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The Kindest Cut

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First cut: Dr. George Ferzli of SUNY Downstate on Staten Island.  

But there is considerable disagreement on how to do the math in comparing the costs of new and older surgeries. Let's say a new procedure's complication rate is so low that a hospital knows it will have fewer return surgeries as a result -- do you factor in that loss, perverse though that might be? Even the shorter hospital stays of laparoscopic patients are considered by some to be a suspect stat. "There's a self-selection involved -- the patients who are motivated to get back on their feet go for the surgery that's reputed to have a quicker healing process," says Dr. Stephen Gorfine, a surgeon at Mount Sinai who prefers performing open procedures. "And the minimally invasive surgeons are the biggest cheerleaders of all -- You're doing great, we'll call a car, we'll get you out of here tomorrow."

Many hospitals seem to be heeding overwhelming patient demand, holding their breath and forging ahead with the procedures before the calculus is clear. "There's spillover work that helps the bottom line," points out Dr. Kenneth Abrams, medical director of perioperative services at Mount Sinai. If a patient comes to a given hospital for a particular surgery, that's probably where he'll go for all the other, moneymaking services: the diagnostic tests, the radiological services, and so on. If he's pleased with the care he receives, he'll come back. Says Abrams hopefully: "They'll refer their friends."

There's a long-term concern at play as well: The more patients a hospital attracts, the stronger its negotiating position later on with the insurers. If it pays too much attention to costs and too little attention to patients' wish lists, a hospital finds itself on the start of a perilous downward cycle, with fewer and fewer along for the ride.

Sherry Zubris, a secretary at Rutgers in her fifties, learned from her cardiologist in New Jersey that she needed to repair her mitral valve, which was swollen and impairing the functioning of her heart. The problem can be asymptomatic -- and was, for the most part, in Sherry's case -- so it came as all the more of a shock when her doctor told her she would have to undergo open-chest surgery to fix a problem she had never even felt. Allowing herself to break down and cry as soon as she arrived home, she called her husband, Stephen, at work. Neither of them could imagine this young, healthy woman, who speed-walked with a friend every day at lunch, undergoing the agony of open-chest surgery.

Stephen Zubris spent the next three days researching possibilities on the Internet. Minimally invasive techniques kept coming up. The couple raised the procedure with their cardiologist, who only then mentioned a minimally invasive specialist to whom he sometimes referred his patients, a Dr. Stephen Colvin at NYU. "But if we hadn't done the research, he'd have never even mentioned the possibility to us," says Stephen.

At their doctor's suggestion, the couple went ahead and met with the traditional surgeon he had first recommended. As soon as they asked that surgeon about minimally invasive procedures, says Stephen, still a little annoyed, "it was like a door slammed shut. He told us he doesn't like to do things 'half-assed.' When we asked about cosmetics, he told us, 'We try to keep the scar below the neckline.' That was when we knew we'd be going somewhere else." With Colvin's procedure, a two-and-a-half-inch scar lies mostly unseen, hidden underneath the breast. It wasn't just the scar they were eager to avoid but the six-week recuperation period, and the tremendous pain associated with healing.

Once they met with Colvin, it was "a no-brainer," says Stephen, a bearded man who recounts the story in NYU's sunny lobby on First Avenue. He's waiting to hear the results of the surgery that Colvin ultimately performed. It helped that once they were given Colvin's name, they found more than they could digest about him on the Internet, which is no accident. In a field where old-school surgeons are reluctant to refer patients to laparoscopic surgeons, a strong Web presence -- financed, in some cases, by hospital public-relations dollars -- is important in attracting potential clients (it also draws in relatively well-educated, wealthy patients, every doctor's favorite kind).

In the operating room, where Sherry has just been anesthetized, everything is hushed and dim. Sherry herself is unidentifiable, her face covered in cloth, the rest of her covered in sterile orange plastic coating so that she looks more cyborg than human. Colvin has made a two-and-a-half-inch-long incision just beneath her breast. A rib retractor has pulled the incision and separated the ribs, so that the access site takes on a round shape, enough to fit three fingers or so through. Peeking surreally in and out of vision, as it pulses insistently amid all the plastic coating, is the left atrium of the heart, which Colvin will cut into to access the valve dividing that chamber from the ventricle below.

But before he can do that, he needs to stop the heart. Through incisions at the groin, he feeds one tube into the femoral artery and one into the femoral vein, following them all the way up to the heart. Those tubes are the lifelines to the heart-lung machine, which will take over the work of oxygenating Sherry's blood. Inside the tube to the femoral artery, he threads a guide wire with a condensed balloon at the end of it; when it reaches the top of the aorta and is expanded, the balloon will block the flow of the blood.

As the room grows even quieter, the balloon is unfurled; that, plus a shot of solution containing potassium, stops the heart's beating. The synchronized bleeping of a nearby electrocardiogram machine ceases. A startling slash of the heart, and Colvin has gained access to its interior, a view accessible to the room through the scope attached to his head. Its images are projected to the four TVs in the room, one of them the highest-quality HDTV available (four times the resolution of DVD, his technician says proudly). Up on the screen, the view is of exposed valve, fatty, yellow, and bulbous instead of flat and translucent, the characteristics of a healthy valve.

Dr. Colvin trims away the unhealthy parts of the valve and stitches together the remaining portions so they fit like a jigsaw puzzle, smoothly. All the knot-tying for the sutures happens at a five- or six-inch remove; each knot is then pushed down to the heart by an instrument called, appropriately, a knotpusher. As Colvin prepares to sew in a stabilizing band, it's like watching someone do intricate embroidery at a five-inch remove from the canvas.

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.


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