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 Best Doctors
The Kindest Cut, p. 2 of 7
 
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In defense of the surgeons who hold back, some may be waiting to dive in until the techniques are perfected. "We've had a hundred years of open surgery," says Kenneth A. Kern, clinical professor of surgery at Hartford Hospital and an expert in laparoscopic medical legal issues. "We know what its limitations are. We're only just starting to figure out all the problems with laparoscopy."

Invisible hand: Dr. Dennis Fowler in a New York-Presbyterian operating room.

But already the tide is turning, as a host of local high-end hospitals have wooed minimally invasive surgeons to stay competitive. NYU and Montefiore Medical Center have established new divisions of minimally invasive surgery in the past two years. Dr. Dennis Fowler, Jennifer's surgeon, came to New York from Pittsburgh fifteen months ago to head up a new minimally invasive division at New York-Presbyterian Hospital. Mount Sinai's new director of cardiac surgery, scheduled to arrive this month, is Dr. Lishan Aklog, a minimally invasive cardiac surgeon from Brigham and Women's Hospital in Boston. Memorial Sloan-Kettering Cancer Center, which has hired five minimally invasive surgeons in the past six months, is aggressively trying to hire still more in the next half-year. Recently, Fowler says, "it's really turned around -- there's a craze for everybody to get someone."

Among laparoscopic surgeons, NYU has a reputation for resisting minimally invasive techniques, but it signaled a commitment to changing that when it hired Dr. Michael Edye, a wry Australian who was Barry Salky's first recruit at Mount Sinai. As Edye, preparing for a laparoscopic kidney removal on a Tuesday morning in November, waits impatiently for the anesthesiologist, one of his residents, a young Harvard graduate, offers up his theory of why minimally invasive surgery was relatively slow to catch on among doctors. "It was used early on by gynecologists," he says, tying on his mask. "I think that has something to do with it" -- prestigious surgeons, he speculates, were reluctant to take their cues from gynecology, long considered the least glamorous of the medical practices.

"What I'm doing right now is a cross between flying and scuba diving," says Dr. Michael Edye, cutting through the fatty tissue surrounding the kidney. "It's easy to lose one's horizons."

The atmosphere among the crew is light: By now, Edye has removed some 250 kidneys laparoscopically. In organ donation, the minimally invasive approach has proved to be an enormous boon: In one study done by the University of Maryland, the number of patients who had access to live donors rose from 12 percent to 25 percent over four years -- a huge advantage, given the historical scarcity of organs for transplantation.

The patient, a young man visiting from Vietnam to donate his kidney to his brother, walks into the operating room smiling a bit self-consciously (he speaks no English) and lies down on the table. Five minutes later, he's out, and the team prepares him for surgery, marking the site where the small incision for kidney removal will eventually be, then turning him on his side. After a few more minutes of preliminary stage setting, it's lights out, so surgeons can better see the contrast on the television screens in front of them (this operating room has four). It seems appropriately womblike, as if to protect the internal organs from not only the knife but the startling brightness of the outside world. Four trocars -- stubby plastic tubular pathways -- are inserted, puncturing the skin, to provide access for the instruments.

Minimally invasive surgery is frequently described in terms of video games, but lined up alongside the patient, Edye and his two surgical-team members look more like foosball players: There's that small, tight movement of the hands, their eyes somewhere else, the long levers releasing their surprising power. Using a series of 5- and 10-mm.-around, twelve-inch-long instruments inserted through the portholes, the surgeons snip at the connecting tissue attaching the colon, so that it falls away (the patient's on his side, so gravity helps), allowing access to the kidney.

At no time, however, does something that looks like an organ in its entirety appear on the screen. Instead, the scope zooms in on individual connecting tissues, on tunneling, tubelike vessels, magnifying them up to twenty-fold, so that the geography is hard to assess for all but the carefully trained eye. "What I'm doing right now is a cross between flying and scuba diving," says Edye, who has cut away at the fatty tissue surrounding the kidney and is moving on to the series of veins and arteries that will need to be severed to free up the organ. "It's easy to lose one's horizons."

He won't cut the most essential blood supplies to the kidney until the last minute, to preserve the health of the organ for as long as possible. When he does sever tissue containing blood vessels, he uses what's known as a Harmonic Scalpel, an ultrasound device whose blades whir at a rate of 55,000 oscillations per second, simultaneously cutting and sealing vessels cleanly. At the site of the tool, the tissue bubbles at the point of severance and then blanches, closed off.







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