The history and future of operative laparoscopy.

Laparoscopic sterilization was first performed in the United States in 1941. During the 1950s and 1960s hospitals procured the relatively inexpensive basic laparoscopic instrumentation, and education for physicians learning the techniques was provided mostly by academic centers during residency training. Interest in expansion of laparoscopic procedures was slight until the mid-1980s when operative laparoscopic management of ectopic pregnancies began to spread from academic centers to the private sector. Major technologic developments in instrumentation greatly simplified the endoscopic procedures and provided the first impetus for an explosive growth of operative laparoscopic applications in surgery. The great financial resources of private hospitals enabled them to adapt and retool quickly for operative endoscopy. Lacking these resources, academic institutions lagged behind; thus a growing divergence began between academic and private institutions in their influence on the development, use, and acceptance of the new technology. The development of expensive disposable instruments, with costs passed on to patients by private hospitals, further priced academic institutions out of the market. Two concerns today are paramount regarding operative laparoscopy: (1) The majority of laparoscopic techniques and procedures being performed by surgeons in this country have not been taught in the controlled setting of a residency or fellowship training program; (2) the legitimacy of the procedures themselves is questionable because of lack of sufficient data in the literature to support them. Academic institutions, working in tandem with the private sector, must assume the responsibility for answering these concerns.