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The Kindest Cut

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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.

Not surprisingly, as the number of laparoscopic procedures has risen over the past ten years, so has the number of malpractice suits filed: Between 1990 and 1994, there were 750 laparoscopic malpractice claims; between 1995 and 1999, that number ballooned to 1,426. The uptick raised enough eyebrows that in August 2000, the Physician Insurers Association of America published a study analyzing the most frequent missteps. As the report puts it, "Several of the claims reported indicated that the physician had trouble with visualization of the anatomical structures, which led to the physician dissecting or clipping the wrong duct or artery." Given that it takes around five years for a malpractice claim to makes its way through the system, Lori Bartholomew, director of research for the PIAA, expects to see these numbers keep rising; and so far, the compensation rate has been higher for laparoscopic claims than with the average surgical-malpractice suit. "These are clear-cut injuries that sometimes require another surgery, or even lifelong treatment," says Bartholomew. She adds that hospitals are starting to discourage laparoscopically assisted vaginal hysterectomies, not only because they take longer in the operating room but because "preliminary data suggests we're seeing comparatively higher complication rates in that particular surgery."

There's no denying that closed surgery is more technically challenging than open surgery, although that perception (as well as malpractice rates) may change as medical schools step up the level of training they require for graduates. And it's expected that younger surgeons more familiar with, yes, Nintendo may find the new techniques comparatively intuitive. "It's not that endoscopic surgery is more difficult than open surgery but that it's a different skill set," says Mount Sinai's Abrams. "People who might have been architectural engineers, automobile engineers -- those folks would certainly enjoy doing this kind of surgery," he says. "You'll be drawing from a different pool."

Already, it appears that the laparoscopic surgeons are getting a jump start professionally: Dr. Michel Gagner, the innovative chief of Mount Sinai's prestigious minimally-invasive-surgery center, rose to that position at the tender age of 38. Dr. Ferzli -- known as one of the most experienced general surgeons in minimally invasive techniques -- says his laparoscopic fellows at suny Downstate are being offered starting salaries upwards of $50,000 higher than those available to their less-trained surgical counterparts. For two fellowship spots, he received 140 applications in 2001, up from 90 the year before. "And when I interview these candidates," he says, "it's like they're desperate for the spots. The demand is so much higher than the availability."

As more and more medical students come out of surgical residencies with new training, he predicts a generation of in-between doctors -- the ones too young to retire but too well established to consider retraining -- will be hard-pressed to continue with profitable practices.

"It used to be that a surgeon was like the symbol of man," says Ferzli. "And we were like the feminine aspect of surgery -- we were called wimps." He savors the memory, then shrugs. "But we were right."


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