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 Best Doctors
The Kindest Cut, p. 5 of 7


When the balloon is collapsed and retracted, and Sherry's heart has been jump-started with a defibrillator, Colvin directs me to look at an ultrasound of the repaired organ. Before the surgery, the defective flap of the valve was curling back in on itself, and blood, instead of flowing down through it, was being thrown back up to where it had come from. The blood, represented by splashes of red on the screen, looked like the angry expulsions of a volcano. Now those flashes are gone; only a calm blue pulses in that area on the screen. Just under a week later, I call Sherry, who told me my timing was perfect: She was just finishing eating a full Thanksgiving dinner she and her family had delayed for a few days until her return.

For the past five years, alternatives to open-chest surgery have been expanding for some of the most common, and devastating, operations performed on the motor of the body. In the mid-nineties, Lenox Hill's Dr. Valavanur Subramanian helped perfect a coronary-bypass method in which he manipulated one or two grafts through a small incision -- without having to use the heart-lung machine, which studies have linked to risks of neurological damage. Since then, he's performed hundreds of successful bypass surgeries this way. But it's a practice limited, for the most part, to people who need only one or two bypasses; the need to manipulate three or four or five coronary arteries -- in front, in back, on the side of the heart -- usually precludes the possibility of an operation through a small incision.

Soon, heart surgeries could have doctors at an even farther remove, with robots doing the hands-on work. The million-dollar machines have enterprising names like Zeus and Da Vinci and are equipped with arms attached to surgical instruments no bigger than the joint of a finger. The surgeon sits at a console and manipulates hand instruments; the robot's computer reads those movements and electronically transmits their parameters to the instruments at the end of the robot's arms, which are calibrated to move analogously, only more minutely. The robot smooths out the tremors of a surgeon's hands, which may eventually allow suture tying in small spots that would otherwise be inaccessible.

Even the most devoted of minimally invasive surgeons will admit that the procedures have their limiting factors.

Colvin has used Zeus for several mitral-valve repairs but concedes that at this point, it's more laborious than his current technique; at New York-Presbyterian, surgeons have repaired holes in the heart through entirely closed-chest surgery with the help of the robot; at Lenox Hill, Subramanian has experimented with the robot to perform single bypasses through an even smaller incision. Right now, the use of the robots is still experimental. But Subramanian hopes that within two years, using Da Vinci, he'll be able to send single-coronary-bypass-operation patients home the next day. "That's the goal of all this," he says. Like every other pioneering minimally invasive surgeon I talked to, he quickly grows frustrated with the pace at which other surgeons are keeping up with the possibilities. "Cardiac surgeons are sleeping," he says. "They don't want to do anything different."

Perhaps the only operations more traumatic than open-heart surgeries are those related to cancer. Columbia Presbyterian's Richard L. Whelan is currently doing research on laparoscopic surgery that he thinks will transform cancer treatment. Whereas Fowler and Edye are understated, measured in their manner, Whelan is blunt: "Caveman surgery" is what he calls open procedures. "There's a lot of animosity out there, a lot of bad feeling. But that doesn't mean we shouldn't move forward," he says. "This is the way it's going to be."

It's long been known that after major surgery, the body experiences a drop in immunological response for a week or so -- the longer the incision, recent research has found, the more significant the drop. Whelan compared the results of patients who'd had procedures performed laparoscopically with those who'd had the surgery through a large incision and found that no comparable drop, or a much less significant one, occurred in the former. The results suggest there would be lower rates of infection in patients operated on with minimally invasive techniques, which is itself a noteworthy advance and supports many doctors' clinical findings. But there are even more promising studies, on animals, that indicate that the chance of a tumor's recurring after surgery may be greatly reduced with a small incision as opposed to a large one. "It means that if the surgery is performed closed, you're better able to deal with tumor cells left over in a cancer patient," says Whelan. "Those microscopic cells are the reason why a third to half of people who have surgery have recurrences. In open surgery, those cells are given a chance to run rampant right after the surgery. We think we can minimize that."

Until now, the arguments in favor of laparoscopic surgery have been about immediate quality of life: cosmetics, the quicker recovery time, the reduced pain. But reducing pain may be more than just a luxury -- it may somehow be bound up in the healing process. One recent study found that among rats with tumors, those given morphine had better survival rates. Surgeons aren't sure whether it's the length of the incision that's most influential or the amount of exposure to microbes in the open air that the organs confront. But either way, "when you start talking about things that dramatically affect life span, then it's game over," says Whelan.

Even the most devoted of minimally invasive surgeons will admit that the procedures have their limiting factors, the most compelling of these being the skill of the surgeon. "Would I let someone who has taken out 25 colons laparoscopically take out my colon?" asks Mount Sinai's Barry Salky. "No way." The learning curve is both slower and steeper for laparoscopic surgeons, so patients are advised to ask carefully about the complication rates of a given doctor as well as the number of procedures he or she has performed.

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