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Scoping It Out 'Nintendo surgery' increases

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 common procedure, doctors are performing 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 belly.

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Although the procedure is nothing new in gynecological surgery, it began getting popular for general surgery in 1989, says Dr. Mark A. Talamini, a Johns Hopkins University surgery professor. "Then it became wildly popular in 1990," he says.

"The benefits to patients are many," says the doctor who also heads the hospital's minimal invasive surgery department.

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"It significantly reduces pain and disability. Plus, the patients are out of the hospital quicker." But, he says, there could be disadvantages. "It depends on the procedure." And the cost is sometimes higher than for conventional 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.

"There's no big rule that says you can do this or you can't," says Dr. Norman Halpern, a surgery professor at the University of Alabama and a leader in setting voluntary standards for laparoscopy.

The laparoscope is expected to be used this year in an estimated 600,000 gallbladder operations, 120,000 hernia repairs, 125,000 hysterectomies and countless other operations nationwide. It's a mushrooming field, but the buyer still needs to beware, doctors say.

"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?' And then the big thing is, 'How many complications have you had and what are they?' " says Dr. David Edelman, a surgeon at Baptist Hospital in Kendall, Fla.

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.

Recently, the American Medical Association released a report stating that the availability of the laparoscopic surgery is tied to an increase in gallbladder surgery.

"The introduction of laparoscopic gallbladder surgery . . .," writes Dr. Antonio P. Legorreta and colleagues, "has climbed from 0 percent in 1987 to 80 percent in 1992."

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Some doctors say the increase is for no better reason than because it's new technology that everyone wants to use.

Hopkins surgeon Dr. Talamini agrees the procedure has initiated more gallbladder surgeries.

"There is no question more gallbladder surgeries have been done since the advent of this surgery. But the question is what is necessary," he says.

"Before [laparoscopic surgery] you would have had a big, slash on your belly, a big scar and a longer hospital stay," he says.

People would be willing to tolerate severe symptoms before deciding on such disruptive surgery.

Laparoscopy dramatically lessens the severity of the after-effects and that would explain some of the increase, Dr. Talamini says.

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"It was the most fantastic thing I've ever experienced," says Anita Melnick of Aventura, Fla., who had her gallbladder removed -- the most common use of laparoscopy.

Quick surgery, quick recovery

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 every year have their gallbladders removed because of painful gallstones. Conventional surgery requires up to eight days in the hospital and four to six weeks of recovery.

"I went in at 1 o'clock on a Wednesday. At 12:30 the next day I'm in my apartment, having a breakfast of eggs and muffin and juice and home fries. By Saturday and Sunday, my husband and I went out to dinner," Ms. Melnick says. "I just can't recommend it enough. It's incredible."

Laparoscopy also spared her from the six-inch incision that President Lyndon Johnson proudly displayed for the press when he had his gallbladder surgery in the 1960s.

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It was around that time that 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 one person at a time to look through a lens into the body.

"I've been doing it since 1970,"says Dr. Bernard Cantor, chairman of obstetrics and gynecology at Mount Sinai Medical Center in Miami. "And, for the first maybe 15 to 18 years, it was primarily for diagnostic procedures."

Everything looked small and blurry through these early machines, Dr. Cantor says. Then the same video revolution that brought feature films to our living rooms changed all that, he said.

"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," Dr. Cantor says.

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. Today, there is even a realistic 3-D video screen they can use, rather than the usual 2-D screen. Approved for sale last December, this 3-D imaging system gives a surgeon depth perception inside the body -- making operations easier, faster and less likely to cause inadvertent injury, according to the system's maker, American Surgical Technologies of Chelmsford, Mass.

These innovations have led some doctors to call laparoscopy "Nintendo surgery."

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Coordination was difficult

In the early days of bellybutton gallbladder surgery, surgeons didn't realize how hard it would be for them to coordinate their hands while looking at a TV screen. Young student doctors had an advantage over experienced, conventional surgeons in learning laparoscopy.

"Video surgery is a unique skill that is difficult for some people to learn," says Dr. Nathaniel Soper of Washington University in St. Louis, a leader in laparoscopic gallbladder surgery. "It's much easier to teach a resident who has played video games. . . ."

In addition, a patient's previous surgeries or developmental defects sometimes made their insides look different from the way they were "supposed" to. Plus, the lack of depth perception on the flat video screen added to the confusion.

"There's a definite learning curve for laparoscopic procedures," Dr. Soper says.

"We know, for instance with gallbladders, that it extends at least through the first 15 cases. The risk of injury is the highest for them.

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Not your mother

"A surgeon's got to start somewhere, but I don't know if you want it to be on your mother," he says.

The Society of American Gastrointestinal Endoscopic Surgeons (SAGES) recommends that hospital credentialing committees not allow anyone to do laparoscopic procedures without completing an approved course and serving as an assistant to other surgeons.

It also suggests experienced surgeons, or proctors, directly observe inexperienced colleagues' first few cases before they are approved to do that laparoscopic operation as lead surgeon.

Hospitals also should monitor all their doctors for high complication rates, both SAGES and the American College of Surgeons say.

Still, the same pressures that moved laparoscopic gallbladder surgery so quickly into the mainstream are there for new operations -- with less reason, some critics say. Controversial procedures include:

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* Removing colon sections through the bellybutton. If the cause is an intestinal disorder like diverticulitis, this is not controversial. However, in colon cancer some doctors say laparoscopy is risky and unnecessary. They worry that the cancer won't all be removed, and that squeezing the colon through the navel could spread cancer cells in the abdomen.

* Ovarian cyst removal. If the cyst is cancerous and bursts during removal, the disease could be spread in the abdomen.

* Hernia repair. Laparoscopic surgery minimizes the pain, but another type of small-incision surgery is available and effective, critics say. Long-term results of laparoscopic hernia repair are not known.

* Appendix surgery. No one questions that this can be done easily and effectively. But it's more expensive than open surgery, and not necessary, critics say.

* Lymph node examination. The laparoscope is useful in looking at lymph nodes to see if gynecologic cancers have spread there, Dr. Cantor notes. But in prostate cancer, a blood test is usually sufficient, says Dr. Mark Soloway, chairman of urology at the University of Miami.

* Sterilization reversal. Dr. Jorge L. Coronado in Miami is one of the few surgeons in the nation using the laparoscope to reverse female sterilizations.

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He has performed the experimental operation on 71 women, only 20 of whom have undergone follow-up testing so far. He reports 15 of the 20 with re-opened Fallopian tubes.

The controversy of cost

Cost, too, is a controversial issue in laparoscopy.

Laparoscopy also can cut a patient's total bill by reducing days in the hospital -- an average of $1,545 in savings for gallbladder surgery --it also can result in higher costs. A recent analysis of 1992 figures taken from nine hospitals nationwide found that laparoscopic hysterectomy cost an average of $936 more, 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.

Insurance companies or the new national health plan might also weigh into the picture, says Dr. William Traverso, a Seattle surgeon who co-chairs the SAGES research committee.

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Although laparoscopy might save businesses money by keeping workers out of hospital beds and getting people back to work faster, its surgical costs are almost always more expensive than open surgery, he says. So laparoscopy might be vetoed more and more as the health-care squeeze tightens.

"The patient will have to do what the HMO tells them to do," Dr. Traverso said. "The HMO won't care if you have a 10-inch scar."

As doctors try to resolve such issues, they owe it to their patients to inform them about the advantages and disadvantages of open and laparoscopic surgery, Baptist's Dr. Edelman says.

"We've got to be honest, and be up-front, especially with this new technology. There are so many advances happening every week. It's just amazing."


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