For many centuries, “laparotomy” (derived from the Greek “lapara”, “flank or soft part”, and “tome”, “to cut”) was considered extremely dangerous and rarely attempted. There is a poorly documented report on Jacob Nufer, an Austrian or Swiss veterinarian or even pig farmer, who around the year 1550 saved the life of his wife by removing a protracted retained extra-uterine pregnancy; there are other stories of surgeons reportedly excising dead ectopic or even living pregnancies in the 16th and 17th centuries. Tradition, however, regards the French military surgeon Baptiste Lucien Baudens (1804–1857) as the father of laparotomy for operating on two patients for abdominal trauma and saving the life of one of them. After the introduction of anesthesia and antisepsis, laparotomy became a more reasonable proposition, and the history of surgery for different organs developed in different trajectories.

Ovarian surgery

In 1809, Ephraim McDowell performed a successfully planned laparotomy by removing a 22-pound ovarian tumor from 44-year-old Jane Todd Crawford. Although this achievement inspired other surgeons to explore ovarian surgery, massive ovarian cysts were treated by repeated draining until about 1858, when Spencer Wells refined the techniques he developed from treating battlefield injuries. By 1880, he had performed his thousandth operation and published several series of successful cases. He reduced mortality by promoting cleanliness through hand washing, clean dressings, and instruments. He also improved the design of his instruments, notably by inventing hemostatic forceps that allowed the safer closing of blood vessels.

Gall bladder surgery

German surgeon Carl Johann August Langenbuch performed the first successful cholecystectomy in 1882 for gallstones. His approach, though rudimentary by today’s standards, was groundbreaking at the time. Despite high mortality and complication rates, his success opened the door for further innovation and rapid advances in laparotomy techniques for gallbladder disease.

Gastric surgery

Theodore Billroth performed the first successful gastrectomy in Vienna in 1881, known as the Billroth I operation, in which the cancer was removed and the remaining part of the stomach connected to the duodenum. Later surgeons developed the Billroth II operation, in which the remaining part of the stomach was connected to the jejunum instead of the duodenum. At first both procedures were beset with numerous complications such as leaks, bleeding, and infections. In time, the technique improved, and gastrectomy became popular, especially to deal with the epidemic of duodenal ulcers requiring surgical treatment for hemorrhage, perforation, and intractable pain. Many surgeons became famous for their ability to operate safely and quickly, and at one time the surgical wards were full of patients needing treatment. The introduction of cimetidine in 1977 and later of ranitidine dramatically reduced the need for gastric surgery. The more recent introduction of weight loss drugs will limit future need for bariatric surgery on the stomach.

Pancreatic surgery

In 1882 Friedrich Trendelenburg attempted to treat a pancreatic cyst by surgical means. However, early pancreatic surgeries were associated with an extremely high mortality rate. In 1912, Allen Whipple performed the first partial pancreaticoduodenectomy, a precursor to the modern Whipple procedure (for cancer and rarely for chronic pancreatitis), which consists of removing the head of the pancreas, the duodenum, the gallbladder, and part of the bile duct. Sometimes the entire organ or only its tail (and the spleen) is removed. Advances in islet cell transplantation are providing hope for patients with chronic pancreatitis and diabetes.

Spleen surgery

The first recorded splenectomy for a traumatic rupture occurred in 1826 by Karl August von Langenbeck in Germany. Early splenectomies were mostly performed for trauma, as elective surgeries for conditions like hypersplenism were not yet common. The procedure began to be used not only for trauma but also for conditions such as hereditary spherocytosis, idiopathic thrombocytopenic purpura, and certain cancers.

Later advances

A better understanding of fluid and electrolyte balance, as well as advances in critical care medicine, have all contributed to making laparotomy safer. Surgeons learned that the location and direction of the incision significantly impacted patient recovery and complications. They also developed techniques to operate through small incisions using specialized instruments and cameras. Better wound care, pain management, and early mobilization resulted in faster recovery, better cosmetic results, and shorter hospital stays. New protocols for treating cancer have reduced the need for extensive surgical interventions, and technical innovations such as wound protectors, specialized retractors, and new closure methods have improved overall results.

The future

Abdominal surgery now stands at the threshold of a revolutionary transformation through the integration of robotics, artificial intelligence, machine learning algorithms, and enhanced visualization of anatomical structures in real time. An increasing shift toward minimally invasive techniques will continue, enabled by advances in miniaturization and imaging technologies and microscale robots. 3D bio-printing technology will likely advance to the point where custom tissue and organ replacements can be manufactured on-demand, and artificial intelligence will play an increasingly key role in surgical decision-making—to an extent that would astound great early pioneers of surgery such as Theodor Billroth.

Further reading

James L. Franklin. “Billroth.” Hektoen International Winter 2015. https://hekint.org/2017/01/22/billroth/