Although one day slips seamlessly into another, it is fitting to mark the beginning of a new year and reflect on our activities. The commencement of the second millennium Christian era seems, therefore, an appropriate time to examine the advances in surgery and, particularly, laparoendoscopic surgery. A well-worn aphorism notes that only by knowing where you've been can you determine where you're going.There is little question that laparoscopic cholecystectomy was one of the first truly consumer-driven medical advances. It was fueled in part by the application of exotic technology (including lasers, CCD chip cameras, mechanical clips, and suture and stapling devices) to a common operative procedure and by the public's growing awareness that laparoscopic surgery could reduce postoperative pain and morbidity. A revolution in surgery occurred 10 years ago and its effects are still being felt.The revolution incited by laparoscopic cholecystectomy, however, has exhausted its initial unbridled enthusiasm. Interest in laparoscopy remains high, but thoughtful surgeons in academic and clinical communities are examining laparoscopic procedures in the light of clinical out-comes and risk/benefit/cost ratios. No longer is a procedure being performed laparoscopically just because it can be done. Every aspect of laparoscopic surgery is being examined, and careful analysis is providing the information for an evolution of the laparoscopic revolution.Georg Kelling in 1901 was the first person to utilize a laparoscope to examine the intra-abdominal cavity of a living creature using pneumoperitoneum. In those days, bleeding into the abdominal cavity secondary to injury of a major vessel or ectopic pregnancy and bleeding into the gastrointestinal tract secondary to peptic ulcer disease was usually fatal. Laparotomy was the only method available to diagnose and treat these conditions.Kelling suggested that increased intra-abdominal pressure by air insufflation might stop intra-abdominal bleeding. He called this technique “lufttamponade” (air-tamponade) and used a Nitze cystoscope to examine the effects of lufttamponade (pneumoperitoneum) on the abdominal organs of a dog model.[1] Kelling was the first to label this examination (he called it “kölioskopie” today it is known as laparoscopy) and thus entered medical history. Kelling described coelioscopy, however, as a method only to observe the effects of lufttamponade; he did not suggest its use for diagnostic or therapeutic purposes.It remained for Hans Christian Jacobaeus to detail the first diagnostic use of laparoscopy in his 1910 paper entitled, “Concerning the Possibility of Applying Cystoscopy in the Examination of Serous Cavities.”[2] Jacobaeus described the diagnostic value of laparoscopy and, in addition, reported the first therapeutic application of this technology, which left air in the peritoneal cavity of patients with tuberculous peritonitis.After Jacobaeus there were only scattered reports of laparoscopy in the medical literature. The emphasis was on open surgery and it seemed that “big problems required a big incision.” It remained for gynecologists to develop laparoscopy, which was used prominently in the study of fertility and in tubal sterilization procedures. “Band-Aid” surgery for tubal ligation became quite popular in the United States during the 1960s and 1970s. Laparoscopy, however, had little impact on other surgeons.Complacent general surgeons in the United States were stunned, therefore, with the 1988 announcement of “Laparoscopic Laser Cholecystectomy.”[3] A wildly different way to remove gallbladders turned the surgical world upside down. Reddick, Olsen, Saye, McKernan, and others actively promoted laparoscopic laser cholecystectomy, and a revolution was launched. Since that time minimal access techniques utilizing laparoscopes and smaller and smaller instruments have been used to perform virtually all operative procedures in the general surgery armamentarium. In parallel, advanced laparoscopic methods have been developed in gynecology, urology, thoracic, vascular, orthopedic, cardiovascular, and plastic surgery.The advances in laparoscopic surgery have been impressive and, to date, relentless. But there is a question whether these advances can be sustained in this manner. Evolution of laparoscopy is in progress, and refinement of the indications for a laparoscopic approach are being developed. An example of this might be laparoscopic hernia repair.Laparoscopic access to the groin permits a complete evaluation of the myopectineal orifice of Fruchaud and hernias formerly classified as femoral, direct, and indirect inguinal can be completely addressed. Bilateral inguinal hernias and hernias that recur after open procedures are particularly suited to a laparoscopic approach. However, there are occasions when a lesser procedure might be indicated. For instance, in patients with severe cardiovascular disease and those who cannot tolerate a general anesthesia, open hernia repair under local anesthesia is optimal therapy.Similarly, open techniques for malignant disease may serve patients better until a more clear understanding of the mechanics of tumor implantation is gained.Laparoscopic instruments are, in general, unergonomic and typically clumsy in application. There have been reports of excess muscle fatigue, tendonitis, bursitis, neck pain, and headache by laparoscopic surgeons. The bio-mechanics of laparoscopic intervention is only now being understood, and this knowledge is leading to the development of operating room tables that specifically address the needs of laparoscopic procedures. The optimal height of operative video monitors has long since been determined; however, monitors in the operating room are still placed above the surgeon's line of sight and contribute to neck and head ache. Pistol-grip instruments are still being use. They are difficult to manipulate and contribute to fatigue and forearm tendonitis. These problems are now being addressed with instruments more friendly to the human hand. The operating room of the near future will be designed with these biomechanical facts in mind and be more hospitable for the surgeon-operator.[4]The effects of pneumoperitoneum on normal physiology is receiving more attention. Surgeons are well aware of the possibility of blood clots and deep venous thrombosis secondary to positive intra-abdominal pressure. Lower intra-abdominal working pressure, anticoagulation programs, and lower extremity compression devices are now in general use and continue to be refined. Additionally, under-standing the effects of cool, dried gas to maintain pneumoperitoneum is under investigation, and there is scientific evidence that patient morbidity and comfort are improved with the use of warm, humidified gas as the insufflation agent.[5]There is continued investigation into telesurgery. Originally the impetus for telesurgery was to develop a means to operate on people in a hostile environment remote from the operating team. Typically, this scenario involved an injured soldier on the battlefield or an astronaut in space. However, telesurgery would have real value in the management of people with highly communicable diseases who require surgical intervention. Operating from a site remote to the contagious patient would protect the operating team and decrease the chance of transfer of infected blood, tissue, or body fluids. This technology is available and only needs to be developed for introduction into mainstream surgery.There is continued reduction in the diameter and size of laparoscopes and instruments. It is intuitive that this reduction would be of benefit to patients, but studies that address the panoply of surgical procedures are needed to confirm this notion.From the preceding, it is evident that laparoscopic surgery is now entering a period of consolidation of the initial promise of laparoscopic cholecystectomy. Refinement of the instruments of laparoscopy, laparoscopes, video equipment, and operating room equipment, along with a better understanding of operating team ergonomics, will lessen the physical stress of laparoscopic surgery. Defined protocols for standard laparoscopic interventions will be established along with more appropriate patient selection and education, coupled with anesthetic measures to reduce postoperative pain (preoperative nonsteroidal antiinflammatories, preoperative intravenous narcotics, and pre-emptive local anesthetic infiltrated in port sites).[6] A better understanding of the physiology of laparoscopic intervention will lead to better patient selection and improved operating room techniques to monitor and protect patients during a surgical procedure.The evolution of laparoscopic surgery is in progress and the field is open to those minds who are challenged by a desire to “do it better.”