When surgeons at the University of Maryland Medical Center reported they had dragged a diseased gallbladder through a hole concealed in the bellybutton, one couldn't help but feel uncomfortable.
That was three years ago.
Today, laparoscopy -- a technique that enables surgeons to perform delicate operations through a series of small incisions -- has become the hottest trend in surgery. Not only has it become the dominant method of removing gallbladders, but it is also being used to repair hernias, re-inflate collapsed lungs, perform hysterectomies, excise early cancers and remove diseased appendixes, kidneys and spleens.
How far will it go?
"Originally I was a little pessimistic, but now I think perhaps 60 to 70 percent of general surgical procedures will be done this way in the next 10 years," said Dr. John L. Flowers, who heads the University of Maryland Center for Advanced Videoscopic Surgery.
The method has much to offer: less pain, shorter hospital stays and a faster track back to work. One patient, Christine Couchman, speaks glowingly of how she had her appendix removed one day, left the hospital two days later, and returned to work about a week after that.
The traditional method, which involves an incision several inches long, usually means two to four days in the hospital and four to six weeks of recovery before the patient feels strong enough to return to work. And much pain along the way.
"I never had the prescription for the pain medication filled," said Ms. Couchman, a University of Maryland nurse. She added that over-the-counter pain relievers were sufficient to cut the little pain she felt.
Whether it's the appendix or the gallbladder, the method works like this: Surgeons slide their cutting and grasping tools through a few small holes in the abdomen. Through another hole they slide the laparoscope, a fiber-optic camera that "sees" the patient's anatomy and displays it on a video screen.
The operation is much like traditional surgery, except the surgeons let the laparoscope rather than the naked eye guide their maneuvers. If tissue needs to be removed, the surgeon either slides it whole or in pieces through a slit that may be only an inch wide.
Some surgeons have adopted a novel technique to remove organs that are too large to slide through a small incision. They place the whole organ in a plastic bag, then pulverize it with a hand-held blender before pulling the sealed bag out.
The excitement over laparoscopic surgery has some observers questioning whether surgeons have embraced it too quickly, performing difficult operations before they have mastered the art. Questions grew out of the experience in New York state, where seven patients died and 185 others suffered serious complications in laparoscopic gallbladder operations over a two-year period beginning in August 1990.
Most complications, according to a state health department audit, were the result of mistakes made by surgeons who had little experience with the laparoscope. A frequent mistake was cutting the common bile duct, which drains bile from the liver into the intestines to aid digestion.
To reduce such accidents, New York now requires that surgeonsperform at least 15 laparoscopic procedures under supervision before going solo.
Although Maryland hasn't followed suit, individual hospitals are setting their own requirements. At the University of Maryland, a surgeon first must perform 10 supervised procedures. In contrast, Johns Hopkins and the Greater Baltimore Medical Center are not setting a precise number, judging each physician separately based on the competence shown during supervised operations.
"I'm hesitant to put an absolute number on it," said Dr. Robert Bailey, head of general surgery at GBMC. "While one surgeon is able to master it in five cases, another may need 15 to 20 cases. There's going to be individual variation."
At all three hospitals, surgeons are required to try the technique on pigs before attempting it on people.
Both Hopkins and Maryland report complication rates that are wellwithin the rates found in national studies. In those studies, problems occurred within a range of one in 200 operations to one in 500 operations. In contrast, injuries in New York occurred in approximately one in 40 cases.
In light of the New York experience, the case for consumer caution is easily made.
"A consumer would be wise to ask a surgeon about his experience with the procedure," said Dr. Mark A. Talamini, director of minimally invasive surgery at Johns Hopkins.
"But just because the surgeon hasn't done a ton doesn't mean he's not a good surgeon and capable of doing it safely. I think a good surgeon in the open belly is a good surgeon with a laparoscope. A lot of people think surgery is a big technological thing, but much of it is in your head -- good decision-making."