephrectomy in two patients. I had an 85-year-old woman who came to my office with a renal mass. It was about just under 4 cm. The operation for a renal mass like that in 1990 was to proceed to a nephrectomy. Today, in our hospital with Dr. Jaime Landman, that mass would be biopsied. It would come back as oncocytoma and we would never have operated. But in those days, no biopsies were being done. Partial nephrectomy was rarely done. She was very frail, and so the idea was that laparoscopic nephrectomy should be less difficult for her to have as a procedure. That was the idea and thus we went ahead, in June of 1990, to do the first laparoscopic nephrectomy. We had spoken with the anesthesiologist, Terry Monk and it
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