Modern Advances in Surgery and in Medical Technology

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Modern Advances in Surgery and in Medical Technology

Overview

The science of surgical care has advanced further in the last 50 years than it has in all preceding years combined. Complicated procedures such as natural and artificial organ transplants, xenotransplants (organs transplanted from non-human animals), neurosurgery (brain surgery), coronary artery bypass surgery, laparoscopic surgery, and "laser" surgery were rare, if not completely unknown 50 years ago, but these procedures are becoming more commonplace today. As with many aspects of our lives, computers have also extended the practice of medicine into previously unknown territory. Indeed, through the use of the Internet, "telemedicine" has become not just a possibility but a probability: soon, surgeons will be able to operate on patients remotely via live "webcasts."

What is more, surgeries generally have become far less invasive, thus requiring in many cases little, if any, hospital stay. As a result, the overall cost of many of these procedures has decreased dramatically in terms of both the financial costs to patients (and their insurance companies) as well as recovery costs to patients in terms of lost wages and physical and emotional strain. In short, advances in surgery and medical technology have allowed many more people to live healthier and longer lives than at any preceding time in history. Many diseases like cancer, for example, which used to nearly always be fatal, are now often eradicated entirely in patients due to the technological advances made in surgery over the past 50 years.

Background

Perhaps the most pervasive technological advance today in medicine is laparoscopic surgery. First introduced in the early 1970s, laparoscopic surgery is a technique whereby a surgeon makes four tiny "pinhole" incisions in a patient's body and then inserts a miniature camera, light, and the required surgical instruments for performing the procedure. Today's advanced digital technology allows magnification of the laparoscopic surgery site up to 20 times its actual size, thereby permitting surgeons to see anatomical structures in exquisite detail. Furthermore, new three-dimensional imaging technology allows the surgeon to view internal organs stereoscopically rather than in two dimensions only, as would be required if viewed on a regular monitor. Intraoperative ultrasound allows "real time" scans of the surgery site as the operation proceeds, providing additional valuable information. Because laparoscopic surgery is minimally invasive, patients recover much more quickly.

Laser surgery is also growing in popularity and application. As its name suggests, surgeons utilize a laser to perform various procedures, including during laparoscopic procedures. For example, lasers currently are used to excise cancerous tissue from the larynx, reshape the cornea of an eye to allow a patient to see better, and even to "resurface" the skin of a patient's face by burning off old layers skin so that new skin can grow. The growing popularity of lasers as surgical devices is due mainly to their ability to precisely destroy unwanted or abnormal tissue without bleeding.

Another well-known example of advancing surgical techniques involves combating cardiovascular disease. Because of lifestyle habits or genetic predisposition in many people, fatty acids (plaque) sometimes build up in the arterial walls of a person's heart. As more plaque builds up, less blood is able to flow through the artery to the heart. Ultimately, the plaque build-up may completely block the artery, preventing any blood from flowing through it. The result is cardiac arrest, which can be fatal. Surgeons have developed a technique known as angioplasty to combat the onset of cardiovascular disease. Using a technique similar to laparoscopy, a surgeon inserts a thin tube into the patient, working it up the artery to where the blockage resides. At the end of the tube is a small, balloon-like device that inflates, pressing the plaque against the arterial walls so that blood flow through the artery can be increased.

Surgeons have also developed another, more popular, procedure for dealing with coronary artery disease: the coronary bypass graft operation. By taking a portion of an artery from elsewhere in the patient's body—usually the internal mammary artery from inside the chest cavity—the new artery is grafted around the blockage of the old artery to allow blood to flow around the blockage via the new arterial route. Despite the fact that this procedure requires open-heart surgery, it is performed more than 300,000 times per year in the United States alone.

Like bypass grafting operations, transplantation procedures involve the replacement of organs and tissue from one location in the body to another location. Unlike bypass grafting operations, however, organ and tissue transplants often come from the bodies of another person, and sometimes even animals (known as xenotransplantation). Kidneys, hearts, lungs, and recently even hands have been transplanted successfully. According to the United Network for Organ sharing, there currently are more than 61,000 persons waiting for an organ transplant in the United States alone. Every 16 minutes, a new person is added to the waiting list. Though these procedures have become more commonplace with higher rates of success, unfortunately there simply are not enough organs available to meet the demand.

Just as computers pervade our everyday lives, so also do they pervade operating rooms. Currently, computer-aided surgery is being studied for various applications including simulating surgery in three-dimensional "virtual" environments. By using data from hundreds of x rays, or from magnetic resonance images, a composite picture of a patient's internal organs and skeletal frame can be produced with incredible detail. Such computer-designed images allow surgeons to practice complex procedures before they actually perform them. By exploring these three-dimensional environments for problematic areas, surgeons no longer are required to perform exploratory surgery in order to determine where a problem area lies; they simply may move about in the computer-reproduced virtual body to find the problem. When working on an organ as complex as the brain, computer-aided surgery helps to minimize the risk of needlessly or inadvertently damaging other areas.

Impact

According to American Hospital Association statistics, hospital outpatient surgeries, which do not require overnight hospital stays, have increased by more than 2 million, to 14.7 million, between 1993 and 1997; and inpatient surgeries, which require a stay of more than a day, have decreased by nearly 700,000 to 9.5 million during the same time period. As these statistics indicate, more people than ever before are "going under the knife" as the prospect of surgery becomes less daunting and more readily available.

Not surprisingly, a large and rapidly growing proportion of these surgeries consist of cosmetic, or "plastic," surgeries. Over the past two years alone, the number of plastic surgeries has increased by 50%, with more than a million performed in 1999 alone. According to the American Society of Plastic Surgeons, the most popular procedure in 1999 was liposuction—the removal of fat from the body by means of a suction device, followed by breast augmentation, eyelid surgery, facelift, and chemical peel—the removal of the top layer of skin from the face by chemical means. These surgeries are performed not so much to improve or maintain the health of the patient but to "aesthetically enhance" his or her physical features.

With many of these surgeries, however, there has come unforeseen risks. Breast augmentation surgery, for one, has sparked multi-billion-dollar class action law suits against the manufacturers of the breast implants, the silicon prostheses inserted during the surgery. Early studies suggested that silicon may leak into patients' bodies, causing significant physical damage, although more recent studies have indicated no convincing evidence that breast implants can be harmful. Other cosmetic surgical procedures such as liposuction, however, may result in unforeseen physical damage. Thus, although intended to improve one's physical image, plastic surgery sometimes can gravely endanger one's health.

Another problem, albeit more philosophical in nature, that has developed with the advancement of surgical techniques concerns the very definition of life. Fetuses can now be delivered as early as the beginning of the third-trimester of pregnancy and survive. As prenatal and postnatal care improves, this "viability" line may move back to even earlier times in a woman's pregnancy. Such viability issues, of course, have played crucial roles in abortion-rights debates over the past 25 years, most famously in the United States Supreme Court case of Roe v. Wade.

Similar to the problem of determining when life begins, modern medicine also has muddled the definition of death. Historically, when a person ceased to breath on her own, and/or her heart stopped beating, that person was considered dead. With surgical advancements, we no longer look to the heart and lungs to determine death, but the electrical activity of the brain. Indeed, human bodies can be kept functioning for years on cardio-respiratory machines—machines that pump blood for the heart and breathe for the lungs—long after the brain has died. Yet, at just what brain-activity level one can be considered dead is the focus of much debate. In the celebrated case of Gannon v. Albany Memorial Hospital, for example, an 86-year-old woman named Ms. Coon was hospitalized after a massive stroke. Soon thereafter she fell into a "persistent vegetative state," which has been described not as a coma but as a state of "wakefulness without awareness." Ms. Coon's sister, believing that Ms. Coon would never wish to be kept in such a state, and believing her to be essentially dead, successfully petitioned a court to allow her to take Ms. Coon off life-support so that she could "die." Luckily for Ms. Coon, prior to the withdrawal of her feeding tube, she woke-up! So, just when a person may be considered alive or dead is no longer a simple matter given advances in medical technology.

Finally, perhaps the most wide-ranging impact that advances in surgery in particular, and medicine generally, have had on society over the past 50 years is to increase the average life-span of human beings. In 1950 the average life-span for a man born that year in the United States was 66, and for a woman, 71; today a man born in the United States can expect to live, on average, to the age of 73, and a woman to the age of 79. The rise is even more dramatic in poor, third-world countries, although in places such as Africa factors ranging from war to famine to newly emerging diseases continue to hamper life-expectancy rates.

As medical technology improves, life expectancies will continue to grow. Ironically, though modern medical technology has allowed many people to enjoy healthier and longer lives—a seeming societal benefit—advancing medical technology has simultaneously created an enormous societal burden. It is no accident that the fastest growing segment of the U.S. population today consists of those aged 80 and over. Inevitably, as people grow older and live longer as a result of better medical care, their continued care can become quite expensive for the private insurance companies and public organizations, such as Medicare, that pay for it.

Likewise, because people over the age of 65 are entitled to social security benefits as well as funds from private pensions, as their ranks grow in proportion to the rest of the population, they will draw out more funds than can be replenished by the younger, working generations. This situation has caused many economists and politicians to worry that government programs like social security will become bankrupt in the near future, thereby leaving nothing for the younger generations.

Undoubtedly, as surgical techniques advance, more people will have the opportunity to enjoy the benefits of long and healthy lives. Though this is a noble endeavor, the impact that modern medical technology has had on society nevertheless can manifest itself in unusual, and sometimes undesired, ways.

MARK H. ALLENBAUGH