Operating in the 21st Century

Doctors at the Penn Medical Center are pushing the frontiers of surgical procedures with a variety of new high-tech devices. No matter how hi-tech things seem to get around the University's Medical Center, less is still more. This philosophy governs the wide array of new, space-aged surgical techniques being performed at the Hospital of the University of Pennsylvania, all of which are designed to be less painful, less invasive or less debilitating than conventional operations. The result: patients are spending less time in the hospital and getting back on their feet faster than ever before. Surgery Professor Daniel Becker is pretty familiar with the less-is-more philosophy in his work as a cosmetic surgeon. Last month, Becker received a patent for the liposhaver, a new alternative to liposuction that minimizes trauma to the patient's face. The procedure is likely to cost patients the same amount as conventional liposuction. The liposhaver is a small, pen-shaped tool which uses a small cutting blade to delicately remove fat from underneath the chin. "It's a pretty common procedure," said Becker, who has used the liposhaver about 10 times since coming to HUP from the University of Illinois. The tool used in liposuction, by contrast, "is held like a carving knife," Becker explained. Surgeons use a vigorous back-and-forth motion during the procedure, often causing post-operative bruises. The liposhaver cuts down on that bruising and is "less traumatic," he added. The new technique takes 30 minutes and can be done under local anesthetic, forcing patients to endure only a day or two of "down time," a period marked by exhaustion and body pains that usually confines patients to their homes. Down time can be a major deterrent for people considering elective surgery such as kidney removals, another surgical procedure being revamped at HUP. "That loss of time from work is pretty significant," Surgery Professor Jo Buyske said. Buyske and Surgery Professor Ken Brayman have developed a new way to remove a kidney that minimizes down time by using a laprascope, or miniature camera, which is inserted into the body through small incisions in the abdomen. The new technique turns four to six weeks in the hospital into only a five- to 10-day stay because the four small abdominal incisions it requires heal much faster than the single foot-long slice in the back inflicted in conventional procedures. Buyske is an expert in laprascopic techniques, while Brayman is more familiar with the kidney's anatomy, having performed many conventional kidney removals at HUP in the past. "We're kind of cannabalizing on each other's expertise for this procedure," Brayman said. The two surgeons make the tiny incisions for the camera and other surgical tools, and coordinate the procedure with one another on a television screen. "With more than 36,000 people waiting for kidney transplants in the United States today, the availability of an easier donor removal technique is crucial [for promoting organ donation]," Brayman said. But while the laprascope is easier than conventional surgery for the donor, the new technique is a little harder for the operating surgeons. "[Laprascopy] takes sort of a special connection between your eyes, you brain and your hand," Brayman said, adding that "up isn't always up." Surgeons hoping to gain proficiency with the technology can practice using the laprascope with a model in HUP's surgical library. And although the laprascope is widely gaining popularity among surgeons as a viable surgical tool, the major drawback to the tool is its hefty price tag, which virtually ensures that the surgical procedure will cost patients more than a conventional operation. "The technology itself is absurdly expensive," Buyske said. "Practically every [disposable] instrument costs several hundred dollars and then goes in the garbage." Buyske also stressed that the laprascope isn't for everyone, noting that only the "easiest and best cases" of kidney donations qualify for the new technique. That kind of patient selectivity often slows the development of new medical technologies. HUP Surgery professors Frank Spitz and Douglas Fraker are developing new ways to kill liver cancer, but only a narrow group of patients are eligible for these procedures. Patients' cancer must be confined to the liver, and their tumors must be well defined enough to see in an ultrasound to qualify for either treatment. The real advantage to the patient in these procedures is the destruction of the tumors in one hospital visit. Although chemotherapy, the conventional cancer treatment, is an out-patient procedure, it requires patients to undergo several highly toxic doses of radiation. "The idea that you can eliminate all measurable disease in one treatment is what we think is so appealing [about the two new procedures]," said Spitz, who stressed that neither procedure has proven to be a definitive "cure" for cancer. The elder of the two new treatments, cryosurgery, involves freezing individual tumors within the liver using liquid nitrogen. "We can effectively kill the tumor cells with this therapy," Spitz said. The other treatment blasts the tumors with intense heat, using high frequency radio waves. Both treatments are equally invasive and require open surgery, Spitz said. "Whether you freeze them or cook them, as long as you kill them," he explained. Both surgeries are also equally expensive for the patient and are billed the same way as a conventional tumor removal, a procedure covered by Medicare and most insurance companies. When HUP purchased the technology involved in cryosurgery, it was originally meant to serve in treating patients with prostate cancer. But that technique didn't work out the way Fraker thought it would, leaving HUP with an oversized spray can without anything to spray. Fraker, the chief of Surgical Oncology at HUP, later brought Spitz to the hospital to work on developing cryosurgical techniques and revive the technology. Future developments in the radio frequency technique could lead to less invasive surgeries using the laprascope. "If the radio frequency [technique] pans out, then our hope is that it would likely replace cryosurgery," Spitz said.