The Kindest Cuts of All

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 thoracoscope (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 videoscopes 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 videoscope 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 inkling 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."