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The Kindest Cut

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

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.

Edye, his eye still on the screen, corrects a resident controlling the scope, which also provides the light source in the body cavity: "Don't weave around," he tells him. "You're moving the camera like you move your eye. We need smooth movements." The directive sums up the challenges of the surgery, which requires a rethinking of all the basics: Move your hand to the right, and the instrument moves to the left; your surgical eye is not your own but the camera's. Sensation, for novice surgeons at least, is limited. Edye, on the other hand, has a strong tactile feeling for his work. "It's like using chopsticks -- you can stroke the instrument over a structure and get a good appreciation for textures and fixation," he says. "You feel it like a blind person feels the road with a stick."

With the kidney nearly freestanding, Edye withdraws the instruments, the lights go back on, and the residents make a small incision, only about two inches long, in the young man's side. Then the laparoscopic mode is reestablished. The lights dim again, and an instrument with a compressed plastic bag wrapped tightly around it is inserted through the incision. Through a series of careful pokes and pulls, it's pulled off the instrument, then wrapped around the kidney. "It protects the organ when it's pulled out," explains one of the residents. "It also gives you something to grab on to." Some two and a half hours after the surgery started, the kidney, gleaming and red, is pulled out intact and transferred to a waiting basin with ice. I half expect it to let out a wail.

Edye believes that laparoscopy is still in its early stages; every week brings new triumphs. "Last week, I took out a swollen nine-pound spleen -- it was one and a half times the size of a football -- through an incision about this big." He spreads his thumb and forefinger apart. He used a technique called morcellation -- the spleen is broken up into pieces inside a plastic bag in the body, then withdrawn bit by bit. What kind of surgery, I ask him, does he think could never be adapted to minimally invasive techniques? He thinks for a moment, then comes up with an answer: "Amputations."

It's nine o'clock on a Saturday morning, and Dennis Fowler has just sat down with oatmeal at Eli's Vinegar Factory Café on the Upper East Side when his beeper rings. Fowler, who frequently bikes in the park with Edye -- the circle of laparoscopic surgeons is small and close -- is now director of New York-Presbyterian Hospital's Minimal Access Surgery Center. As his meal, the only one he'll eat until dinner, grows cold, he steps outside to return the call from an anxious father. Mustached and vested, a native of Kansas, Fowler looks and sounds like the kind of doctor who'd do house calls with a shiny black bag. Instead, he's a high-tech gadgeteer, the first general surgeon to use the Harmonic Scalpel, a collaborator on the invention of some 25 or 30 surgical tools now on the market (though few were patented by him: "I wasn't smart enough for that"). For Fowler, who most recently worked in Pittsburgh, one of his new job's most glamorous perks is the chance to meet with Cornell and Columbia engineers. He started out working with engineers in 1990, when he needed a flat laparoscopic tool that would move a colon out of the way without puncturing it. Now he brainstorms with them about space-age designs, the possibility of a tiny freestanding robot that could operate inside the body.

Fowler's mild midwestern manners probably served him well when hospital management was looking to hire its first director in charge of programs at both Cornell and Columbia, which recently merged -- a tricky proposition politically. But Fowler's no stranger to controversy: Shortly after he started using the new laparoscopic techniques at a hospital in Kansas, a colleague started harassing him. "He told me, 'I will do everything I can to hurt you,' " recalls Fowler. "He tried to get me off the staff. He succeeded in dissuading doctors from referring patients to me. He threatened my children." A certified medical professional threatened to harm Fowler's kids? "He told me he'd catch them on the way home from school if I didn't stop doing it," says Fowler.

The story could be dismissed as an exaggeration, except that almost every other laparoscopic surgeon who started practicing in the early nineties has his own war story, some tale of sabotage, subtle or overt, from veteran surgeons. "They were threatened by it economically," Fowler says simply, pointing out that gallbladder removal, for example, has always been the bread and butter of general surgeons. "It appears to me they could see the benefit of it but were afraid they couldn't learn to do it. And if the benefits were really there and I could do it, I would take away all their cases."

A decade later, financial issues are still roiling hospital departments: Take a colon-resection procedure Fowler pioneered in October 1990. Although cancer patients often prefer the laparoscopic procedure, because their recovery is swift and substantially less painful, the operating-room supply costs can be much higher -- at NYU Medical Center, they're nearly five times as expensive as open surgery. But the insurance reimbursement paid out to the hospital is no higher than it would be for the open surgery. Nor is the differential unique to colon resections. "Take an outpatient appendectomy -- what we get from insurance doesn't even cover the cost of the laparoscopic instruments alone," explains Mona Sonnenshein, vice-president and senior administrator at NYU. And those instruments are largely disposable, used once and discarded.

Some of those higher costs, including operating-room time, will eventually plummet through experience and experimentation. (suny's Ferzli has been known to forsake the Endocatch bag, a $139 plastic bag used to surround the kidney during organ removal, in favor of a two-cent Zip-loc baggie.) And already, argue the champions of the minimally invasive approach, hospitals should be recouping costs through shorter hospital stays, which net savings for hospitals since many insurance payers (including Medicare) reimburse them based on the diagnosis, not on the number of days a patient is on the premises.


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