200 Years of Surgery: Cutting to Cure Has Come a Long Way

Cutting to cure has come a long way.

May 02, 2012, 3:41 PM

May 3, 2012— -- The three-and-a-half-inch tumor in Cynthia Miller's throat threatened to choke her, leaving her no choice but to have it removed.

"I had no idea I was even sick," said Miller, 55, who lives in Maitland, Fla. "I woke up in the middle of the night coughing. … The next thing I knew they were booking emergency surgery."

Instead of radical surgery -- which would involved cutting her face, pulling teeth and breaking her jaw -- Miller had her tumor removed through her mouth by a miniature robotic arm guided by the surgeon.

"With the robot, there are no cuts anywhere. No breathing tube, no broken bones," said Dr. Bert O'Malley, who pioneered the procedure at the University of Pennsylvania's Head and Neck Cancer Center in Philadelphia. "We go in through the mouth with a high-magnification 3-D camera and very small instruments, like a surgeon's fingers but very tiny, and we're able to remove the tumor without the side effects of traditional surgery."

Side effects like spasms, difficulty with swallowing and speech, not to mention chronic pain.

"The more you disrupt and injure tissue, the greater the risk of dysfunction and chronic problems," said O'Malley.

Today's minimally invasive surgery is far different from the procedures of 200 years ago, when surgeons hacked through skin, muscle and bone briskly and brutally without anesthesia or antisepsis.

"Pain and the always-looming problem of infection restricted the extent of a surgeon's reach," Dr. Atul Gawande, a surgeon at Brigham and Women's Hospital in Boston, wrote in a review published Wednesday in the New England Journal of Medicine's 200th anniversary issue.

Even after the advent of anesthesia in 1846, surgeons continued to "choose slashing speed over precision," Gawande wrote, describing a 19th century leg amputation in which the surgeon accidentally cut an assistant's finger along with the patient's limb.

"The patient and the assistant both died of sepsis, and a spectator reportedly died of shock, resulting in the only known procedure with a 300 percent mortality," he wrote.

Unlike today's surgeons dressed in sterile scrubs, masks, caps and booties, surgeons of yore wore black Prince Albert coats speckled with pus and dried blood from procedures past. It would take decades for them to recognize the importance of sterility.

Soon after, however, the arsenal of surgical procedures and their success rates quickly grew. From heart procedures to organ transplants to joint replacements, the "invasion of people's bodies for cure" was becoming the norm, Gawande wrote.

American surgeons perform more than 50 million procedures a year, according to the review, meaning the average American can expect to undergo seven operations during his or her lifetime. Miller, who's had four surgeries so far, said she's amazed at how far the field has come.

"I went in on a Friday morning and came home on the Monday," she said, recalling her surprisingly quick and painless recovery. "I'm thoroughly amazed. I'm in awe. Technology and man are coming together to enrich our world in ways that we could never have imagined."

But being a pioneer in the field of surgery is not for the thin-skinned.

"The first time we presented this technique to head and neck community, most people stood up and said, 'This is crazy. You don't need this expensive technology. There are other surgical approaches.' It never crossed our minds that the biggest barrier wouldn't be the tumor, but others in our field," O'Malley recalled. "But we kept going. And the more we did, the better we got. And it finally started gaining acceptance."

Anesthesia, too, was once considered a fad that would fade with time.

"It takes creativity and a desire to change something for the better, not for the sake of innovation, to be a pioneer in surgery. But it takes organization and persistence to see it through," said O'Malley.

The Future of Surgery

Indeed, surgery has come a long way, but it has room to improve. The risk of complications, while smaller than before, still looms.

"Just because you're working through smaller holes doesn't mean there's no risk," said O'Malley. "The risk is still there, just the side effects are smaller."

If the 20th century brought minimally invasive procedures, the 21st may bring zero-invasive procedures.

"Scientists are already experimenting with techniques for combining noninvasive ways of seeing into the body through the manipulation of small-scale devices that can be injected or swallowed," Gawande wrote.

He added that over time, surgery might even become fully automated. "A century into the future, a surgeon will tell the tale."

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