The surgeon is hunched over an unconscious patient, his eyes focused on the deep recess of an open abdomen.
It has been more than six hours since this difficult operation started at Johns Hopkins Hospital. Two anesthesiologists have traded off to give each other breaks. The nurses have changed shifts. But Dr. John Cameron has rarely looked up. He is determined to miss nothing, and at 2:31 p.m., he sees something he doesn't like.
The young surgeon he is training is poised to sew a single stitch - one of hundreds in this operation - into tissue from which it could break loose. Cameron erupts.
"Now that's fat," Cameron snaps. "Damn it, you know that. Pay attention to these things."
Cameron is at work. He is trying to cure his patient while teaching Dr. Harry Zemon. The younger man is already a fine surgeon, but he has much to learn from a mentor who has done more pancreatic cancer surgeries than anyone else in the world.
The Whipple surgery, as the operation is known, once caused fatal complications in about a quarter of those who underwent it. But Cameron and a few others have made it far safer and more commonplace. His high volume - he completed his 1,388th Whipple last week - represents a trend. Medical centers are becoming expert at particular treatments, because the more they do, the cheaper the cost and the more reliable the results.
Patients have gained an option in trying to survive a disease that is the fourth-leading cause of U.S. cancer deaths. So far, the Whipple is the only available cure for pancreatic cancer. Tenor Luciano Pavarotti is among those who recently underwent the surgery, at a hospital in New York.
Cameron embodies the way that powerful personalities spur advances. At 69, he has been at Hopkins for 48 of the institution's 117 years. He is a throwback to surgeons of old, the sometimes surly gods who helped push medicine to new frontiers.
Hopkins' Dr. Alfred Blalock, for example, co-developed a surgery to save babies with heart defects in the 1940s. Elsewhere, Dr. Denton Cooley perfected heart transplants beginning in the 1960s.
Cameron's work comes at a pivotal moment, as medicine shifts from heroics to prevention in many types of health care. He has managed to bridge the eras, helping to move academic medicine from a time when surgeons ruled their hospitals to a more collaborative one.
"He was god: He perfected this operation so the mortality is around 1 1/2 percent," said Dr. Julie Frieschlag, chairman of the Hopkins surgery department. But, she said, "I think the new generation doesn't want to be god. They want to be part of the team. The god can't do everything."
If pancreatic cancer is to be widely cured, it will take more than surgery and the standard therapies of radiation and chemotherapy. Even with a Whipple, only about a fifth of Hopkins patients with an aggressive form of pancreatic cancer live five years.
Cameron has been improving the surgery for more than 20 years. No breakthrough catapulted him. His achievement came in increments - one patient, one operation, one stitch at a time.
The hallmark of what some call the Cameron school of surgery is an attention to detail that is well known at Hopkins and at other medical schools where his proteges have gone on to operate and teach.
He combines obsessiveness with a calculating ambition that leads him to cross boundaries others wouldn't. He has, for example, raised eyebrows by operating on someone as old as 103. His confidence and expertise lead him to believe that he can remove tumors others can't.
Cameron estimates that nearly 30 percent of pancreatic cancer patients have tumors that can be safely removed. Other experts believe that only 10 percent to 20 percent do.
Cameron's chosen operation remains among the most technically challenging of general surgeries. If a hernia repair is the equivalent of patching drywall, the Whipple is remodeling the kitchen of a house with plumbing problems. It requires digging out a buried tumor, sparing surrounding blood vessels and disconnecting and then rebuilding part of the digestive system.
There is, said Dr. Jay Grosfeld, the American Surgical Association president, "a little aura about it."
Cameron's work is a window into the side of a teaching hospital that patients never fully see. The Sun was given access to the operating room to show how, amid the drama of surgery, techniques are passed from doctor to resident. But human anatomy varies in surprising ways from person to person. No matter how much experience a doctor has, the body's complexity presents pitfalls that arise as each operation unfolds.
Judge Bloom's chance
It was morning when Cameron strode into the operating room and joined those already gathered around the table on which a sleeping Theodore Bloom lay.
It had been Zemon's job, as one of two young surgeons known as assistant chiefs of service, to make the initial incision. He had cut vertically down the precise middle of Bloom's abdomen, from just below the sternum to just below the navel.