Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  Like bacteria, tumour cells can also disseminate via the lymph vessels to the lymph nodes. In rare cases of tumours in the skin, the spread of cancer through the lymph vessels can be seen with the naked eye, like the red line on the skin visible in the case of lymphangitis. With a little imagination, it looks like a crab: the tumour is the body and the dissemination via the lymph vessels the legs. That is where we get the name ‘cancer’, from the Latin word for a crab. Mostly, however, the dissemination of cancer cannot be seen with the naked eye.

  Tumour cells that spread via the lymph vessels are captured by the lymph nodes, which work like filters. In the lymph nodes, the tumour cells grow to become tumours. The invasion is then no longer local, but regional. At this stage, the enlarged lymph nodes can be felt. As with Lully, this would first have been noticeable with Bob Marley in the hollow of the knee and then the groin. Total excision of the original tumour is no longer effective. A regional excision becomes necessary – in other words, removal of the tumour together with the affected lymph nodes. This is known surgically as a radical excision. The medical term ‘radical’ comes from the Latin radix (root) and means removing something ‘by the roots’. As you do not know in advance whether there are already tumour cells in the lymph nodes, you can best remove them all. Surgical resection of cancer must therefore be both total (leaving nothing of the tumour behind) and radical (leaving none of the lymph nodes related to the tumour). Antibiotics can mostly reduce an infection from regional to local level. With some forms of cancer, chemotherapy and radiation treatment can do the same.

  Once the intruders invade the circulation system, they can spread to other organs. That is known as ‘distant metastasis’. At this stage usually the disease can no longer be treated surgically. Only antibiotics (for infections) and chemotherapy (for cancer) can be effective.

  The stages of cancer are classified at local, regional and systemic level, on the basis of the TNM staging system. T stands for tumour. T1 is the earliest stage of the tumour, T3 is a tumour that is growing through the barrier of the organ, T4 means it is penetrating the barrier of an adjacent organ. In most cases, a total surgical resection is possible. The surgeon must then apply a safe margin, removing a few centimetres of tissue around the tumour. This is because the invasion of tumour cells is often more advanced at microscopic than at macroscopic level. N stands for node. N0 means that the lymph nodes have not been affected by the tumour cells and N1 indicates that the cells have spread to the closest group of nodes. Up to this stage, a radical surgical resection can still cure the disease permanently. N2 usually means that lymph nodes have been affected that can no longer be removed surgically. M stands for metastasis. M0 means there has been no distant metastasis, while M1 indicates that distant organs have been affected. In some cases, such as limited dissemination to the liver, lungs or brain, stage M1 cancer can also still be treated surgically.

  The TNM stage of the cancer not only determines the prognosis – how long the patient has left to live – but also the options for treatment. Treating cancer can serve multiple purposes. Curative treatment aims to rid the patient of the cancer completely and permanently. It can then be worth considering the risk of serious side effects or mutilating resections. That is usually only possible in the early stages. Palliative treatment aims to prolong the life of the patient by restricting the progress of the disease or the increase in the number of tumour cells in body. In that case, the benefits – in terms of extra years of life – must be weighed up against the disadvantages of the treatment. The final stage of treatment, end-of-life care, aims to bring the patient’s life to an end as comfortably as possible, while doing nothing more to combat the disease.

  Based on the advice given to Bob Marley to have ‘only’ one toe amputated, his cancer must at that time still have been local. Because the small tumour was under his nail, it must have quickly caused him pain, explaining why he discovered the disease in its earliest stage. Surgical resection of a malignant melanoma at this stage (T1N0M0) offers a 90 per cent chance that the patient will still be alive five years later. But Bob Marley refused to give up his toe and did not live to be old. But he did become a legend.

  15

  Abdomen

  The Romans and Abdominoplasty: Lucius Apronius Caesianus

  OF ALL POSSIBLE lifestyles, our own Western way of life is most likely to cause obesity. Obesity lies at the root of a wide range of diseases in the modern age, spreading around the world like an epidemic. There is a strong link between obesity and type 2 diabetes, cardiovascular diseases and cancer. The Western lifestyle is therefore an important driver of the steadily rising costs of medical care. And that lifestyle has its origins in ancient Rome. Then too, as now, obesity was a growing problem and, as now, especially among young people. It is perhaps significant that the Romans invented the hamburger.

  At the start of the first century AD, Rome was flooded with luxuries from all corners of the empire, at least for those who could afford them. And the most decadent aspect of the lifestyle of the city’s wealthy citizens was their eating habits. A slave with a bucket and a feather to tickle the backs of the throats of the guests reclining at table, to arouse a retching reflex to make room for the next course, was a familiar sight at Roman banquets. Roast neck of giraffe, stuffed elephant’s trunk, baked hog’s womb, dolphin meatballs, fresh deer’s brain and peacock tongue pies were actual dishes from the period.

  The young Lucius Apronius Caesianus must have enjoyed all these culinary delights. He was severely overweight. His father, Apronius Senior, was a tough, seasoned barbarian-slayer, who had no qualms about punishing a cohort that had shown cowardice in battle by decimation (executing 1 in 10). The region that Julius Caesar had conquered for the Imperium Romanum many years before had to be defended, day in day out, against the rebellious peoples in the north. Life in Germania was in stark contrast to life in the city. It consisted of building forts, and attacking and securing positions, and all on a simple, meagre diet of what could be found or caught in the local area: acorns, rabbits, wild boar … For this work, Apronius was rewarded in 15 AD with the highest honour granted in the Roman Empire – a triumphal procession in Rome. His career took off, he was a consul for some months and later proconsul of Africa, and the spear with which he had struck a barbarian full in the face was dedicated to the gods. As far as he was concerned, his fat dumpling of a son was seriously in need of a lifestyle change. He was to become a soldier, like his father.

  There is only indirect evidence of this conflict between father and son. The great Roman encyclopaedist Pliny the Elder referred to the operation that Lucius had to undergo in his life’s work, Naturalis Historia, published in 78 AD. In chapter 15 of the eleventh book, on fatty tissue, he writes: ‘It is on record that the son of the consular Lucius Apronius had his fat removed by an operation and relieved his body of unmanageable weight.’ Pliny mentioned this operation to support his claim that fatty tissue has ‘no sensation’ and contains no blood vessels. He also wisely notes that overweight animals (and he does not exclude people from this category) do not live to be a great age.

  The operation was certainly performed more than once in the Roman Empire, as there is a report from a distant province, in Judea, of a local official in the service of the Romans undergoing the procedure some hundred years after Pliny. According to the account, in the Talmud (Baba Mezi’a, chapter 83b), the patient was the exceptionally corpulent Rabbi Eleazar ben Simeon: ‘They gave him a sleeping potion and took him into a marble room and ripped open his abdomen and were taking out baskets of fat…’ The reason for this operation was not cosmetic but functional. According to the Talmud, Eleazar’s belly was reduced in size so that his judgements would be based less on gut feeling and more on good sense. The fat allegedly also obstructed his freedom of movement during copulation.

  It is inconceivable that these operations were genuine laparotomies, which involve cutting through the abdominal wall to access the abdominal cavity. Many centuries pre
viously, Hippocrates had written that cutting open the abdomen was always fatal, and the Romans also knew that. In 46 BC, Roman senator Cato had even chosen to cut his abdomen open as a sure way of committing suicide. After a lengthy conflict, Caesar had him cornered in Africa and he decided to end his life. He was found in his bedchamber, still alive. A doctor closed the wound, probably against his better judgement, but during the night Cato picked out the stitches and was dead by sunrise. It would be more than 1,800 years before abdominal operations could be performed successfully.

  In times of war, of course, surgeons had to deal with plenty of ripped open abdomens with the intestines spilling out, but the chances of these unfortunate victims surviving were so slight that no self-respecting surgeon would ever contemplate inflicting similar wounds on a patient in peacetime. So what is so dangerous about an open abdomen that it was taboo for surgeons for such a long time? Actually nothing at all. Opening and closing an abdomen is no different from treating any other wound. The danger lay in the complexity found behind the abdominal wall.

  Simple folk tales show that early ideas of what happens in our abdomens were not very sophisticated. In reality, you cannot walk into the belly of a whale and then walk back out again a few days later. Nor can you easily free a grandmother in her nightdress, a little girl in red hooded cape, or six baby goats from the belly of a wolf, fill the belly with stones, and then sew the belly back up again. Apart from anything else, what we eat doesn’t end up in the abdominal cavity, but in the intestines.

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  The first laparotomy

  The first successful abdominal operation (laparotomy) was performed, remarkably, several decades before the invention of anaesthesia and the understanding of asepsis. Ephraim McDowell, a rural surgeon in America, removed an enormous tumour from the left ovary of a forty-four-year-old woman, Jane Todd Crawford, on Christmas Day 1809, by performing a laparotomy in the living room of his house in Danville, Kentucky. The woman kept herself calm by singing psalms. The operation lasted half an hour and the patient recovered well. She lived a long and healthy life, dying at the age of seventy-eight. McDowell kept a cool head when he opened the abdomen and the intestines spilled out onto the table. He wrote that he was unable to push them back during the operation but, after he had removed the enormous tumour, there was apparently enough room for them again. Today, a laparotomy is the standard procedure for all organs in the abdominal cavity. The abdomen can be opened in various ways: vertically along the centre line, horizontally, diagonally, with a hockey stick incision, a chevron incision, a McBurney’s incision, a Kocher’s incision, a Battle’s incision or a Pfannenstiel incision. A laparotomy can be performed for an infection in the abdomen, a perforation of the gastrointestinal tract, to remove a tumour, or to repair an ileus, an obstruction in the passage of food and faeces through the intestines. The procedure is, however, increasingly being replaced by a laparoscopy, keyhole surgery in the abdomen.

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  The gastrointestinal tract is in essence one long tube that runs from the mouth to the anus. The different components of the tube have various functions, structures and names, but it remains one single tube. After the oral cavity (the mouth) comes the pharynx, then the oesophagus, the stomach, the duodenum, the small intestine, the large intestine (colon), which incorporates the caecum and the appendix, and finally the rectum. From the stomach to the rectum, the tube – which is about nine metres long in total – lies folded up in the abdominal cavity. For its whole length, it is connected to the back of the abdominal cavity by an attachment called the mesentery. The stomach and intestines are therefore not completely free within the abdominal cavity. Blood vessels run to the intestines and the stomach through this mesentery. There are four other organs in the abdominal cavity: the liver, the gall bladder, the spleen and the omentum, a large fold of fatty tissue. In the case of women, there is the womb and two ovaries as well. That’s it. There is a small quantity of fluid between the intestines and the organs, but no air. The abdominal cavity has not a single connection to any of the body’s natural orifices and that is why there are no bacteria in it.

  Because the abdominal cavity is almost completely filled with intestines and organs, the bowels lie directly against the abdominal wall. You have to cut the wall open very carefully so as not to damage them. But that has almost always been impossible, for various reasons. The pressure in the abdomen is high because the abdominal muscles are continually under tension. There are four muscles on each side: the rectus abdominis (the right and left one together are more popularly known as the ‘abs’), which each run vertically, the outer and the inner oblique muscles, which run diagonally downwards and upwards respectively, and the transverse muscle, which runs horizontally. We use all of these muscles to stand or sit upright, and to bend. But the abdominal muscles also tense when the abdominal wall is cut open, as a reflex response to the pain, panic and struggles of the patient. The abdominal wall then presses against the intestines, making it difficult to avoid them with the scalpel. The pressure also makes them spill out through the wound as soon as the incision is made so that, before you know it, they are lying on the outside of the belly or on the table. That, of course, makes life very difficult for the surgeon. The reverse process is just as tricky, because it is almost impossible to push back the intestines of a conscious patient, let alone close the wound up neatly.

  In the third century BC, two physicians in Ptolemaic Alexandria called Erasistratus and Herophilus were given permission to investigate the anatomy of the human abdomen by experimenting on living prisoners who had been sentenced to death. They would certainly have encountered the high pressure in the living abdomen, but there would of course be no need to stitch it back together again. What their unfortunate victims underwent must have been horrific, but it perhaps spared them an even more terrible death by torture. They will have noticed that the pain of the incision was followed by pain in the peritoneum, the inner lining of the abdominal cavity that stretches around the intestines and abdominal organs (the word peritoneum means ‘stretched around’). It contains nerve fibres, and touching it causes severe nausea and retching. How can you operate effectively while your patient is screaming with pain and starts to vomit every time you touch the inside of his open abdomen? And, if you damaged the intestines when opening the abdomen, their contents and all the bacteria they contain will have spilled out into the abdominal cavity and the patient will die within a few days of peritonitis. So you need a calm patient, who does not feel anything, does not tense up his abdominal muscles and does not start to vomit. And, of course, a surgeon who works hygienically and does not harm the intestines.

  In the story from the Talmud, the special marble room in which Rabbi Eleazar was operated on may suggest some idea of the basic hygienic conditions required for surgery. But the operation would certainly not have been performed in the kind of clean environment that is essential for abdominal surgery. The sleeping potion given to the rabbi before the operation is also a hint of some sort of anaesthetic, but it would certainly not have been powerful enough to sufficiently relax his abdominal muscles and anaesthetise the peritoneum. Neither Apronius nor Eleazar could have undergone a genuine operation in the abdomen as both men are known to have survived their operations for many years. In the case of a fat belly, the superfluous fat does not all have to be inside the abdominal cavity – it can also have accumulated subcutaneously, between the skin and the abdominal muscles. If the two men did not undergo operations to remove fat from inside their abdomens, then they must both have had fat removed from around their bellies. In other words, an operation outside the abdominal wall and not in the abdominal cavity. In medical terms, such an operation is known as an abdominoplasty (from abdomen and the Greek -lastos, meaning moulded or formed). In popular terms, it is called a ‘tummy tuck’.

  Yet, even that must have been a perilous undertaking in those days. We know now that problems with the wound occur so often if you remove skin and subcutaneous fatty t
issue from patients suffering from obesity that abdominal wall corrections are only performed on people who have first lost a considerable amount of weight. In that respect, Pliny was almost correct when he used the operation on Lucius Apronius to illustrate the properties of fatty tissue. Although subcutaneous fatty tissue does contain blood vessels, there are very few of them. That means that the thicker a subcutaneous layer of fat is, the greater the risk of a wound becoming infected or not healing properly.

  In Roman times, wound infections were still life-threatening complications. As we know from other sources that Lucius lived a long and healthy life after the operation, the abdominal wall correction clearly proceeded without serious complications in his case. Perhaps he first lost some weight before undergoing the surgical procedure and that what Pliny referred to relieving ‘his body of unmanageable weight’ did not refer directly to his obesity, but to the layers of excess skin remaining after he had lost weight. We know that Rabbi Eleazar, on the other hand, suffered terrible pain in the final years of his life. Could that have been as a result of complications arising from his operation?

  Today, an upper weight limit of 100 kilograms is often applied for those undergoing an abdominoplasty. Howard Kelly, a gynaecologist in Baltimore, described the first abdominoplasty in modern times in 1899. In the 1960s the Brazilian plastic surgeon Ivo Pitanguy, who became renowned for his work on Elizabeth Taylor, developed the cosmetic abdominoplasty. This procedure became the basis of all present variants of abdominal wall correction. In 1982, French surgeon Yves-Gerard Illouz presented a new trick for removing subcutaneous fat using a steel tube and a powerful vacuum. This method, liposuction, involves making a small incision in the skin and pulling the steel tube forcefully back and forth through the fatty tissue, breaking it into smaller fragments and sucking it away. Here, too, Pliny was almost right. Fatty tissue is not completely without ‘sensation’, but contains so few nerve fibres that liposuction can be conducted under local anaesthesia. The options for corrections to remove excess skin have now expanded enormously, the pinnacle being the ‘contour operation’, a 360-degree correction procedure. The patient first lies on his or her back and undergoes an operation on the skin of the abdomen and is then turned over while under general anaesthesia onto his ‘new’ stomach so that the surgeon can also correct the back.