After the first World War, and about the same time, the American internist John C. Ruddock (1891-1964) left the United States Navy to enter private practice in Los Angeles. However Ruddock concentrated on cardiology in the 1920s. He was an active member of the American College of Cardiology and, in 1931, became president of the California Heart Association.4
According to one of his assistants, Irving Wills of Santa Barbara, Ruddock used the McCarthy cystoscope at the beginning of his laparoscopic efforts. Wills noted, “It was really quite amazing to me how much one could see with that rather limited instrument. It had a small telescope, too short, and there were many other difficulties…”5
An incision was necessary to insert the instalment into the abdominal cavity and stitching was required to keep it tightly fixed and prevent the loss of pneumoperitoneum. Ruddock added a trocar quite early to his peritoneoscopy set so that proper access could be gained to the abdominal cavity.
Ruddock presented his peritoneoscope for the first time in 1934. The term “peritoneoscopy” was initially proposed by Orndoff of Chicago in 1920.6
Ruddock's instrument consisted of a fluid evacuator equipped with an air-tight lock, a pneumoperitoneum needle, sheath and bistoury-tipped obturator which acted as a trocar, “Telescope” (14-inch, preoblique optic), and biopsy forceps.7
Ruddock “borrowed” the idea of combining biopsy forceps with a peritoneoscope from urologists. He successfully obtained specimens from numerous solid organs, including the liver, spleen, stomach, omentum, and peritoneal surfaces. Ruddock coagulated all wounds, regardless of whether they were bleeding or not ().
Peritoneoscopic biopsy (Ruddock, 1934). Figure 3-6 in Highlights in the History of Laparoscopy.
In contrast to Kalk, Ruddock devoted a great deal of attention to the topic of gastric malignancy in his publications. Ruddock proposed a combination of gastroscopy and peritoneoscopy to examine the stomach for malignancy. While observing the stomach surface through a peritoneoscope, the physician introduced a “special stomach tube” (Rehfuss tube) per os into the stomach (
). This instrument was outfitted with an electric light at the tip to transilluminate the stomach wall. In order to make the examination more effective, Ruddock distended the stomach with air.8
Transillumination of inflated stomach (Ruddock, 1937). Figure 3-7 in Highlights in the History of Laparoscopy.
In the late 1930s and early 1940s, many North American physicians not only embraced Ruddock's technique, but contributed their own refinements to the procedure. Robert Hope, who assisted Ruddock for three years, examined the use of peritoneoscopy for diagnosing extra-uterine pregnancy.9
Edward Benedict of Boston described the aspiration of an ovarian cyst under peritoneoscopic view.10
William Lee of Philadelphia performed cholecystography under peritoneoscopic examination.11
Robinson and Fiske of Santa Barbara, California, presented a retractor for displacing viscera during peritoneoscopic examination.12
“Peritoneoscopy has received much more attention during the past year than ever before,” summarized Beling in 1941.13