Under the Knife

by Arnold van de Laar, Laproscopic surgeon

  If all the official data and reports are correct, neither the bullet nor the operation caused Lenin’s death. It is not too late to examine Lenin’s left carotid artery and discover whether Lenin underwent an operation deeper in the neck in search of the second bullet. The dictator’s embalmed body, ninety years after his death, is on public display in his mausoleum in Red Square and, thanks to a monthly bath in chemicals to combat a persistent fungal infection, is still in reasonable condition. And, all being well, Fanya Kaplan’s bullet should still be in there too.

  26

  Gastrectomy

  Cowboys and Surgeons: Frau Thérèse Heller

  IN THE EARLY nineteenth century, surgeon Robert Liston was the big hero in London. He was known as ‘the fastest knife in the West End’. Speed, an absolute necessity in the time before anaesthesia, was his trademark. Spectators could hardly keep up with his knife and saw. He always had his scalpel in his inside pocket and it is said that he sometimes held it in his mouth when operating so that it was close to hand to make the next incision. As was customary at the time, he had a bundle of thread through the buttonhole of his lapel, ready to tie off spouting blood vessels. And he sometimes also used his teeth to pull his ligatures tight, so as to keep both hands free. Anything not to slow down. Precision was apparently of less importance. He once cut off a patient’s testicles while amputating his upper leg. And there was a notorious case when his knife shot out while he was operating and slashed the fingers of his assistant. There was so much blood pouring out of the patient and the assistant’s hand that one spectator literally dropped dead from fright. Since both patient and assistant eventually died from gangrene, this must be the only operation on record with a 300 per cent mortality. And yet, Liston was a great surgeon, achieving results that made his contemporaries green with envy. He devised the small ‘bulldog’ forceps that are still used to clamp small blood vessels temporarily, and large bone cutters, known as Liston shears.

  About two hundred years later, surgeons are shocked when they see the scars of patients operated on in the 1970s and 1980s. A diagonal scar 30, 40 or even 50 centimetres long on the upper-right abdomen is no exception for a regular gall-bladder operation performed before the 1990s. It sometimes seems that the previous generation of surgeons needed an incision big enough to stick their whole head through. For almost every regular abdominal operation, it was the rule rather than the exception to cut the abdomen open with the largest possible incision along the midline – from the point of the sternum all the way down to the pubic bone.

  ‘A big surgeon makes big incisions’ was a proud and often-heard statement in those times. With our current knowledge, we can safely say that is complete nonsense. Yet, back then, there would have been plenty of surgeons who thought the opposite: that the younger generation who practised minimally invasive keyhole surgery were cowboys, just as we now consider the big surgeons with their big incisions to be. Every period has its cowboys in the operating room, but in the context of their time, they were heroes.

  * * *

  Frau Thérèse Heller survived an operation to remove a tumour on the outlet of her stomach three months longer than the first man in history to survive the procedure. Today, we would consider both cases a failure. But Theodor Billroth became a hero after treating Heller, while Jules-Émile Péan – who had successfully performed the operation two years earlier – has almost been forgotten. Péan’s patient survived less than five days. Both were prominent surgeons at the end of the nineteenth century. Péan, the man who had fitted the baker with a platinum shoulder prosthesis, was a self-confident surgeon in Paris, the cultural capital of the world, while Billroth was the great professor in Vienna, at that time the scientific capital of the world.

  A tumour on the stomach outlet was, at that time, one of the most common forms of cancer. Why that is no longer the case is not completely clear, though it may have something to do with the invention of the refrigerator. An important factor in the development of cancer at that precise spot depends on the presence of a specific bacteria. A series of stomach infections caused by eating contaminated food can cause stomach cancer, even at a relatively young age. Improvements in producing and preserving food in the twentieth century probably reduced the incidence of this form of cancer, but in the nineteenth century it was a widespread problem for which surgeons had no solution. Dying from a tumour on the stomach outlet was an inhuman way to meet one’s end. With continual pain, vomiting, thirst and starvation, it was a living death, and the surgeon who could operate successfully to relieve such suffering would be an international hero.

  In the second half of the nineteenth century the two basic conditions for performing such a dangerous operation were in place: general anaesthesia (first introduced by William Morton in Boston in 1846, see chapter 10) and antisepsis (Joseph Lister, Glasgow,1865, see chapter 11). It must have felt like a race against the clock to the revered professors of the surgical world to be the first to successfully perform this operation, known medically as a distal gastrectomy [removal (-ectomy) of the last (distal) part of the stomach (gastr-)]. Péan’s patient survived the operation in April 1879, but not the difficult post-operative phase, despite the surgeon’s efforts. This was because Péan was unable to administer the man sufficient fluid, and direct injection of fluid into a vein – what we now call an intravenous drip – was yet to be invented. Péan nevertheless published the results of his ‘successful’ operation in the Gazette des hôpitaux under the title ‘De l’ablation des tumeurs de l’estomac par gastrectomy’ (the removal of tumours in the stomach by gastrectomy). Note the plural of tumours, suggesting that Péan was convinced that stomach tumours could now be successfully removed surgically. A year and a half later, Polish surgeon Ludwik Rydigier attempted to perform the operation, but his patient did not even survive the first day.

  It was a treacherous operation, seemingly straightforward but in many ways complex. Probably much more complex than surgeons realised at the time. Their publications show that they were mainly concerned with the best method of joining the two loose ends together after removing the tumour, which is not the most difficult part of the procedure – there are three tricky problems lying in wait for the unsuspecting surgeon. Firstly, the outlet of the stomach is located at the intersection of a number of important structures in the abdomen. The vulnerable bile duct, the portal vein, the artery of the duodenum and the pancreas are all very close by. It is difficult enough with a normal, healthy stomach to dissect the stomach free from these surrounding structures without damaging them; a tumour in this already crowded environment makes the job even more complicated. Secondly, the contents of the stomach are as acidic as hydrochloric acid. The tiniest leak in the join between the stomach and the duodenum has a corrosive effect and causes peritonitis. Effective drugs to neutralise gastric acid were not yet available. Thirdly, the duodenum, the next section of the gastrointestinal tract after the stomach, is firmly attached to the back of the abdomen. You then have to be fortunate to bring the ends of the duodenum and the stomach together without too much difficulty.

  Billroth’s patient was at death’s door. Thérèse Heller was forty-three years old. She had been unable to keep any food down for weeks and had been living on sips of soured milk. The tumour could be clearly felt in the emaciated woman’s upper abdomen, and was about the size of an apple. Before the operation, Billroth rinsed her stomach with 14(!) litres of lukewarm water and on 29 January 1881 he performed the historic procedure. He became a hero overnight and surgeons still write and speak about him with awe and reverence. His historic distal gastrectomy was a genuine turning point, but not because his patient survived the removal of the tumour. More significant was that she had survived the joining together of the stomach and the intestine for more than ten days, proving that a successful intestinal reconnection was possible. This was an achievement that literally pushed back the frontiers of surgery.

  An intestinal join, known medically as an intestinal anastomosis, refe
rs to a connection between intestine and stomach or between two sections of the intestine. As such, it cannot be considered a wound like any other. The unclean contents of the stomach and/or intestine must be able to continue to pass through the system immediately after the join has been completed, without obstructing the healing of the wound. It was not clear until ten days after the operation whether the body would tolerate this exceptional situation.

  Why the ten days? The success of an intestinal anastomosis depends on two phases. Firstly, during the operation, an air- and watertight seal has to be created between the two loose ends. That ensures that the harmful contents of the stomach and intestine remain in the system and cannot enter the abdomen and cause peritonitis. That is purely a matter of surgical technique, choosing the right thread, the right knot, enough stitches (fifty in Billroth’s case) and making sure the two ends match. A technically well-executed intestinal join will always stay in place for a few days. But then comes the second phase.

  The wound healing process in the patient’s tissues must take over from the suture. If the tissues around the stitches die, as can happen with wounds, the suture will tear open, no matter how well the stitches have been placed. But if the tissues remain healthy, the process of wound healing will be activated and seal the connection between the two ends with connective tissue. The sealing of the wound with connective tissue occurs in the first ten days. Once that time has passed, a leak can in theory no longer develop. As with a wound in the skin, where the stitches can be removed after ten days, the stitches in an intestinal join are also superfluous after ten days. But you cannot, of course, open up the abdomen again to take them out. The stitches therefore remain in place for the rest of the patient’s life or are made with absorbable thread, which completely disappears within a few months.

  After Billroth, all stomach and intestinal operations were suddenly possible: for cancer, infectious diseases, functional disorders and life-threatening obstructions of organs. Gastrointestinal operations soon became the most common procedures performed in general surgery and, in the twentieth century, operations were developed that would have been unthinkable in the hundreds of years before that. The profession of surgeon changed unrecognisably.

  With hindsight, however, it must be said that the great Theodor Billroth severely lacked modern surgical insight. The most important criticism would be that he focused on the tumour rather than the patient. The patients of Péan, Rydigier and Billroth were all emaciated and at the end of their tether. That made the operations a lot easier for the surgeons, both technically, as there was almost no fatty tissue in the way, and morally, because doing nothing would condemn their patients to an even more miserable death. We now know, however, that being malnourished is not an advantage at all, but creates an enormous risk of serious complications after an operation. Moreover, it was a complex operation, for which you need to take some basic precautionary measures. For maximum safety, for example, good exposure is required; in other words, not only the tumour, but also the area around it, must be clearly visible. You therefore have to take the time to not only dissect the tumour free, but also the organ on which it is growing and other important nearby structures. Billroth did not do this. On the contrary, he made a horizontal incision in the skin above the tumour, so small that he could not even see that the cancer had spread to the rest of his patient’s abdomen. Thérèse died from the metastasis only three months after the operation. Secondly, Billroth had not sufficiently thought out his plan for joining the two loose ends after removing the tumour. He himself said that he had been fortunate in being able to bring the ends of the stomach and the duodenum together without too much tension. But what if that had not been possible? What he had taken into account was that the two ends are not the same size. The duodenum is about three centimetres in diameter and the stomach more than six. He eventually needed at least fifty stitches to overcome the discrepancy.

  It should therefore be seen as a miracle that Frau Heller survived for another three months. In the years that followed, Billroth performed thirty-four similar operations, with a success rate of less than 50 per cent. And yet, he became world famous. He then abused his position to assert, with no sound arguments to back it up, that surgeons should not attempt operations on the heart or even operate on varicose veins. Billroth’s operation, known as Billroth I, was soon replaced by a better method, called Billroth II. The B-II is also a distal gastrectomy but includes a trick that no longer makes it necessary to pull the two ends together. This solution was not devised by Billroth himself, but by his assistant, Viktor von Hacker. A number of disadvantages of the B-II were later solved by a French surgeon called César Roux, who added a second join in the intestine, forming a Y intersection. The distal gastrectomy procedure used today is therefore known in full as the ‘Roux-en-Y Billroth II’ – a strange name for an operation that is still performed regularly.

  * * *

  Staples

  In 1907, Hungarian surgeon Hümér Hültl devised a solution to the problem of intestinal joins (anastomoses). They have to be sewn up stitch for stitch, meaning that the success of the entire join depends on the reliability of each stitch. Hültl believed he could achieve a better seal by completing the anastomosis automatically all in one go. He constructed a heavy stapling machine that could simultaneously insert a whole row of staples in the intestinal tissue. Another Hungarian, Aladár von Petz, refined the concept, producing a less bulky version, which was used in the 1920s, but only in exceptional situations. After the Second World War, surgical staples fell into disuse on this side of the Iron Curtain. However, surgeons in the Eastern bloc continued to use them and the stapling machines were further developed and refined in the Soviet Union. Surgeons in the West did not know that their colleagues in the Eastern bloc were still using them, and those in the East did not know that their Western colleagues did not know. In the 1960s, while visiting Moscow, an American surgeon saw a Soviet stapling machine in a shop window. Unable to believe his eyes, he bought it and took it home. He showed it to an entrepreneur, who adapted it to produce surgical staplers on a large scale under the brand name AutoSuture. They were a worldwide success and, since then, almost no operation on the stomach or intestines is performed without the use of staples.

  * * *

  Although Billroth had done something revolutionary and, in the years that followed, would clearly demonstrate a systematic surgical professionalism, he still practised according to the prevailing tradition of short and sharp operations. All in all, Billroth did not as much herald the start of modern surgery – with which he is so often attributed – as mark the end of ‘old’ surgery. If great men like Péan and Billroth were the cowboys at the end of the nineteenth century – one with his shoulder prosthesis and the other with his stomach operation – two other men stood for the new order of precision surgery in the early twentieth century: Theodor Kocher in Europe and William Halsted in America.

  Theodor Kocher’s importance for modern surgery is illustrated by the fact that no other surgeon has given his name to so many surgical terms. There are three Kocher’s incisions: the first runs obliquely over the right upper abdomen and is used to access the gall bladder, the second is on the side of the thigh and is used for hip operations, while the third is used for removing a goitre, an enlarged thyroid gland. Also, there are two Kocher manoeuvres, one to replace a dislocated shoulder and the other to free the bend of the duodenum in the abdomen, even a verb to describe the latter procedure: to kocherise; a Kocher syndrome, a muscular disorder in children caused by a deficiency of thyroid hormones; a Kocher’s point, a location in the skull where a hole has to be drilled to drain cerebrospinal fluid from the brain. Pain shifting from the centre of the abdomen to the right lower abdomen in patients with appendicitis is ‘Kocher’s sign’. A Kocher table can be wheeled over a patient’s legs during an operation, Kocher’s forceps are the most well-known clamp in general surgery, and Kocher was the first surgeon to be awarded the Nobel Prize in Physiology o
r Medicine. In 2009, they even named a crater on the Moon after him.

  Kocher’s main contribution to surgery was the thyroid operation. Under normal circumstances, the thyroid gland is a small organ in the front of the neck that uses the iodine in our food to produce a hormone that regulates our metabolism. In the case of an iodine deficiency, the thyroid slowly gets bigger in order to keep producing sufficient quantities of the hormone. After a number of years it can take on gigantic proportions. The medical term for this growth is goitre. Fortunately, it does not occur as much today, because bakers add extra iodised salt to their bread, but in the past goitre was particularly common in areas where iodine does not occur very much naturally. Because iodine is mainly present in seawater, iodine deficiency is usually prevalent in countries that are far from the sea and in people living in mountainous areas. It was no coincidence, then, that Kocher was Swiss. Because a badly enlarged thyroid can eventually obstruct the windpipe, a goitre operation was sometimes a matter of life and death. Before Billroth settled in Vienna, he had been a professor in Switzerland. He had tried his hand at resecting goitres, but almost 40 per cent of his patients died, so he stopped performing the operation. Later, Kocher tried it and, by 1895, his precise approach to surgery had reduced the mortality rate to less than 1 per cent.