Ad Astra Per Alia Porci

“Thinking again?” the Duchess asked … “I've a right to think,” said Alice sharply, for she was beginning to feel a little worried. “Just about as much right,” said the Duchess, “as pigs have to fly …”

Alice's Adventures in Wonderland —Lewis Carroll

O ne of the strengths of medical practice is the use of known scientific facts to cure disease. This permits uniformity in success and best outcomes based on state-of-the-art knowledge. A great investment has been put into each physician to be sure we understand and accept these facts. Unfortunately, some of these “facts” are not facts. As we were indoctrinated as students to quote and hold fast to what we have learned, it sometimes makes it difficult to accept new knowledge.

Medical practice evolves over time to incorporate newly discerned truths. Experimental method is used to make discoveries that support forward strides in medical knowledge. Most of these are humble changes that slowly build upon existing data. These kinds of changes are easy to accept. Less frequently, major paradigm changes occur. These are usually not readily apparent because of discord with what we believe we know. Great insight is needed to question basic principles turned dogma.

The development of the laparoscopic nephrectomy is an example of how seminal changes occur in surgery. Ralph Clayman had an idea that at the time was outlandish. Remove a solid organ from the body through a 1 cm incision. This was a dream that turned to passion when he heard the first report of the laparoscopic pelvic lymph node dissection in 1990.

Dr. Clayman set forth in an organized way to develop the technique and prove feasibility in a regularly scheduled pig lab. He first engaged a team including a general surgeon who was familiar with the laparoscopic cholecystectomy, a lab technician, a resident in the lab, a fellow and a junior attending. He convinced these individuals to participate with infectious enthusiasm, energy and logical plan.

Specific equipment did not exist for this procedure, but with the advent of the laparoscopic cholecystectomy, the technology finally become available that could be the starting point for this venture. Rudimentary equipment, clip appliers and staplers were just becoming available. However, a method to extract the kidney did not exist. Dr. Clayman's vision engaged engineers at Cook Urological who would drive back and forth every lab evening from Spencer, Indiana, to St. Louis, Missouri, and came up with a device for morcellation. The last piece for removal was an entrapment sac that would prevent tumor spillage. This technology was born, of all places, on a run where Clayman recognized that the shorts he was wearing had ideal characteristics for a bag.

The initial clinical case took tremendous preparation to be sure documentation, personnel, equipment and expectations were all in place. Paramount to all, he never let the team lose focus on the safety and personal importance of each patient be it the 1^st or the 101^st.

Execution brought elation; however, reproducibility, improvement and dissemination became new goals. The team expanded with new fellows, residents and technicians. Most importantly, a momentum developed with all participants fully engaged in the project. The sincere appreciation and love Dr. Clayman had for the team was palpable. We were focused, dedicated and having fun as it was realized that all were part of something important.

Clayman subsequently put great efforts into replicating and standardizing the approach. Courses sprung up all over the world with Ralph or one of his disciples spreading the word. The rest is history, and laparoscopic renal surgery has evolved to a standard for the surgical management of renal diseases. Of note, there was no interest in Dr Clayman's proposal for a prospective randomized study. To this day none exist.

Laparoscopic nephrectomy was born out of great insight and courage to question basic principles turned dogma. Ralph Clayman had a creative idea to solve a problem, a maniacal passion, out-of-the-box thinking, purity in the enthusiasm and a few unwitting accomplices he brought together in the framework of the scientific method. Laparoscopic neprectomy ushered in a new era of endourology and has served as the seed for other minimally invasive procedures such as prostatectomy and cystectomy. The goal of making it an everyman procedure helped others to push and seek out new technology including the da Vinci Surgical System, whose main benefit has been to expand the footprint of minimally invasive surgery.

As physicians we have seen pregnant women with life threatening pyelonephritis cleared by antibiotics, teenagers with cancers cured and enjoying grandchildren, kidneys removed through 1 cm incisions, solid organs being ablated without any incisions and tissue replacement being grown in the laboratory. With such once seemingly impossible developments and the special individuals in our field who have cultivated these changes, I dare predict that one day we truly will see pigs fly.