Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  How did life fare for the two heroes of this story? Lucius Apronius did become a soldier and fought alongside his father in Africa. There, far away from the decadence of the city, he apparently had no difficulty in maintaining his healthy new lifestyle. He also reached the highest rank and, in 39 AD, became a consul, together with the Emperor Caligula.

  Around two thousand years later the Western lifestyle that had caused him such suffering resurfaced. At the start of the new millennium, one in eight adults worldwide suffer from obesity, and only 5 per cent of those who try to follow in the footsteps of Apronius Junior and radically change their lifestyle succeed in doing so permanently.

  Pliny the Elder died during the eruption of Mount Vesuvius in 79 AD, which covered the city of Pompeii with lava. He had tied a cushion on his head for protection against the pumice falling from the sky, but it was to no avail. He suffocated in the smoke. Incidentally he was overweight, at least, if we are to believe his nephew, Pliny the Younger, who recorded the circumstances of his uncle’s death.

  In this chapter it is assumed that Pliny meant that it was the son of Consul Apronius Senior who underwent the operation. As the son bore the same name, however, and was also a consul before Pliny wrote his anecdote about the operation, it is possible that it refers to an unknown son of Apronius Junior. That would, of course, have made the story much less fascinating …

  16

  Aneurysm

  The Relativity of Surgery: Albert Einstein

  MODERN SURGERY IS not absolute. It is a science of probabilities and calculating chances. It is probable, for example, that an inflammation of the gall bladder will be accompanied by fever, but it is far less likely that someone with a fever is suffering from an inflamed gall bladder. After all, in general, fever occurs more often than gall-bladder inflammations. The probability increases if another symptom or sign occurs alongside the fever that is typical of an inflamed gall bladder. A third typical symptom or sign will of course make the diagnosis even more probable. A combination of three symptoms or signs is known as a triad. The triad for an inflamed gall bladder, cholecystitis, is fever, pain in the upper abdomen that radiates out to the back, and ‘Murphy’s sign’, tenderness in the right upper abdomen that increases with inhalation. Triads are ‘specific’, in other words the diagnosis is probable and there is a good chance, if all three indications are present, that the patient is suffering from that illness. But they are mostly not ‘sensitive’, meaning that the illness can also often occur without the complete triad being present.

  Supplementary tests – like a blood test, X-ray or ultrasound scan – have their own sensitivity and specificity, which must be taken into account when interpreting the results. Even a decision to perform an operation (the indication of the operation), is relative and based only on probabilities. The chances of the operation being successful must be weighed up against the risk of doing nothing. These chances and risks are expressed in terms like ‘30 days mortality’ (the probability that the patient will die in the first month after the operation), ‘morbidity’ (the probability of side effects and complications arising from the operation), the ‘recurrence rate’ (the probability that the illness recurs) or ‘five-year survival rate’ (the probability that the patient will still be alive after five years). These degrees of probability and risk are now known for most tests, diseases and operations. Taking account of these percentages is known as evidence-based surgery. In practice, this means that surgical decisions have to be made on the basis of figures published in the medical research literature. That literature can be consulted on the Internet, for example on the website www.pubmed.com, where – with well-chosen keywords – you can find everything ever published in medical journals about a certain medical problem. In modern surgery, therefore, it is not about a clear yes or no, but a greater or lesser degree of probability, with a greater or lesser chance of success.

  Of course there are exceptions. Patients who prove that the improbable can occur, by displaying a surprising diagnosis or by surviving against all expectations, are incontestable proof of the relativity of surgery. Albert Einstein, the father of relativity, was one such patient. He had a life-threatening disease of the aorta, but his symptoms resembled those of an inflammation of the gall bladder and he lived longer with the disease than was actually considered possible.

  The aorta is the largest blood vessel in our bodies. It runs vertically downwards through the thoracic (chest) cavity and the section of it that passes through the abdomen, the abdominal aorta, is normally some two centimetres in diameter. If the rigidity of the wall of the aorta is compromised, the pressure of the blood flowing through it will cause it to slowly blow up like a balloon. Unlike other cardiovascular disease, there is not always a clearly demonstrable cause. Such an inflation of an artery is called an aneurysm and, in the abdominal aorta, an abdominal aortic aneurysm, or AAA for short. Because an aneurysm does not restrict the flow of blood, it does not usually display any symptoms. And yet, an AAA will eventually rupture and so, once it reaches a certain size, it will need treatment. The AAA becomes an AAAA, an acute abdominal aortic aneurysm, which unlike an AAA, does show symptoms. The sudden strain on the artery, the small tears that this produces in the artery wall and the subsequent leaking of blood cause severe pain, in the abdomen or the back, which without urgent treatment can rupture fully within hours or days. Albert Einstein had an AAA and he had symptoms, but not for hours or days. He had them for many years.

  Einstein was twenty-six when he presented his theory of relativity in 1905. It turned the world on its head, and E=mc2 became the most famous formula of all time. But fascist ideas and open anti-Semitism were brewing in Europe and by 1933, the year in which the National Socialist German Workers’ Party – the Nazis – came to power in Germany, Einstein – who was Jewish – left Germany for America after receiving an attractive offer to work in Princeton, New Jersey. In the same year, Berlin surgeon Rudolf Nissen also fled Germany for Istanbul.

  Nissen might not be as well known as Einstein, but among surgeons he is remembered for an operation known as a Nissen fundoplication. This elegant surgical procedure is used to treat gastroesophageal reflux disease (acid reflux), where the contents of the stomach can enter the oesophagus, causing unpleasant symptoms like heartburn and belching. But Nissen had a much greater impact as a general surgeon. In 1931, he performed the first successful resection of a whole lung; he developed the frozen section procedure – a method of performing rapid microscopic analysis of a specimen during an operation – and he was the first to perform a complete resection of the oesophagus. When the Second World War broke out, he also emigrated to America but, because his qualifications were not valid there, he had to work first as a surgical assistant before opening his own private practice in Manhattan in 1941. A short time later, he accepted a position as chief surgeon in two hospitals in New York, the Brooklyn Jewish Hospital and the Maimonides Hospital, where he built up a great reputation.

  It was there, in 1948, that he met his most famous patient. Albert Einstein was then already sixty-nine years old and had never had health problems, though he smoked a pipe his whole life, never played sport and had gained some weight in recent years probably due to his famously unhealthy eating habits. Einstein consulted Nissen because, several times a year, he had pain in the upper right of his abdomen, which lasted for a few days and was mostly accompanied by vomiting. These were symptoms that could easily be caused by gallstones. The triad for a gallbladder attack is pain in the upper right abdomen, nausea or vomiting and an inability to sit still. But Einstein explained how this time he had also fainted in the bathroom of his house in Princeton – a symptom that was no longer typical of gallstones. An X-ray showed no signs of stones in the gall bladder and during the physical examination, Nissen felt a pulsating mass in the centre of the abdomen. He feared that it might be an aneurysm of the abdominal aorta and that what Einstein had experienced in his bathroom – sudden pain and fainting – could be symptomatic of
an AAAA. In that case, the patient was risking imminent death if he were not operated on.

  Today, this is a standard operation with good results and an acceptable risk, certainly in the case of a relatively young patient of sixty-nine. Its success, however, depends on two preconditions that could not be fulfilled in 1948. Firstly, before the operation X-ray studies have to be made to determine the size (diameter), the extension (length) and the location of the aneurysm (in relation to the arteries of the kidneys). Today, that takes the form of a CT scan with a contrast medium and an ultrasound scan, but, in 1948, these methods had not yet been developed. Nissen therefore had to plan the procedure during the operation itself. Secondly, he actually had little treatment to offer his patient. The first successful operation to replace an AAA was not performed until 1951 in Paris, in which surgeon Charles Dubost used a piece of aorta from a deceased donor. In the event of an acute ruptured aneurysm in 1948, a surgeon could tie off the aorta to save the patient’s life, but, as that cuts off the supply of blood to the legs they would die off. In Albert Einstein’s case, such a horrendous complication was unthinkable, as his life did not seem to be in danger.

  When Nissen performed the abdominal operation on Einstein, he found a normal gall bladder with no stones, but also an aneurysm of the abdominal aorta the size of a grapefruit. As the aneurysm was still intact, Nissen applied an experimental method: he wrapped it in cellophane. The idea was that the cellophane – the same synthetic material used to wrap sweets, bread and cigars – which was alien to the body but completely soluble, would stimulate a connective tissue reaction, resulting in the formation of scar tissue that would strengthen the thin wall of the distended artery and perhaps postpone the inevitable rupture for some time.

  Cellophane, a transparent cellulose polymer developed in 1900, has a wide variety of uses and experiments were carried out to explore its potential in surgery. Although the method had already been used for some time, the long-term results were not yet clear. And it required guts to wrap the aneurysm of the greatest scientist of all time in what was essentially a sandwich bag. In the years following Einstein’s operation, the use of cellophane was completely superseded by vascular prosthetic surgery, in which the diseased section of the aorta is replaced by a plastic tube. Today many a vascular surgeon will laugh heartily at the mention of cellophane in surgery. And yet, Albert Einstein lived for another seven years with his neatly packaged grapefruit aneurysm. With what we now know about AAAs that is a small miracle.

  Nissen probably did not estimate the size of Einstein’s AAA randomly. Doctors frequently used fruit to describe the size of a ‘space-occupying lesion’ like a tumour or an aneurysm. The mandarin, orange and grapefruit were especially popular because they indicated a diameter of two, three and four inches, respectively. Nissen would have chosen his fruit carefully, as the larger the aneurysm, the worse the prospects for the patient. An average grapefruit is ten centimetres in diameter. The median survival of patients with an untreated AAA larger than seven centimetres is only nine months, which means that half of these patients die before that. The annual risk of an aneurysm larger than eight centimetres rupturing is more than 30 per cent, year in, year out. With an aneurysm of ten centimetres, therefore, Einstein should have been dead within one or two years. His chances of surviving for seven years were only a few per cent.

  Despite the perilous situation that Einstein was in, he recovered quickly from the operation and left the hospital just three weeks later. Four years after his operation, he was even offered the presidency of the state of Israel. In the final seven years of his life, Einstein, whose scientific research had not produced any more great breakthroughs since his theory of relativity, was still at work at the Institute of Advanced Study in Princeton. But while he tried in vain to reconcile the laws of gravity with those of quantum mechanics, the physical Law of Laplace – a law that says the tension on the wall of an aneurysm, at a constant pressure, is proportional to the diameter – was at work on his aneurysm. The larger the aneurysm, the more tension the same pressure exerts on the wall, and so an aneurysm not only tends to get bigger, but also to get bigger more quickly as the wall of the aneurysm becomes progressively thinner and the risk of a rupture rises.

  * * *

  Stitches and knots

  Surgeons can tie knots in a thread very quickly and neatly, with one finger, with both hands, or using a needle holder. There is a special surgeon’s knot, a variant on a reef knot, where you begin by turning one thread twice around the other, rather than just once. You then pull the thread tight, holding the knot flat. The double twist will help stop the knot from coming loose, while you tie a single knot on top. When you pull the whole knot together, the double thread will crumple up, pulling the first part of the knot even tighter. All the twists will prevent it from slipping. The most commonly used knots in surgery, however, are simple jamming knots. By not pulling the knots tight, but tying them one after the other on the same thread, the whole knot can still be slipped, allowing the tension to be adjusted knot for knot. The final knot is then pulled tight in the other direction, ‘locking’ the whole knot. The simplest stitch is a single loop: you pass the needle and thread from the outside to the inside and, on the other side, from the inside to the outside, and finish off with a knot. To approximate both edges of the skin as precisely as possible, surgeons use the ‘Donati stitch’. After making a simple stitch, the thread is not yet tightened. The needle and thread are passed back through the skin, but now only one millimetre from the edges on both sides. And then you finish off with a knot.

  * * *

  In April 1955, Einstein experienced abdominal pain again, this time with fever and vomiting. He was seventy-six years old. Although everything once again pointed to an inflammation of the gall bladder (the full triad was present), doctors were naturally afraid that it was an AAAA. By 1955, it was possible to treat an aneurysm with a vascular prosthesis and Frank Glenn, a vascular surgeon from New York who had experience with this procedure, was asked to come and discuss the operation with Einstein. He visited the professor at home and suggested the operation, but Einstein declined the offer. ‘It is tasteless to prolong life artificially,’ he said, ‘I have done my share, it is time to go. I will do it elegantly.’ Einstein was given morphine and admitted to Princeton Hospital. Two days later, during the night of 17 April, he died. His exceptional clinical symptoms of a rupturing aneurysm with the triad of an acute inflammation of the gall bladder were named the ‘Einstein Sign’, in his honour.

  So did Nissen’s trick with the cellophane work after all? Probably not: Einstein was just lucky. The following day, pathologist Thomas Harvey performed an autopsy on the body of the world-famous scientist. He observed smoker’s lung, hardening of the arteries, an enlarged liver and a ruptured abdominal aorta aneurysm, with at least two litres of blood in the abdomen. The gall bladder was normal, but the professor’s brain weighed 1,230 grams, 200 grams less than the average adult male.

  17

  Laparoscopy

  Endoscopy and the Minimal Invasive Revolution

  AFTER A SCIENTIFIC meeting at the Josephinum, the medical academy in Vienna on 9 December 1806, seven gentlemen withdrew to a small back room, where an assistant had laid out the body of a young woman. The professors were to use the corpse to test a device developed by a German doctor, Philipp Bozzini from Frankfurt.

  Bozzini called the device – comprising a candle, a speculum (a medical instrument used to inspect bodily orifices) and an ocular lens (the eyepiece that you look through on a microscope or telescope) – a ‘light conductor’. It promised to be a remarkable invention. Every doctor knew that the design of the speculum was flawed. Ideally the speculum, the light source and the eye were all aligned to prevent shadows, but then either the candle was in the doctor’s way, or the doctor’s head obstructed the light – and the candle caused the device to be too hot. But when the Herr Direktor, the Herr Vizedirektor, four honourable professors and the Herr Stabsarzt (st
aff physician) used Bozzini’s device to inspect the vagina and anus of the body on the table they noted delightedly: ‘The light conductor sent from Frankfurt by Dr Bozzini was presented and inspected, and it was decided to test it directly on a female corpse that had been laid out for this purpose. The results were promising beyond expectations.’

  Although Hippocrates and the surgeons of the ancient world already used specula to examine bodily orifices, this satisfactory experiment with the ‘Frankfurt light conductor’ is now seen as the real birth of endoscopy, a technique that allows doctors to look inside the body with sufficient light. In the years that followed, the light conductor was improved by doctors and instrument-makers in various countries. In 1855, French surgeon Antonin Jean Desormeaux called his improved version an endoscope, which gave the name to the discipline: endoscopy, ‘looking inside’.