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                                                                                MEDICINE, Page 52

The Kindest Cuts of All


Palm-size video cameras, miniaturized scissors and staplers, and
minute incisions are starting to take the ouch out of surgery

By J. MADELEINE NASH/BOSTON


    Like a kid intent on a Nintendo game, Dr. David
Sugarbaker looks not at the patient lying senseless on the
operating table but at the TV positioned by her side. "I think
we're right on target," he exults. Displayed on the screen is
a larger-than-life section of the woman's right lung, a rosy
mass marred by a couple of suspicious lumps. "Fire away,"
Sugarbaker directs the assisting surgeon. On the screen a tiny
pincer appears. Grabbing hold of the lung just above the lesion,
the pincer makes a clean slice through the quivering tissue,
simultaneously sealing the wound by laying down a triple row of
surgical staples. A few more snips and the task is complete.
Sugarbaker, chief of thoracic surgery at Boston's Brigham and
Women's Hospital, draws a 10-cm-long sliver of lung through a
finger-size hole in the patient's side and sends it for biopsy.

    This nearly bloodless procedure, which Sugarbaker began
performing just nine months ago, is one of the most recent
applications of a new approach to surgery that is rapidly
displacing the dreaded knife and scalpel. "We are witnessing the
greatest surgical revolution in the past 50 years," exclaims Dr.
William Schuessler, a urological surgeon from San Antonio. The
instrument sparking such enthusiasm is variously known as a
laparoscope (when used in the abdomen), an arthroscope (when
applied to the joints), a thoraco scope (when the chest is
involved) and an angioscope (when the target lies inside blood
vessel walls). But apart from differences in length and
thickness, all these scopes are fundamentally alike: slender
fiber-optic tubes that can be inserted deep inside the body
through minute (1-cm-long or less) incisions. With the addition
of a tiny telescopic lens, a miniature light source and a
palm-size video camera, these tubes are transformed into video
scopes that project images of the patient's internal organs and,
even more important, of the snippers, staplers and graspers that
the surgeons manipulate.

    The reason for the surging popularity of videoscope
surgery is simple: correctly performed, it can dramatically
reduce surgical trauma. Since 1987, when the first diseased gall
bladder was removed in this fashion, rave reviews from patients
have made it almost rare for a gall bladder to be removed the
old-fashioned way. And for good reason. "Before," says Dr. Eddie
Joe Reddick, a retired Nashville surgeon credited with
popularizing the technique, "we were committing assault and
battery on our patients. It wasn't what we did to their insides,
but what we did in order to get there that was the problem."
Now, instead of an 8-cm to 15-cm slash down their abdomens,
patients wake up with four small incisions that not only heal
more quickly but also are far less painful. In fact, most
patients whose gall bladders are removed laparoscopically leave
the hospital the next day and return to work within a week.

    As their skills improve, videoscope surgeons are
attempting more daring feats. In 1990, for example, a surgical
team led by Dr. Ralph Clayman of Washington University in St.
Louis devised a clever technique for removing problem-plagued
kidneys laparoscopically. Because the kidney is a solid organ
about the size of a fist, it has to be reduced in size before
it can be drawn through a 2 1/2-cm incision concealed in the
patient's belly button. So after cutting the kidney free of
connective tissue and sealing off the big artery that supplies
it with blood, the surgeons move the organ into an impermeable
sack and, while it is still inside the patient, chop it up with
a tiny rotating blade. The sack and its pulverized contents can
then be safely drawn out. "I just can't believe these little
scars," exclaims Maria Pfeiffer, now a freshman at a small
college in Kansas City. Ten days after having an infected kidney
removed last spring, Pfeiffer felt well enough to play
volleyball. In a month she felt glamorous enough to don a
bikini.

    Nowhere is videoscope surgery likely to have a greater
impact than in the field of thoracic (chest) surgery. Only a
year ago, patients requiring a lung biopsy would inevitably be
subjected to a muscle-slicing, rib-bruising operation that
typically involves two or three days in intensive care followed
by weeks of painful recovery. For elderly and frail patients,
this often meant that a biopsy, and hence a firm diagnosis, was
out of the question. Now a few pioneering surgeons are
developing less traumatic ways of gaining access to the chest
cavity. Sugarbaker, for example, makes a slash through the skin
of his patient's side that looks no more serious than an
accidental nick from a razor. Then he pushes a series of
blunt-tipped probes through the bundles of muscle that lie
between the ribs. Rather than tearing, the muscle fibers stretch
to accommodate the probes, providing the surgical team with a
temporary passageway about as thick as a man's finger. At the
end of the operation, a couple of stitches and a Band-Aid
suffice to close the patient up. (Unfortunately, if a biopsy
reveals a malignancy, the patient will probably undergo an
open-chest operation. At present there is no other way to remove
a whole lung.)

    For the surgeon, operating by video scope means mastering
a totally new set of skills. The experience can be
exhilarating. "It's sort of like hang gliding in the abdomen,"
exclaims Clayman as he reruns a video of his instruments
swooping toward a patient's kidney. But there are serious
drawbacks. In open-lung surgery, for instance, when Sugarbaker
can't see the lesion to be biopsied, he simply uses a gloved
finger to locate it by feel. He can still do this, of course --
provided the lesion is no more than a finger's length away. Even
more challenging is the fact that the image displayed on
operating-room TV screens is only two-dimensional. This makes
it easy to misjudge the distance to a blood vessel or organ,
which is a major hazard of videosurgery. A tiny nick to the
lung, for instance, could unleash a bloody torrent that even the
best surgeon would be pressed to stanch in time.

    Might enthusiasm for videoscopes be in danger of
outrunning common sense? In the past four years, 28,000 U.S.
surgeons have learned how to remove gall bladders
laparoscopically. "That may be too quick," acknowledges Dr.
Nathaniel Soper, a general surgeon at Washington University in
St. Louis, since laparoscopic surgery takes considerable
practice. Currently, for instance, laparoscopic gall-bladder
removal appears to carry a slightly elevated risk of bile-duct
injury, but the injuries seem to be concentrated in the first
operations a surgeon performs. For this reason, medical
societies have begun drawing up training standards that direct
novices to practice on animals first and then to conduct their
first operations under an expert's eye.

    Videoscope surgery will never completely replace open
surgery, but it may come closer than anyone a year or two ago
might have imagined. Already, of nearly 600,000 gall bladders
that are removed in the U.S. annually, an estimated
three-quarters are removed laparoscopically. Other common
operations, from hysterectomies to hernias, seem likely to
follow suit. At Loyola University Medical Center near Chicago,
a trauma team has begun using the technology to diagnose
injuries from knife wounds and automobile crashes. Soon the team
expects to move from diagnosis to laparoscopic repair of tears
to the diaphragm and abdominal wall. Eventually, if doctors
become convinced that operations performed in this manner do not
inadvertently spread malignant cells, this kinder, gentler
surgery will touch the lives of an even larger group of people:
cancer patients.

    Today's videosurgeons fervently hope that by that time
their equipment will have greatly improved so they will no
longer get cricks in their necks (from craning to watch a TV)
and elbows (from manipulating long-handled instruments of
awkward design). A few dream of operating by remote control,
their heads encased in virtual-reality helmets. Don't laugh,
they chide skeptics. On the drawing boards at SRI International
is an ink ling of just such a system, one that might someday
allow a surgeon in St. Louis to operate on an astronaut in low
earth orbit. Even better may be novel ways of destroying
diseased organs -- through heat, perhaps -- without cutting into
the body at all.

    But more important than any futuristic technology is the
change in attitude that has begun to occur. "Why punish the
skin, the muscles, the fat when all you want is the kidney?"
demands Washington University's Clayman. "Once you ask that
question, everything changes. Soon, to make any kind of incision
will be seen as an admission of failure."