HEALTH / Second opinion

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The Independent Culture
WHENEVER some new technology comes along and sweeps away the old, young people adapt most easily; their middle-aged and elderly relations become converted slowly, or sometimes not at all. Many, in fact, still seem to think there is a virtue in their inability to programme a video recorder.

Surgeons,however, cannot afford the luxury of indifference to the recent revolution in operating techniques. Within the last five years, a great deal of surgery has become a video game for grown-ups. Removal of the gall bladder, the appendix, even a kidney is now possible without a long surgical incision. Instead the surgeon makes four holes, no wider than a fountain pen, through the skin and muscles of the abdomen and introduces miniature instruments - including a video camera. He or she then manipulates the tools by remote control while observing the interior of the patient on a video screen.

Instead of spending 10 days waiting for an eight-inch surgical wound to heal, the patient is able to go home within 48 hours. This is 'minimally invasive' surgery and it accounts for much of the dramatic improvement in productivity in hospitals, which administrators and politicians have tried to claim were due to management innovations.

The problem with any new technique is learning it. Most changes in technical skills are incremental, building one small advance on another.

Video surgery is another matter. It is a whole quantum different from conventional hands-on operating, in which the fingers, the forceps and the scalpel are all deep inside the operation site but are all under vision. The new technique puts the operatordoubly at a distance, watching on a screen manipulations done by remote instruments. If something goes wrong, the old surgical instincts are not much help. Indeed if something serious goes wrong the solution is to convert to old-style surgery, opening up an incision so that the surgeon can deal with the problem.

Pity, then, surgeons in their sixties with little enthusiasm for acquiring the new technique, but underhuge pressure to do so. Their patients will have talked to friends who have had minimally invasive surgery and been impressed by their rapid recovery. The hospital managers will have been impressed by the prospect of rapid bed turnover, and younger colleagues will have become slick operators in the new style. The effort has to be made, so they attend training courses, carry out operations with an experienced colleague close at hand, and become competent themselves. They can scarcely hope, however, to acquire in a week or two the same confidence in their skills as they had in the methods they used for 30 years. In some countries surgeons practise their new techniques on animals, but in Britain animal rights legislation makes such practice illegal: patients have to act as guinea-pigs. What is euphemistically called the 'learning curve' is a long process, and research reports are agreed that 30, 50 or more operations need to be done while skills improve. So the choice for the patient may not always be as clear-cut as the innovators would have us believe. In a hospital where new techniques are still in their infancy, it may be better to be some way down the waiting list.

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