One of the most common surgical procedures in the country, performed on 750,000 patients annually, laparoscopic gallbladder removal has a record of success stretching back almost two decades. Serious complications are rare; less than 1 percent of patients die. Along with other surgeries that rely on scopes as well as scalpels—including gastric bypass, hernia repair and appendectomies—the “lap chole” has largely supplanted open operations, helping millions of patients avoid long and potentially dangerous recoveries in hospitals. “Minimally invasive surgery was a revolution,” says California Pacific Medical Center’s Leonard Shlain, who was one of the first to perform it.
But some doctors now say the demands of an overeager public have pushed them over the years into doing minimally invasive procedures before they had the necessary skills. In the rush, says Ram Chuttani of Beth Israel Deaconess Medical Center in Boston, “major complications occurred which might have been prevented.” Shlain says some laparoscopic operations have “a dark side” of rare but serious complications, and that patients go into them falsely believing they are more or less risk-free. As doctors begin to perform new minimally invasive operations that seemed unthinkable a few years ago—including one that involves no skin incision at all—there is a danger that they, too, will overlook risks that have been there all along.
The first minimally invasive procedure to gain wide acceptance, the laparoscopic cholecystectomy arrived in the 1990s “like a thunderbolt,” says Josef Fischer, chair of surgery at Beth Israel Deaconess Medical Center. Surgeons quickly adopted it as the standard of care for gallbladder infections, practicing on pigs at weekend workshops and then quickly moving on to human patients who lined up for it—even some whose problems were too mild to warrant open operations. Though popular with both docs and patients, the operation carried new risks, some more severe and more common than those of the procedure it was replacing. Most serious was the rising rate of injury to the common bile duct, at least five times higher than it was in open surgery. Most doctors, however, blamed this on the inevitable awkwardness of novices. The learning curve, they thought, would flatten out with time, and the operation would become safer.
Since then, the tools of minimally invasive surgery have improved greatly; today’s equipment includes high-definition cameras and rotating scopes and lights that put the anatomy “right up in your face,” says Ed Phillips of Cedars-Sinai Medical Center in Los Angeles. Surgeons have adopted preventive measures, such as X-rays that offer clear views of the common bile duct. They also now have experience with other minimally invasive procedures to treat heart failure, obesity and other ailments. Not all of them are better than their open counterparts, but overall, says Tom Russell, executive director of the American College of Surgeons, “pretty much everything in surgery is going this way.”
Amid the promising changes, though, a troubling fact: the learning curve for laparoscopic cholecystectomies never flattened out. Just as in the ’90s, in almost one out of every 200 cases, the surgeon cuts the common bile duct. That’s nearly 4,000 patients per year. And the number may be underreported, says Shlain, because “few surgeons rush to tell people about their catastrophes.” At conferences, he adds, he hears of more dire outcomes from laparoscopic gallbladder removal than the statistics suggest.
Why haven’t almost two decades of practice made perfect? The layout of the body makes the “lap chole” an inherently tricky operation. And since “the normal anatomy we see in a textbook only occurs in 25 percent of patients,” says Phillips, through the lens of a laparoscope, it’s easy to be led astray. But not all complications arise from accidents of anatomy or unavoidable difficulties. Doctors can also be victims of their own success. “There’s a sense that ‘Wow, I’ve really got this nailed now’,” says Phillips. “People get cocky and don’t double-check for errors.”
The real problem arises when surgeons wait too long to remedy those errors. Sometimes the delay isn’t their fault. Laparoscopy patients often go home before they start to falter; docs can’t spot complications if they aren’t at the bedside.
When they do realize they’ve made mistakes, most surgeons make the repairs themselves, since they know their own patients best. But in such cases, the patient’s risk of death is 11 percent higher than when the surgery is performed by another doctor. Krystal Lehman, 16, from Shenandoah, Iowa, says she wishes her surgeon had called in another doctor sooner. While removing a cyst from her ovary, she says, he punctured her aorta. During a second operation to stop the bleeding, he cut off circulation to her legs, leading to the loss of a foot. Susanna Brown, an attorney for the surgeon, says he provided the appropriate standard of care and that the initial injury to the aorta was “a recognized complication of the procedure.” As for the second operation, Brown says, the doctor was trying to shunt blood to Lehman’s brain to save her life.
No one, not even malpractice lawyers, is arguing that laparoscopic procedures shouldn’t be performed. Minimally invasive surgery continues to broaden its reach. At Beth Israel in Boston, doctors are developing a new gastric-bypass operation that is as minimally invasive as it gets, conducted through a hole in the stomach, reached via the mouth. The procedure, called “natural orifice transenteric surgery” or NOTES, will leave no scar, says Chuttani, and patients will “go about their work the next day like nothing has happened.”
Chuttani, who is pioneering NOTES, says it could “change the face of surgery,” but he has “issues and doubts” nonetheless. The public, as in the ’90s, will certainly clamor for the new procedure. “This will be hyped, and it will have great appeal,” says Russell. But before people get on the bandwagon again, he adds, “they need to make sure they’re not pushing the health system too fast. We’ve all got to be much, much smarter this time.” As history shows, surgery that leaves no scars can still cause ugly damage.
