The Kindest Cuts of All

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Might enthusiasm for videoscopes be in danger of outrunning common sense? In the past four years, 28,000 U.S. surgeons have learned how to remove gall bladders laparoscopically. "That may be too quick," acknowledges Dr. Nathaniel Soper, a general surgeon at Washington University in St. Louis, since laparoscopic surgery takes considerable practice. Currently, for . instance, laparoscopic gall-bladder removal appears to carry a slightly elevated risk of bile-duct injury, but the injuries seem to be concentrated in the first operations a surgeon performs. For this reason, medical societies have begun drawing up training standards that direct novices to practice on animals first and then to conduct their first operations under an expert's eye.

Videoscope surgery will never completely replace open surgery, but it may come closer than anyone a year or two ago might have imagined. Already, of nearly 600,000 gall bladders that are removed in the U.S. annually, an estimated three-quarters are removed laparoscopically. Other common operations, from hysterectomies to hernias, seem likely to follow suit. At Loyola University Medical Center near Chicago, a trauma team has begun using the technology to diagnose injuries from knife wounds and automobile crashes. Soon the team expects to move from diagnosis to laparoscopic repair of tears to the diaphragm and abdominal wall. Eventually, if doctors become convinced that operations performed in this manner do not inadvertently spread malignant cells, this kinder, gentler surgery will touch the lives of an even larger group of people: cancer patients.

Today's videosurgeons fervently hope that by that time their equipment will have greatly improved so they will no longer get cricks in their necks (from craning to watch a TV) and elbows (from manipulating long-handled instruments of awkward design). A few dream of operating by remote control, their heads encased in virtual-reality helmets. Don't laugh, they chide skeptics. On the drawing boards at SRI International is an inkling of just such a system, one that might someday allow a surgeon in St. Louis to operate on an astronaut in low earth orbit. Even better may be novel ways of destroying diseased organs -- through heat, perhaps -- without cutting into the body at all.

But more important than any futuristic technology is the change in attitude that has begun to occur. "Why punish the skin, the muscles, the fat when all you want is the kidney?" demands Washington University's Clayman. "Once you ask that question, everything changes. Soon, to make any kind of incision will be seen as an admission of failure."