So you think that little video camera in your closet is a marvel of miniaturization? Imagine trying to stick it through your navel. In what has become a common procedure, doctors are doing surgery by viewing their patients’ innards through a skinny video tube-a laparoscope-and by poking long-handled scalpels through a few half-inch slits in the stomach.
Innovative doctors are trying to stretch the limits of this minimal-access surgery, which doctors have nicknamed Nintendo surgery. There’s hardly any organ, from the breast to the appendix to the colon, that isn’t a laparoscopic frontier for an imaginative surgeon, which is why the doctors who are exploring the frontiers of laparoscopy are quick to warn eager patients about its potential pitfalls.
“For general surgeons it’s really new; there’s no big rule that says you can do this or you can’t,” said Dr. Norman Halpern, a surgery professor at the University of Alabama and a leader in setting voluntary standards for laparoscopy. “Some of it is clearly beneficial. Some of it is really questionable.”
The laparoscope was used in 1993 in an estimated 600,000 gallbladder operations, 120,000 hernia repairs, 125,000 hysterectomies and countless other operations nationwide. Doctors say the buyer still needs to beware in this mushrooming field.
“Patients should not be afraid when they meet their surgeon to ask, `Well, how many of these have you done? What type of training did you have to do this?’ ” said Dr. David Edelman, a surgeon at Baptist Hospital in Kendall, Fla. “And then the big thing is, `How many complications have you had and what are they?’ “
The answers are important because, unlike a new drug or medical device that needs federal approval, a surgeon can perform any operation in any way he or she judges best. So while laparoscopy gives patients more and often better choices, it also means deciding whether to be a guinea pig for unproved techniques.
Laparoscopy can cut a patient’s total bill by reducing days in the hospital-an average of $1,545 in savings for gallbladder surgery-but it can result in higher costs. An analysis of 1992 figures from nine hospitals nationwide found that laparoscopic hysterectomy cost $936 more on average, even though it saved two days of hospitalization. This was mainly because the operation took nearly 1 1/2 hours longer than if done conventionally.
Patients who choose minimal-access surgery usually are among those most eager to point out its advantages.
“It was the most fantastic thing I’ve ever experienced,” said Anita Melnick, of Aventura, Fla., who had the most widely accepted laparoscopic procedure, removal of her gallbladder.
This hollow organ on a person’s right side, just under the liver, stores bile until the stomach needs it to digest fats. About 650,000 people each year have gallbladders removed because of painful gallstones.
Conventional surgery requires up to eight days in the hospital and four to six weeks of recovery. Melnick avoided all that, thanks to the laparoscope:
“I went in at 1 o’clock on a Wednesday. At 12:30 the next day I’m in my apartment, having had a breakfast of eggs and muffin and juice and home fries. By Saturday and Sunday my husband and I went out to dinner. I just can’t recommend it enough. It’s incredible.”
Laparoscopy also spared her from the 6-inch incision like the one President Lyndon Johnson proudly displayed for the press when he had his gallbladder surgery in the 1960s.
Around that time the real pioneers of laparoscopy, gynecologists, were gaining experience with a primitive forerunner to today’s laparoscope. This single eyepiece atop a viewing tube allowed a look into the body.
“All gynecologists have been using laparoscopy for many years,” said Dr. Bernard Cantor, chairman of obstetrics and gynecology at Mt. Sinai Medical Center in Miami Beach. “I’ve been doing it since 1970. And for the first maybe 15 to 18 years it was primarily for diagnostic procedures.”
“The major breakthrough really has been the video systems, the cameras that allow us to see so much more clearly and which allow more than one person to see it at the same time, so you can operate together,” Cantor said.
Once that happened, and as long-handled instruments with gentle clamps, knives and needles at the end were developed, general surgeons began experimenting with abdominal procedures. Now there is even a realistic 3-D video screen they can use, rather than a 2-D screen. Approved for sale last December, this 3-D system gives a surgeon depth perception, making operations easier, faster and less likely to cause injury, said its maker, American Surgical Technologies of Chelmsford, Mass.
The biggest success, technically and financially, has been for gallstones. In four years it has gone from the first reported surgery in this country, in 1989, to the undisputed “gold standard” operation.
Insurance companies or a new national health plan might weigh into the laparoscopic picture, said Dr. William Traverso, a Seattle surgeon.
Laparoscopy might save businesses money by keeping workers out of hospital beds and getting them back to work faster, but it almost always is more expensive; so laparoscopy may be vetoed more as the health-care squeeze tightens, he said.
“The patient will have to do what the HMO tells them to do. The HMO won’t care if you have a 10-inch scar.”
