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invasive lung surgery

http://www.sfgate.com/cgi-bin/article.c ... NKA3H1.DTL

Being small has its advantages, especially with minimally invasive lung surgery

Sam Whiting

Sunday, February 11, 2007

Lung tumor removal is a two-finger job if they are the thin fingers on the surgical right hand of Dr. Jasleen Kukreja of the UCSF Comprehensive Cancer Center.

Using the narrow space between ribs, Kukreja makes a small horizontal incision, wiggles her index and middle fingers in there to form a scissors and runs a deflated lung between them until she feels a hard mass. Then the mass is pulled out through that same 2-inch hole the way an ice fisherman pulls out a northern pike.

Minimally invasive thoracic surgery, as the procedure is called, has been around for years, but was previously used for notching out a wedge biopsy, to be taken to the lab. If cancerous, the patient would then be turned on his side, unzipped with a foot-long incision and some ribs removed, or spread apart to get at the lung for a traditional open procedure, among the most painful and debilitating in surgery.

The advancement, practiced at only three or four hospitals nationwide, is that the patient doesn't have to be unzipped for a lobectomy, in which an entire malignant lobe of lung is removed. Three small slits -- one for the fingers, one for a camera and one for a forceps -- are all it takes.

The job takes 2 1/2 hours, which is about an hour less than an open procedure. That hour will mean a lot to the patient waking up from general anesthesia. Kukreja did her first solo operation just two months ago, and she thinks that with practice she can get it down to an hour-and-a-half.

Kukreja is not the first surgeon to perform a minimally invasive lobectomy at UCSF, but she may be a pioneer in the two-finger clamp technique, because her predecessors are men who have a tougher time squeezing in both fingers. Last summer, she became the first doctor to be hired by UCSF to focus primarily on this discipline. Before that she was the first woman to graduate from the two-year UCSF residency in cardiothoracic (heart and lung) surgery, going back to 1968.

When she finished in 2006, Kukreja had offers from four hospitals, including one from Dr. Robert McKenna, an expert in minimal invasion at Los Angeles' Cedars-Sinai Center for Chest Diseases. This would have put her an hour's drive from Irvine, where her family has lived since emigrating from India in 1986. Kukreja was only 19 when they moved, but she already had a master's degree of science in molecular biology and biochemistry from a university in India. This was bolstered by a second bachelor's degree from UC Irvine, a medical degree from UCLA and a residency in general surgery at Harvard.

To keep her at UCSF wasn't like bidding for a free agent ballplayer, but pretty close.

"We only take the best, and you've got to be able to woo them," says Dr. David Jablons, chief of thoracic surgery. Jablons called in his friend and advocate Jeff Peterson, who runs the Peterson Family Foundation, which assists and supports lung cancer research at UCSF. Aware that Kukreja is "a rising star," Peterson drove up from his Aptos headquarters to meet her. The conversation came around to housing costs, so Peterson, who has 20 years of experience in the Bay Area real estate market, loaded Kukreja in his car and they went out looking. By the end of the day, Kukreja had decided on a top-floor flat in the Marina District.

"She has a quiet demeanor," Peterson says. "You can tell she's patient-friendly, but when she gets in the game room she puts it on. Not one bit of arrogance."

Kukreja, 39, signed a three-year contract as an assistant professor in residency and joined the team with Jablons, 50, and Pierre Theodore, 38, assistant professor of surgery. Then she was sent for intensive training under McKenna at Cedars-Sinai.

On her first two cases she assisted Theodore, who has been at UCSF for just two years and is already on the short list for an endowed chair at the medical school. "The beauty of this program is you get a lot of responsibility early," Jablons says. "Thoracic is the fastest growing division in the department of surgery."

As partners, Theodore and Kukreja are a sight. He is 6 feet 5, weighs 205 pounds and played football at Princeton. She is 5 feet 4 and 105 pounds, and when she operates she has to stand on steps. Her glove size is 6 and a thin 6 at that.

Her first solo case was Vladimir Yudin, 69, who immigrated to San Francisco from Russia after retiring as an engineer in the Soviet army. With that duty came a pack-a-day habit for 50 years, which caught up to him four years after he quit.

He was expecting "a big surgery, big incision and a long and painful recovery," he recalls. "She said, 'We'll make small incisions between the ribs.' I agreed right away."

The tumor was in his left lung, so he was turned on his right side, put to sleep and his left lung deflated to the size of a glove. The utility port was made just below the armpit. The other two were made 2 1/2 inches below the first hole, in the front and back. A 5mm camera was inserted in the front, to provide an image on a monitor to work from.

With her left hand she inserted a ring forceps, which looks like a long needle-nosed pliers through one of the secondary holes. The forceps allowed her to reach deep into the cavity to grab the lobe of lung and draw it up to her right hand, poking through the utility portal.

Yudin's tumor wasn't hard to trap between her fingers, it was the size of a golf ball. A synthetic bag was then stuffed through the utility portal. The diseased lobe was the size of her fist, and it had to come out through the 2-inch slit. Since no rib spreaders are used, it took a resident-in-training to hold the patient on the table while Kukreja tugged and shimmied the bag holding the tumor out of the chest. Then the lymph nodes were sampled, to make sure it hadn't spread.

Yudin expected a week's stay but he was discharged after three days. He went home and was able to walk up the four flights -- 48 steps -- unaided by his wife. By New Year's Eve, he was singing in the choir at his Russian Orthodox church, and he didn't cough once. By January, he was taking a daily walk from the Haight through Golden Gate Park to Ocean Beach. He hasn't needed any follow-up chemotherapy.

Informed a month after surgery that it was Kukreja's first solo attempt at a minimally invasive lobectomy, Yudin says "that is unbelievable." He'd recommend her to any smoker. "This is a very joyful surgery."

E-mail Sam Whiting at swhiting@ sfchronicle.com.

This article appeared on page CM - 4 of the San Francisco Chronicle

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