The Kindest Cuts of All

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As their skills improve, videoscope surgeons are attempting more daring feats. In 1990, for example, a surgical team led by Dr. Ralph Clayman of Washington University in St. Louis devised a clever technique for removing problem-plagued kidneys laparoscopically. Because the kidney is a solid organ about the size of a fist, it has to be reduced in size before it can be drawn through a 2 1/2-cm incision concealed in the patient's belly button. So after cutting the kidney free of connective tissue and sealing off the big artery that supplies it with blood, the surgeons move the organ into an impermeable sack and, while it is still inside the patient, chop it up with a tiny rotating blade. The sack and its pulverized contents can then be safely drawn out. "I just can't believe these little scars," exclaims Maria Pfeiffer, now a freshman at a small college in Kansas City. Ten days after having an infected kidney removed last spring, Pfeiffer felt well enough to play volleyball. In a month she felt glamorous enough to don a bikini.

Nowhere is videoscope surgery likely to have a greater impact than in the field of thoracic (chest) surgery. Only a year ago, patients requiring a lung biopsy would inevitably be subjected to a muscle-slicing, rib-bruising operation that typically involves two or three days in intensive care followed by weeks of painful recovery. For elderly and frail patients, this often meant that a biopsy, and hence a firm diagnosis, was out of the question. Now a few pioneering surgeons are developing less traumatic ways of gaining access to the chest cavity. Sugarbaker, for example, makes a slash through the skin of his patient's side that looks no more serious than an accidental nick from a razor. Then he pushes a series of blunt-tipped probes through the bundles of muscle that lie between the ribs. Rather than tearing, the muscle fibers stretch to accommodate the probes, providing the surgical team with a temporary passageway about as thick as a man's finger. At the end of the operation, a couple of stitches and a Band-Aid suffice to close the patient up. (Unfortunately, if a biopsy reveals a malignancy, the patient will probably undergo an open-chest operation. At present there is no other way to remove a whole lung.)

For the surgeon, operating by videoscope means mastering a totally new set of skills. The experience can be exhilarating. "It's sort of like hang gliding in the abdomen," exclaims Clayman as he reruns a video of his instruments swooping toward a patient's kidney. But there are serious drawbacks. In open-lung surgery, for instance, when Sugarbaker can't see the lesion to be biopsied, he simply uses a gloved finger to locate it by feel. He can still do this, of course -- provided the lesion is no more than a finger's length away. Even more challenging is the fact that the image displayed on operating-room TV screens is only two-dimensional. This makes it easy to misjudge the distance to a blood vessel or organ, which is a major hazard of videosurgery. A tiny nick to the lung, for instance, could unleash a bloody torrent that even the best surgeon would be pressed to stanch in time.